- Frank W. Chen [forum discussion]

Health care education entails building the foundation of ushering in new generations of physicians and professionals to deliver quality care to patients on a global scale.  The very notion of training doctors has experienced tremendous upheaval in the history of America.  From the 1700s, medical education and licensure has undergone remarkable reform in the struggle to balance medicine as a business practice and a humanitarian pursuit.  In the early 20^th century, the Flexner report helped culminate a major upheaval to effect a radical change in perspective to bring about the professional ethic we see in the practice of medicine today.  However, one can argue that another round of reform is now in order to enable the standard of continuous quality improvement expected in a discipline grounded in utilizing best practices to help alleviate suffering and promote good health.  What type of initiative would best be put to use to fundamentally revolutionize the health care education system to empower the workforce to deliver coordinated and patient-centered medicine?  Implementing this reform must be rooted in measures that tackle performance-based goals on both an individual and system-wide level.  The most important change requires tackling this reform on both fronts simultaneously, recognizing that each goes hand in hand with the other.  Unifying these various efforts can be federally galvanized via a newly established National Health Education Reform Taskforce (NHERT), jointly governed under the Department of Health and Human Services and the Institute of Medicine.

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- Mallika Mendu [forum discussion]

Health professional schools, and medical schools in particular, aim to select candidates who are intelligent, motivated and who embody the qualities of leadership and compassion.  Matriculating students begin their careers in medicine with a passionate desire to serve and have demonstrated an ability to work effectively with others, often in a leadership role.  Medical education should be designed to foster this enthusiasm and eagerness to provide care.  However, there is evidence that medical students become more cynical over the course of their medical school education.¹ In light of the current state of our healthcare system, with over 45 million uninsured, a significant percentage of patients with numerous barriers to care, and rising medical costs often attributable to avoidable medical errors due to a lack of interdisciplinary coordination, attitudes and values among health professionals in training are of utmost importance.  The question arises as to how to capture the original motivations of health professional students and ensure that those motivations are not lost as they embark on a career in medicine.  Health professional or medical student-run clinics have been developed by students in a number of medical institutions across the country.  These clinics are often founded by a core group of motivated students interested in serving the unmet healthcare needs of an underserved population in their community.² Though the main mission of these clinics is to alleviate barriers to care for disadvantaged patients, another important goal is to offer a unique educational experience to student volunteers.  Student-run clinics offer students, at all levels of training, the opportunity to understand the challenges of managing healthcare for underserved patients with limited resources and to work closely in teams, often with health professional students in varied disciplines.  Medical schools that have implemented student-run clinic programs have observed the value of this unique educational opportunity: students are engaged in clinical care early in their medical education; they are involved in all aspects of healthcare from social services and education to primary care and specialty referrals; they are responsible for coordinating care for their patients by working in teams. As a result, students are better able to relate to their patients, often the most disadvantaged of patient populations.³ In order to create a healthcare workforce equipped to provide a high-value team approach to coordinated, patient-centered healthcare, a fundamental change required of the healthcare education system is to support and help fund health professional student-run clinic programs in all medical institutions across the country.

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- Morgan Medlock [forum discussion]

Introduction

For decades, lawmakers have pondered the prospect of sweeping health care reform in America, and the current economic crisis has intensified its importance. We can no longer endure the rising costs, declining value, and lack of coverage plaguing our health care system. At 16% of gross domestic product, U.S. health spending is double the median of other industrialized nations, yet America ranks 15th to 40th on several key health measures, ranging from life expectancy to years of life lost due to preventable causes.^1,2 The U.S. health system is not the best in quality of care, nor is it a leader in health information technology.³ Our challenges are complex, and the burden of harm is staggering.

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- Wael Salem [forum discussion]

The renaissance era of medicine is in full force and the body of knowledge is growing exponentially.  As the knowledge base balloons, the onus is on health care professionals to amass this knowledge, stay current, push forward with research and then educate the next generation.  Meanwhile the health care system in which these physicians, nurses and allied health professionals must work is evolving at an equally dizzying pace.  The medical education model at most institutions, however, has changed little to accommodate the recent changes in the biomedical sciences and even less in its attempt to make sense of the health care delivery system [1, 2].

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- Duc M. Chung [forum disccusion]

Introduction

Global-minded and culturally-sensitive communication skills are pertinent yet often overlooked components of our health care education system. Emphasis in health professional schools has been on mastery of scientific concepts via problem and system based learning, following didactical algorithms to make diagnoses. While these do provide necessary clinical skills to treat patients, of equal importance is that health care providers are aware of national health care issues and attain effective communication skills to promote healthcare prevention and continuity of care for all patients. Research from the World Health Organization indicates that although the US has the most costly healthcare system, it is the only developed nation aside from South Africa that do not provide healthcare to all of its citizens.ⁱ In fact, an estimated 42.6 million people are uninsured.ⁱⁱ These astounding statistics account for the US’s low ranks in health and well-being (it ranks 26th amongst industrialized nations in infant mortality rate) and healthcare satisfaction (only 40% of US citizens are satisfied with their healthcare system).ⁱⁱⁱ

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- Donna Kaminski [forum discussion]

According to several polls, between 60 to 82% of the United States public believes that our health system needs fundamental change. ^(1,2) When we take a closer look at our current system, it would seem that the public would have a basis for this assertion. Our system of care is by far the most costly in the industrialized world, absorbing 15% of our gross domestic product (GDP), a figure that continues to rise. It is expected to reach 19.2 % by the year 2017. ^(3,4) Despite the large amount of funds we invest in our care, the United States ranked 37^th in overall performance and 72^nd in overall level of health, when evaluated among 191 countries by the World Health Organization (WHO).^(6,7). Part of this discrepancy between cost and care may be explained by inefficiency. According to the National Academy of Engineering, between 30 and 40% of U.S. health care spending is associated with failures, such as poor communication or duplication. ⁽⁸⁾ However, beyond failures, our health care system suffers from an approach that is less focused on overall patient health, and at times overuses technology. For example, while in the U.S. the MRI-to-person ratio is ten times that of Canada’s, each year, many children will go unvaccinated. In addition, despite spending as much as we do on health care, 16 out of every 100 Americans continue to go uninsured, and another 10 are underinsured. ^(1). These statistics suggest what the American public has been sharing from their dining room tables to the many polls that have been taken, we as a country are in dire need of health care reform.

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- Salim Abboud [forum discussion]

Health care needs in the United States have evolved over the years due to several factors, including an aging U.S. populace that has ever increasing demands in managing chronic illnesses. The U.S. health care system, meanwhile, has in many ways failed to adapt to these changing needs and the result has been increasing health care costs and unsatisfactory or largely unavailable medical care to those in need. A shortage and underutilization of primary care physicians, a group that has an important role in preventative care and the coordination of care for chronic illnesses, is key to both understanding and resolving this failure of the health care system.¹² Like so many problems in U.S. health care, this problem of too few primary care physicians is one of finances. A career as a primary care physician is by default less attractive to many students considering medicine as a profession simply because it is typically far less lucrative than most medical subspecialties. Even for students who would prefer a career in primary care medicine, the prospect of paying student loans may steer them towards a higher paying subspecialty or prevent them from pursuing a medical education at all.¹² Reducing the time and cost of an M.D. degree may therefore have an important role in relieving the over-burdened health care system by removing barriers to practicing primary care and increasing the amount of primary care physicians, thereby enabling the current health care system to better satisfy the country’s need for better coordinated, patient-centered care of chronic disease.

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- Tamara Bavousett RN, MSN, C-PNP Texas Tech University Health Sciences Center, DNP (2010), Simon Curtis University of North Carolina, Gillings School of Global Public Health, MHA (2010), Desiree de la Torre, MPH Johns Hopkins University, Carey Business School, MBA (2010), Amelia Walling Maïga Duke University, School of Medicine, MD (2011), Valerie P. Pracili Jefferson School of Population Health, Thomas Jefferson University, MPH (2010). [Forum Discussion]

The Institute for Healthcare Improvement (IHI) has stated that the United States remains the best country in the world for patients seeking an advanced medical intervention or technology; however, many leading health outcome measures suggest that the care in the United States is sub-optimal (Commonwealth Fund, 2008). Evidence of sub-optimal outcomes was highlighted when the Institute of Medicine (IOM), through the report To Err is Human: Building a Safer Health System, asserted that each year as many as 98,000 people die and thousands more are injured as a result of medical errors (Kohn, Corrigan, & Donaldson, 1999). The human toll cited in the report To Err is Human was not a new phenomenon. More than 100 years earlier, Florence Nightingale reported the relationship between safe institutions and positive patient outcomes (Wakefield, 2008). The healthcare system in the United States is broken. IHI asserts every system is perfectly designed to achieve exactly the results it gets. Many sub-optimal outcomes can be traced directly back to the deficiencies in health professionals’ educational curriculum, specifically in the areas of understanding quality improvement (QI) concepts, communication skills, and teamwork.

In another report, Crossing the Quality Chasm, the IOM identified six characteristics of an ideal health system: safe, effective, patient-centered, timely, efficient and equitable. The IOM stated that the biggest barrier to improving the current state of patient safety (PS) was ignorance about what was occurring each day in healthcare settings and organizations (Wakefield, 2008). Overcoming this ignorance was the subject of yet another IOM report, Health Professions Education: A Bridge to Quality (2003). In this report the IOM stated that most current medical education programs are in need of major renovation to bridge communication breakdowns that occur between healthcare providers. Accordingly, each discipline involved in patient care is unaware of the action and interests of the other disciplines. The report urged changes in healthcare systems to coordinate PS, informatics, QI and evidenced-based practice and to incorporate them into an interdisciplinary academic environment (Wakefield, 2008).

Sadly, the majority of healthcare facilities and educational programs continue to function without regard for changes called for in the IOM report. Medical education programs operate in individual silos and forego interdisciplinary interaction and coordination, resulting in professionals who are trained to work in a silo environment and who are ill prepared for the necessary interdisciplinary discussions and coordination of care to improve quality. A solid understanding of quality and a constant focus on QI must be inherent in every medical education program to ensure that quality is a focus in every healthcare facility.

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- Claire Fung, MD/MPH Candidate & Jessica Schumer, MD Candidate Tulane University School of Medicine, New Orleans, LA [Forum Discussion]

From May 2007 to July 2008, six Tulane University medical students, originally from various parts of the United States and Canada, found a home in the small town of Pierre Part, Louisiana.  What began as a Tulane Family Medicine Clerkship to inspire and support a culture of health and wellness in this small community of roughly 3,500 people became a partnership that would unite the medical and public health community; local, regional, and national government; schools; businesses; and families.  This initiative was thoughtfully named “JumpStart Pierre Part”.

Pierre Part, Louisiana is located approximately 75 miles northwest of New Orleans.  The town was landlocked until the 1970s, and as such is home to a tight-knit Cajun population with only one full-time primary care clinic.  Despite their efforts in nutrition and exercise counseling at every doctor’s visit, the town’s two family physicians had developed a growing concern about childhood obesity and metabolic syndrome in the community.  In addition, Pierre Part lacked playgrounds, sidewalks, and a communal engagement towards healthy living.  JumpStart Pierre Part quickly became a huge success.  In just months, our JumpStart team, with the support of Pierre Part’s family physicians and town council, labeled healthy choices in the local grocery store and established a nutrition and exercise curriculum at Pierre Part Elementary School that reached beyond the classroom.  We involved families, inspired Kindergarten and Pre-K parents to change classroom snacks to healthier options, and started a dialogue about health and wellness that was to be reinforced through weekly articles in the local newspaper, as well as community events such as cooking classes and the annual health fair and food festival (Supplemental Figure 1).

When we presented our experiences and findings from JumpStart Pierre Part to colleagues and at local and national meetings, we were often asked: “How did you make this project a success?”  After multiple evaluations and analyses, we have since concluded that the answer lies in our model, which is rooted in a fundamental belief in and application of primary care and community health principles (Supplemental Figure 2).  We believe that in order to create a health care workforce equipped to provide a high-value team approach to coordinated, patient-centered health care, we must redesign the medical school curriculum such that it grows from a foundation of primary care and community health.

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- Paul Di Capua (paul.dicapua) [Forum Discussion]

Introduction

In a cohort of 80 undiagnosed patients presenting to a primary care center, the medical interview alone yielded the correct diagnosis in 76% of visits.¹ Another study found that while diagnostic imaging was accurate in only 35% of cases, the combination of the medical history and physical examination produced the right diagnosis in 70% of cases.² Physicians facing malpractice claims are less likely to use patient‐centered interviewing than are physicians without malpractice claims.³ Moreover, patients are significantly less satisfied with their visits when physicians ignore psychosocial aspects of their care.⁴ As Holmboe argues, clinical skills, defined as the medical interview, physical examination and counseling, “remain the most important and effective diagnostic and therapeutic tools.” ⁵ The most important change required of health care education is ensuring all providers are equipped with high quality clinical skills; this can be achieved by the implementation of a quality improvement mechanism in health care education.

Quality improvement is the fundamental driver of this proposal. Lessons from industrial manufacturing on quality teach us the value of observation and feedback in continually improving quality. However, the current system of health care education lacks structure and yields graduates with low quality clinical skills. This essay proposes the implementation of a system of observation and feedback as means of assessing and improving providers’ clinical skills. For medical education, this can be achieved through the implementation of the mini‐CEX, a validated evaluation tool discussed in greater detail below. I support my argument by describing my own experience of implementing the mini‐CEX at a student‐run clinic at my medical school. A significant shift towards quality improvement in education may result in a cultural change in medicine in which providers continually help each other improve their care of patients.

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