The officials said they were particularly concerned about shortages of primary care providers who are the main source of health care for most Americans.

One proposal — to increase Medicare payments to general practitioners, at the expense of high-paid specialists — has touched off a lobbying fight.

Family doctors and internists are pressing Congress for an increase in their Medicare payments. But medical specialists are lobbying against any change that would cut their reimbursements. Congress, the specialists say, should find additional money to pay for primary care and should not redistribute dollars among doctors — a difficult argument at a time of huge budget deficits.

Some of the proposed solutions, while advancing one of President Obama’s goals, could frustrate others. Increasing the supply of doctors, for example, would increase access to care but could make it more difficult to rein in costs.

The need for more doctors comes up at almost every Congressional hearing and White House forum on health care. “We’re not producing enough primary care physicians,” Mr. Obama said at one forum. “The costs of medical education are so high that people feel that they’ve got to specialize.” New doctors typically owe more than $140,000 in loans when they graduate.

Lawmakers from both parties say the shortage of health care professionals is already having serious consequences. “We don’t have enough doctors in primary care or in any specialty,” said Representative Shelley Berkley, Democrat of Nevada.

Senator Orrin G. Hatch, Republican of Utah, said, “The work force shortage is reaching crisis proportions.”

Even people with insurance have problems finding doctors.

Miriam Harmatz, a lawyer in Miami, said: “My longtime primary care doctor left the practice of medicine five years ago because she could not make ends meet. The same thing happened a year later. Since then, many of the doctors I tried to see would not take my insurance because the payments were so low.”

To cope with the growing shortage, federal officials are considering several proposals. One would increase enrollment in medical schools and residency training programs. Another would encourage greater use of nurse practitioners and physician assistants. A third would expand the National Health Service Corps, which deploys doctors and nurses in rural areas and poor neighborhoods.

Senator Max Baucus, a Montana Democrat and chairman of the Finance Committee, said Medicare payments were skewed against primary care doctors — the very ones needed to coordinate the care of older people with chronic conditions like congestive heart failure, diabetes and Alzheimer’s disease.

“Primary care physicians are grossly underpaid compared with many specialists,” said Mr. Baucus, who vowed to increase primary care payments as part of legislation to overhaul the health care system.

The Medicare Payment Advisory Commission, an independent federal panel, has recommended an increase of up to 10 percent in the payment for many primary care services, including office visits. To offset the cost, it said, Congress should reduce payments for other services, an idea that riles many specialists.

Dr. Peter J. Mandell, a spokesman for the American Association of Orthopaedic Surgeons, said: “We have no problem with financial incentives for primary care. We do have a problem with doing it in a budget-neutral way.

“If there’s less money for hip and knee replacements, fewer of them will be done for people who need them.”

The Association of American Medical Colleges is advocating a 30 percent increase in medical school enrollment, which would produce 5,000 additional doctors each year.

“If we expand coverage, we need to make sure we have physicians to take care of a population that is growing and becoming older,” said Dr. Atul Grover, the chief lobbyist for the association. “Let’s say we insure everyone. What next? We won’t be able to take care of all those people overnight.”

The experience of Massachusetts is instructive. Under a far-reaching 2006 law, the state succeeded in reducing the number of uninsured. But many who gained coverage have been struggling to find primary care doctors, and the average waiting time for routine office visits has increased.

“Some of the newly insured patients still rely on hospital emergency rooms for nonemergency care,” said Erica L. Drazen, a health policy analyst at Computer Sciences Corporation.

The ratio of primary care doctors to population is higher in Massachusetts than in other states.

Increasing the supply of doctors could have major implications for health costs.

“It’s completely reasonable to say that adding more physicians to the work force is likely to increase health spending,” Dr. Grover said.

But he said: “We have to increase spending to save money. If you give people better access to preventive and routine care for chronic illnesses, some acute treatments will be less necessary.”

In many parts of the country, specialists are also in short supply.

Linde A. Schuster, 55, of Raton, N.M., said she, her daughter and her mother had all had medical problems that required them to visit doctors in Albuquerque.

“It’s a long, exhausting drive, three hours down and three hours back,” Ms. Schuster said.

The situation is even worse in some rural areas. Dr. Richard F. Paris, a family doctor in Hailey, Idaho, said neighboring Custer County had no doctors, even though it is larger than the state of Rhode Island. So he flies in three times a month, over the Sawtooth Mountains, to see patients.

The Obama administration is pouring hundreds of millions of dollars into community health centers.

But Mary K. Wakefield, the new administrator of the Health Resources and Services Administration, said many clinics were having difficulty finding doctors and nurses to fill vacancies.

Doctors trained in internal medicine have historically been seen as a major source of frontline primary care. But many of them are now going into subspecialties of internal medicine, like cardiology and oncology.

Original post:
NYT article: Shortage of Doctors an Obstacle to Obama Goals

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.

The first step in this paradigm shift includes acknowledging the benefits in providing a high-value team approach to coordinated and patient-centered care.  There is true value to be found in fostering a culture of interdisciplinary teamwork amongst medical practitioners.  For example, combining doctors and nonphysician professionals like nurses in primary care practices can increase patient satisfaction and improve health outcomes.¹ Oftentimes, patients feel more comfortable discussing issues to clinicians that are not physicians.  However, teamwork success is contingent on cohesive health care teams that share divided tasks, clear communication, and straightforward goals.  Instilling a sense of camaraderie in a health care setting as early as medical school can aid in facilitating the interactions necessary to engender this level of teamwork.  A key point in progressing with these efforts is recognizing the value inherent in quality improvement.  Recently, a study demonstrated that training in quality improvement lowered mortality rates caused by coronary artery bypass graft surgery.² The Institute of Medicine defines six aims for improvement in quality: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.^{3, 4} These aspects are meant to highlight a means to deliver quality care that patients deserve on a daily basis.  This kind of practice takes into account patient values and preferences and transforms medicine from treating merely diseases to the person as a whole.  Clearly, providing coordinated and patient-centered care utilizing teamwork models is a fundamental facet of advancing health care systems to a new level in the 21^st century.

Creating a National Health Education Reform Taskforce (NHERT) would prove instrumental in coordinating and effecting change from coast-to-coast because of momentum built at the federal level.  The NHERT could act as a clearinghouse for approved medical education reform on both an individual and system-wide level.  Measures focused on improving individual patient care on a case-by-case basis include the promotion of student-initiated learning and evaluation, problem-based learning, evidence-based medicine, and utilization of established clinical guidelines.  Changes geared towards a holistic systems approach in improving health care delivery systems include supporting quality improvement approaches, coordinated care, health information technology, interprofessional learning, dedicated leadership, and valuing medical performance indicators. ⁵

One of the first steps in realigning medical education objectives to those that are competence-oriented is empowering individual physicians to deliver quality care to individual patients.  An important component of this method has already been incorporated in the form of problem based learning.  Empowering students from year one with techniques that enable self-reliance on reviewing established medical practices for various cases is an effective method in applying medical knowledge for usage in treating individual patients.  Along these lines, it is also important that medical schools base their third and fourth year curriculum on exposing students to a diversity of patients, because learning from different types of people can build cultural competence and awareness in a broad range of medical issues.

Another important component entails promoting evidence-based medicine to deliver care that is well-rooted in demonstrated best practices.  Evidence-based medicine is implemented by setting two priorities: first, bridging the gap between scientific discoveries and clinical practice by making information more accessible to providers, and second, establishing the infrastructure of an agency such as the NHERT.  Unfortunately, the health care model Americans follow today revolves around providers, but this focus needs to be quickly redefined to instead become patient-centered.  Such steps include promoting the automation of patient-specific clinical information and tying this to decision-making that minimizes doubt according to a comprehensive set of standards that attempt to use tangible scientific evidence to best treat each individual.  The Mayo Medical Clinic states that over half of the nation’s medical care is not based on a consensus of best practices.⁶ In an approach to implement evidence-based medicine, which relies on the ideal that more care is not necessarily better care, the government must ensure the accessibility of conveying scientific evidence to both patients and clinicians.  By using health information technology to analyze large sets of data from across the nation, the NHERT can delineate which variations in procedures should have the most desired effect on corresponding patients with differing conditions.  Guidelines of best practices and outcome measures can restore a system beset with human mistakes.  For example, preventing adverse drug reactions like installing hospital machines which only dispense chemotherapy medications within a safe guideline could be extremely effective, saving $1 billion a year.⁷ In turn, providers must be trained to utilize health information technology and the Internet while other continuing education programs can train doctors in novel treatment methods suited for a wide range of cases.  This process can be ingrained as early as in the first year of medical school, as utilizing programs like PaperChase and MedLine can be encouraged in analysis of case studies.  Millions of new drugs, procedures, and tests have been released, and the NHERT will be responsible for evaluating comparable procedures to identify those that work best for particular conditions and cases.  These measures will leave as little to chance and variability and simultaneously aid clinicians in delivering medical treatment that is both evidence-based and patient-specific.

Finally, another important facet in the medical education reform movement on the scope of improving individual patient care entails implementing standardized clinical guidelines that are based in the evidence-based medicine previously mentioned.  It is important to develop a uniform set of broad performance distributions that train allied health practitioners to follow practices that are well-grounded in best practices.  Once established, proper means of assessment should be developed to encourage adherence.  For example, Atul Gawande recently published a study detailing how adhering to a simple checklist for an operation can reduce infection rates in the ICU of a hospital, save lives, and consequently improve overall quality of care in the medical setting. ⁸ If aspiring physicians, nurses, and technicians can learn to base their work in clearly delineated clinical guidelines from the very start of their medical education, they will build a foundation for taking advantage of these measures in the context of lifelong learning.

Types of systems-levels changes address aspects like organizational culture, education and training, work setting, equipment, teamwork, and interpersonal relationships.  One of the most important means of promoting high-quality care in a setting based on patient-centeredness and teamwork is a massive mobilization of health information technology, access to clinical computing, and the utilization of skills and simulation facilities in medical education.  Other initiatives would include quality improvement approaches, encouraging coordinated care, and expanding interprofessional learning opportunities.

As evidenced by the inclusion of a stipulation for electronic medical records in the recent federal stimulus bill, leaders everywhere are realizing the practical utility of health information technology.  What is now the Center for Clinical Computing in Boston was one of the first academic divisions dedicated to using computers for patient care and research.  It was started over 30 years ago at Beth Israel Deaconess Medical Center.  Throughout the history of its inception and development, health information technology has been praised for its straightforward and cost-effective means to improve quality of care.  This practice includes widespread best practices dissemination, allowing providers to access updated clinical information, cross-reference patient history and allergies, and evaluate drug interactions.  Further, these simple measures halt preventable mistakes from occurring, such as prescription errors and procedural missteps.  Furthermore, use of clinical computing initiatives are instrumental not just for physicians, but also for allied health professionals, such as nurses, therapists, and technicians.  Government sponsored subsidies and market-based practices may assist in startup fees for hospitals that desire to implement such technology.  Training health care professionals at an early stage in their instruction to make the most of such accessible forms of health information tools will encourage best practices and quality improvement.

Another initiative that is of the utmost importance to advocate is the widespread dissemination of access to Skills and Simulation Centers across the nation to all health care professionals in training. ⁹ As of today, only about 1/3 of accredited medical schools in the nation offer convenient access to these facilities for their medical students.  The Shapiro Simulation and Skills Center at the Beth Israel Deaconess Medical Center, a teaching affiliate of Harvard Medical School, opened in 2006 and offers interdisciplinary training opportunities for physicians, medical students, and nurses for a broad array of practices ranging from laparoscopic surgery to central line insertions.  Medical students in clinical rotations and residents have 24 hour access to its various training modules.   It makes sense that health care professionals should be able to practice new techniques and gain confidence in various simulation settings to foster high-quality care in various stages of their training.  This revolutionary approach to medical care has set the bar for patient safety and standard practices.  NHERT could facilitate measures to simultaneously administer grants to allied health schools while increasing standards of certification in this respect.  Another highlight of implementing change in this manner is the ability to train and facilitate interactions amongst health care professionals.  While training an individual in a particular technique like gallbladder removal may be useful through simulation, it acts as an even more powerful tool by providing a setting for a team to work together.  Nurses, anesthesiologists, surgeons, and assistants can all work together in a simulated operating room without risking or endangering a patient’s life while perfecting a particular technique and procedural culture.  Access to skills and simulation centers will be instrumental to medical education curricula of the near future.

The notion of continuous quality improvement has garnered great attention from seminal centers, such as the Institute for Healthcare Improvement (IHI) pioneered by Dr. Donald Berwick.  The approach focuses on quality assurance through a systems-based approach rather than relying on penalizing individual providers.¹⁰ By combining objective data from evidence-based medicine with process management, this movement seeks to effect change from the top-down.  Incorporating this approach’s philosophical tenets into medical education means instilling a culture of continuous quality improvement in clinical rotations and patient-centered training.  By highlighting performance indicators and quality improvement approaches, allied health schools can play on the approach’s strengths of patient-centered care, holistic approach to quality, fact-based measures, and empowering practitioners to improve quality. ¹¹

To further the concept of patient-centered care, allied health education must advocate the concept of coordinated care.  Health care should involve a well-orchestrated team of medical professionals working together in an integrated fashion.  Financial incentives can foster a sense of interdependency among providers to help them coordinate a more patient-centered health delivery system.  This teamwork can be encouraged by sharing reporting and electronic medical records between physician groups and hospitals.  In an attempt to further the patient-centered model, clinicians must move beyond the historical focus on just treating diseases case-by-case and instead focus on improving health holistically by conducting preventive, acute, and chronic care on all fronts.  Utilizing computer-based patient-specific records will increase portability, enhance consistency, and enable the network of physicians participating in a broad number of cases to more effectively communicate with each other.  Relying on HIT for chronic care and disease prevention efforts could result in up to $147 billion in savings per year. ¹²

Finally, any discussion on medical education reform must acknowledge the numerous obstacles that stand in the way of future development on a practical level.¹³ First, any significant progress made in quality improvement is contingent on extending coverage of care throughout the nation.  Currently, approximately 47 million Americans are uninsured, making one in six vulnerable should serious health conditions arise.  Second, problems arise from the absence of standardized sets of aims amongst the hundreds of allied health schools in the nation.  Without these uniformly recognized goals, it is difficult to measure performance and achievement between schools.  Third, because facilities are sitting on the cusp of a revolutionary change in system redesign, more capital must be invested to support adequate health information technology.  Finally, professional education has not centered on enough of a systems-level reform that is necessary to enact a paradigm shift.

Fortunately, solutions exist to enable the change we need to see in health care education.  First, strong leadership supportive of the individual and systems-based measures listed above need to be in place at each university to facilitate reform.  Second, centers like the Agency for Healthcare Research and Quality and Institute for Healthcare Improvement have tremendous experience in researching best practices and should be relied on to lead the path in new directions.  Third, preliminary steps should center around consensus-based change, meaning that practical measures that everyone can agree on will set standards on change to come.  Finally, while momentum needs to be generated at all levels of society, the federal government should play a large role in encouraging medical education reform in this respect, like through the formation of the National Health Education Reform Taskforce.

Although significant hurdles remain, consensus-based solutions will lead the way for progressive change.  It is time that health care education addresses both individual provider and systems-level reforms in an attempt to promote coordinated, patient-centered care.  For quality of care, the adherence to evidence-based medicine, use of clinical guidelines, and assessment of subsequent performance will result in consistency and improved results.  In terms of coordinated care, continuous quality improvement and student-initiated learning and evaluation will facilitate the patient-centered model that needs to command the provider relationship.  Finally, health information technology and access to skills and simulation centers will foster the interdisciplinary teamwork and high value care that patients need and deserve in a 21^st century health care system.  Medical education may leave much to be desired, but just as the Flexner report prompted a century ago, a thorough evaluation today may drive us towards a better health care delivery system in the near future.

Word Count: 2,500 Words

Frank Chen

Harvard College Class of 2010

fwchen@fas.harvard.edu

Works Cited

1.      Grumbach K, Bodenheimer T. Can health care teams improve primary care practice? JAMA. 10: 1246-1251, 2004.

2.      O’Connor GT, Plume SK, Olmstead EM, et al. A regional intervention to improve the hospital mortality associated with coronary artery bypass graft surgery. The New England Cardiovascular Disease Study Group. JAMA. 275: 841-6, 1996.

3.      Berwick, DM. A user’s manual for the IOM’s ‘Quality Chasm’ report. Health Affairs. 21(3):80-90, 2002.

4.      Institute of Medicine. “Crossing the Quality Chasm: A New Health System for the 21^st Century.” Report Brief. Washington, D.C.: National Academy Press.  2001.

5.      Davidoff F., Focus on performance: The 21^st Century Revolution in Medical Education. MSM. 6:29-40. 2008.

6.      Mayo Clinic Health Policy Center. Building Upon the Cornerstones: Recommendations, action steps, and strategies to advance health care reform.

7.      “Health Care Fact Sheet.” Hillary for President. 21 Dec. 2007.

8.      Haynes AB, Gawande AA, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. NEJM. 360(5): 491-9. 2009.

9.      Griner PF. Leadership strategies of medical school deans to promote quality and safety. Journal on Quality and Patient Safety. 33(2). 2007.

10.  Blumenthal D, Kilo CM. A report card on continuous quality improvement. The Milbank Quarterly. 76(4): 625-48, 511. 1998.

11.  Shortell SM, Bennett CL, Byck GR. Assessing the impact of continuous quality improvement on clinical practice: what it will take to accelerate progress. The Milbank Quarterly. 76(4): 593-624. 1998.

12.  Hillestad R. et al. Can electronic medical record systems transform health care? Potential health benefits. Health Affairs. 24: 1103-1117. 2005.

13.  The Academic Medical Center Working Group of the Institute for Healthcare Improvement. The imperative for quality: a call for action to medical schools and teaching hospitals. Academic Medicine. 78(11): 1085-1089. 2003.

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.

Though, student-run clinic programs have been in existence for over two decades,⁴ there has been minimal research conducted regarding the prevalence and clinical/educational impact of these programs.  Simpson et al. provided the only review to date by conducting a survey of student-run clinics throughout the United States.⁵ The review estimates that there are 111 student-run clinics affiliated with 49 medical schools in 25 states.  This group defines a medical student-run clinic as the following: “…a healthcare delivery program in which medical students take primary responsibility for logistics and operational management and which is capable of prescribing disease-specific treatment to patients.“  Simpson et al. identify most clinics as providing for low-income adult patients, often uninsured and frequently homeless, who are at a risk of serious chronic medical conditions such as diabetes, hypertension, and mental illness; 88% of clinics care solely for uninsured patients and 78% do not accept any form of payment from patients. Seventy-five percent of the clinics’ patients are ethnic minorities. The majority of clinics operate once a week in an off-campus site such as a community health center or homeless shelter, with which they have developed an affiliation. In addition to providing primary care and management of chronic health conditions, many clinics provide a variety of medical services such as specialty referrals (86%), laboratory services (81%), on-site dispensation of medications (79%), and patient education (66%).  The average number of student volunteers (weekly) was 16, supervised by at least one faculty physician.  On average 39% of first year medical students participate in their institution’s student-run clinic and this degree of participation declines over subsequent years.  Some clinics are not limited to medical students and incorporate health professional students across disciplines.  Most clinics report a significant amount of teaching between students at all levels.  The mean operating budget among clinics is $18,889 annually (the median operating budget is $12,000), and most are funded by private or community grants.  In their census, Simpson et al. estimate that as an aggregate these clinics represent thousands of student volunteers, tens of thousands of patients, and at least 37,000 annual patient visits.

In order to appreciate the unique educational opportunity a student-run clinic affords its volunteers, it is essential to examine the various facets of an individual program.  The author of this essay was fortunate to have personal experience co-founding and co-directing the first student-run clinic in New Haven affiliated with the Yale health professional schools, the HAVEN (Healthcare, Advocacy, Volunteerism, Education, Neighborhood) clinic.  The HAVEN clinic opened its doors on November 12, 2005 and has since seen 400 patients, representing 1800 patient visits.  HAVEN’s mission is to serve as a sustainable free clinic that will provide primary care, wellness education and assistance in securing healthcare coverage to uninsured adults at no cost.  The founders also sought to develop a multidisciplinary student-run clinic that would serve as a valuable educational resource by allowing students from all health professional schools to become involved in both administrative responsibilities and clinical care, during the beginning of their training, and learn to coordinate patient care in teams.  With the support of the Yale administration and by partnering with Fair Haven Community Health Center (FHCHC), this vision has become a reality.  The HAVEN clinic operates every Saturday at the FHCHC site and its medical directors are FHCHC clinicians, both physicians and nurse practitioners.  The heart of the clinic is the clinical team, comprised of a senior medical, nurse practitioner or physician associate student, junior health professional student and if needed, a translator.  The senior clinical team member is responsible for the clinical component of the patient visit and presents to one of the attending clinicians, comprised of both Yale affiliated faculty and FHCHC clinicians.  The junior clinical team member triages the patient and is responsible for coordinating the patient’s visit with the various departments of the clinic.  In order to address the various barriers to care that this patient population faces, the HAVEN clinic has developed a number of departments, operated entirely by health professional students, early in their training, that are a vital part of a patient visit.  Patient services greets patients at the front desk and schedules appointments.  All patients are seen by social services, which screens and enrolls patients for entitlement program eligibility, and refers patients to social service organizations in the community.  Laboratory services are provided on-site by students trained in phlebotomy.  Referral services is responsible for coordinating imaging and specialty referrals.  Patient education conducts individualized sessions to teach patients about chronic disease management.  The pharmacy dispenses medications from a formulary of generics on-site at no cost to the patient, subsidizes the cost of non-formulary medication, and enrolls patients into pharmaceutical assistant programs.  The administration of the clinic is led by student co-directors and an administrative board, comprised primarily of first and second year medical students and junior APRN, PA and EPH students.  The clinic operates on an annual income of approximately $40,000, largely funded by private grants and student fundraising; laboratory and imaging services have been donated by Yale New Haven Hospital.  Though HAVEN has benefited tremendously from mentorship by Yale faculty and FHCHC clinicians, the efforts of engaged and dedicated students from the schools of medicine, nursing, physician associates and public health that have truly led to its success.

The response of HAVEN’s student volunteers regarding their experience at the clinic has been overwhelmingly positive.  Volunteers often rotate through various departments, and fulfill diverse roles at the clinic, which allows them to understand a number of elements involved in providing care to an underserved population.  For example, a student may volunteer in social services one week and learn about a patient’s struggles with medical debt, and next week serve as a junior clinical team member and learn about the challenges of managing diabetes on a fixed income.  Students have come to appreciate the importance of coordinating care between the various departments: the referrals department relies on social services to provide the patient’s financial information in order to obtain donated services; similarly, the pharmacy utilizes patient education to educate patients about administering insulin and dietary issues.  In addition, students from all health professional schools are learning from one another and have gained an appreciation of the diverse training and skills across the health professions. As a result, students have learned how to work effectively in multidisciplinary teams. This interprofessional collaborative model has been employed successfully by the Students in the Community student-run clinic affiliated with the University of Washington.⁶ Similarly the HOMES clinic in Houston has sought to facilitate providing care in multi-disciplinary teams, and their volunteers cite the value of learning from and teaching others by working in teams.⁷ HAVEN’s student volunteers, across disciplines and at all levels, report that they feel a unique sense of ownership with respect to patient care. Students are able to empathize with a patient’s situation to a greater extent because they understand the multifaceted nature of providing care to disadvantaged patients.  Students involved in the HOMES clinic identified four themes that contributed to their professional education and understanding of biopsychosocial issues: social awareness, compassion and empathy, teamwork and confidence building;7 statements by these students include : “I never knew the difficulties a homeless person faces in simply getting a job…I never just talked to a homeless person and came today thinking I was going to give but received much more.“  A medical student-run clinic in Buffalo, NY found that student interaction with homeless patients and coordination of patient-centered care can combat negative attitudes towards this patient population.⁸ The long standing UCSD student-run clinic published its perspective on the impact of the program on student volunteers: “… provide a setting in which the student’s passions, compassion, and potential for leadership can thrive and be reinforced….“⁹ This clinic reports that the students benefit from a sense of ownership, and that the program cultivates qualities of humility, teamwork, and leadership as well among its volunteers.  Teamwork, interdisciplinary coordination and patient-centered care- these are elements of patient care that student clinics have been able to cultivate among their student volunteers, which are essential for the development of an effective healthcare workforce.

The healthcare education system could be transformed by implementing a nation-wide program to promote the development of student-run clinics in all medical schools.  Given that the major challenge in establishing a student-run clinic is funding, the federal government should provide financial assistance to developing clinics, which usually operate with a minimal budget (approximately $19,000 on average).  Medical schools in turn must provide adequate institutional support and guidance; faculty mentorship is vital to establishing the appropriate educational objectives for students and in assisting students both with administrative duties and clinical care.  Community health centers are ideal partners for student clinics, as they tackle identical challenges involved in administering multifaceted care with limited resources, and medical schools could establish affiliations with these institutions in order to foster student clinic programs.  The success of student-run clinic programs can be promoted by adopting a number of principles. First, when possible collaborative efforts across disciplines should be an integral component of the clinic model, and this involves medical schools partnering with other health professional schools.  Second, clinician supervision of both clinical practice and administrative decisions is crucial.  Medical school-based faculty and community based clinicians, experienced in serving underserved patients, are needed to provide the appropriate guidance of student efforts.  Third, students must be organized in teams to provide both clinical and administrative care.  Finally, the student clinic must be incorporated into the school’s curriculum in order to ensure that all students have the ability to participate in the program.  The HAVEN clinic is offered as a primary care elective to senior medical students.  The UCSD clinic has become incorporated in the medical school curriculum as an elective offered during both the preclinical and clinical years of training.⁹ This elective also includes supplemental classroom activities and reflective sessions, which promote the educational values of teamwork and compassion towards patients.

There are limitations to implementing such a broad initiative.  The administrative responsibilities, though extremely rewarding and educational, are often time-consuming and under the purview of a few dedicated students.  Students interested in family medicine, primary care, or serving underserved patients should be identified and enlisted to participate at an early stage of their training to fill these essential roles.  Though these programs have been shown to be a valuable educational opportunity, the primary goal of these clinics should be to provide quality healthcare to its patients.  Again, clinical supervision is essential and research measuring quality metrics must be conducted regularly to ensure quality of care.¹⁰ Finally, maintaining continuity of care for patients is an ongoing issue for the HAVEN clinic and may arise in other clinics.  In order to address this issue the HAVEN clinic requires students to volunteer for consecutive dates, so that follow-up visits can be appropriately scheduled.

In summary, establishing student-run clinics affiliated with all medical institutions will promote team-based, patient centered coordination of care among health professionals in training.  Student-run clinics foster interdisciplinary collaboration and empathy towards patients, particularly the underserved.  By engaging students early in their training, student clinics harness and promote the desire to serve others, which most health professional students identify as their motivation for pursuing a medical career.

2 Beck E. The UCSD Student-Run Free Clinic Project: transdisciplinary health professional education. J Healthcare Poor Underserved 2005;16:207-19.

3 Steinbach A, Swartzberg J, Carbone V. The Berkeley Suitcase Clinic: homeless services by undergraduate and medical student teams. Acad Med. 2001 May;76(5):524.

4 Yap OWS, Thornton DJ. The Arbor Free Clinic at Stanford: a multidisciplinary effort. JAMA. 1995;273:431.

5 Simpson BA and Long JA.  Medical Student-Run Health Clinics: Important Contributors to Patient Care and Medical Education.  Society of General Internal Medicine 2007;22:352-356

6 Moskowitz D., Glasco J., Johnson B., and Wang G. Students in the community: An interprofessional student-run free clinic.  Journal of Interprofessional Care,20:3,254 -259

7 Clark DL, Melillo A, Wallace D, et al. A multidisciplinary, learner-centered, student run clinic for the homeless. Fam Med. 2003 Jun;35(6):394-7.

8 Cadzow RB, Servoss TJ, and Fox CH.  The Health Status of Patients of a Student-Run Free Medical Clinic in Inner-City Buffalo, NY JABFM November-December 2007 Vol. 20 No. 6

9 Beck E. The UCSD Student-Run Free Clinic Project: transdisciplinary health professional education. J Healthcare Poor Underserved. 2005 May;16(2):207-19.

10 Buchanan D and Witlen R.  Balancing Service and Education: Ethical Management of Student-run Clinics. Journal of Health Care for the Poor and Underserved 17 (2006): 477-485.

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.

The transformation of clinical education is one of many factors that will assist in meeting national goals of lowering costs and providing quality care that is patientcentered. It has been shown that professional health education has not kept pace with or been responsive enough to America’s shifting patient demographics, efforts to improve quality, and changing health system expectations.^4,5 In order to improve outcomes, we need an education system that is relevant to our patients and responsive to the changing context of health care. I propose that the most important change required of our system is a paradigm shift from professorcentered to patient-centered education. In this essay, I will discuss the guiding principles of patient-centered education, outline the specific steps for reaching the goal of high-value coordinated care, and consider the consequences of changing the way we educate our health care workforce.

Guiding Principles of Clinical Education

The health education system has a fundamental responsibility to produce a workforce that meets the needs of America’s patients. The U.S. patient population is becoming increasingly diverse, greater numbers are suffering from multiple chronic illnesses, and individuals are more likely now than ever before to seek guidance from health professionals.6,7,8,9 This “new age” of health care must be met with highly competent professionals who are skilled in working with diverse populations, coordinating care across teams, providing long-term management of disease, and educating patients on optimal health behaviors.

As we seek to reform education, we must clearly define our goals. Six national quality measures have been established as important goals for our health care system: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.¹⁰ The Institute of Medicine has clearly defined these terms as follows:¹¹

• Safety is prevention of patient injuries.
• Effectiveness means delivering evidence-based medicine to the patients who will benefit.
• Patient-centered care makes every effort to meet the specific needs, values, and preferences of the patient.
• Timeliness reduces wasted time in provision of care.
• Efficiency avoids wasting resources.
• Equitable care does not deviate in quality because of a patient’s race, age, or other personal characteristics.

At the 2002 Committee on the Health Professions Education Summit, the following statement was issued in support of national quality initiatives: “All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.”¹²

Having reviewed the principles and definitions of quality set forth by the Institute of Medicine and other national committees, I propose the following changes to our current system:

• Creation of a National Council on Health Education (NCHE) whose mission is to identify the over-reaching core competencies required of all health professionals in order to meet national quality measures.
• Compliance of all health professions schools to the rules and standards prescribed by the NCHE.
• Creation of Health Professional and Society (HPS) curricula at all U.S. health professions schools, according to NCHE guidelines.
• Commitment to primary care-focused, interdisciplinary training of all health professions students.
• Commitment to integration of basic science and clinical training, allowing students early and lengthened exposure to real-world patient care situations.

These five objectives will now be discussed in detail.

National Council on Health Education

Creation of the NCHE is an important step toward a coordinated, team approach to health care. The NCHE will assist in integrating competencies and unifying health professions schools around a common goal: graduating health professionals who provide the highest quality care. Currently, each health professions school has its own representative organization, such as the Association of American Medical Colleges (AAMC) and the American Association of Colleges of Nursing (AACN). The NCHE will be a composite team of leaders from these professional health care organizations, from education and practice, and from the patient population. This team will have experienced firsthand a broken health care system and will have constructive ideas and the necessary skills to implement new policies and strategies to prepare health professionals for the future.

Health Professional and Society (HPS) Curriculum

All health professions schools seeking accreditation by the NCHE will be required to integrate HPS coursework into their curricula. I propose that fifteen percent of total teaching time be dedicated to HPS. HPS coursework will educate students on the context and system of U.S. health care, provide opportunities to discuss issues such as patient safety and quality assurance in interdisciplinary settings, and provide opportunities for practicing the teamwork and communication expected of them once they enter the health care field. Students often hear about the issues plaguing our health care system, but they rarely have time to pause and think about solutions. HPS will provide this opportunity. It will also help dissolve the turf battles between different professions, and students will learn to appreciate the contributions of all health workers toward quality, patient-centered care.

Learners completing HPS coursework will be expected to show competency in the following areas:

• Coordination of Care
• Quality Solutions
• Informatics
• Patient Safety
• Medical Economics
• Population Health
• Social Issues in Healthcare
• Navigating the U.S. Health Care System

The rationale and specific objectives of each of these components is as follows:

Coordination of Care – Teamwork across disciplines is the key to high quality, patient-centered care. Students will learn this important skill by working in interdisciplinary teams, providing care to patients in real-world and simulated environments.

Quality Solutions – Through problem-based learning, students will identify barriers to providing high-quality care and devise solutions for system flaws.

Informatics – With a rapidly expanding evidence base, it is important that health professionals learn how to access and evaluate new scientific knowledge. Quality improvement initiatives rely heavily on this skill.

Patient Safety – Medical errors account for roughly 98,000 annual deaths¹³ and around $30 billion in lost income and health care expenditures.¹⁴ HPS will provide opportunities to analyze situations where patient safety was compromised and think of ways to avoid these adverse advents.

Medical Economics – Helping students understand the finance of health care is an important step toward greater efficiency in practice.

Population Health – Students will be exposed to important issues in public health and disease prevention. This knowledge will assist in improving health outcomes.

Social Issues in Healthcare – We need health professionals who understand the many factors leading to disease. Students will consider the influence of socioeconomic background, culture, values, spirituality and religion on health. Practical experiences with the chronically underserved will also be provided.

Navigating the U.S. Health Care System – Tremendous waste and misuse of services pervade our health care system.^15,16,17 Students will learn the many players in the U.S. health care system and how to effectively manage available resources and services.

The HPS curriculum will encourage systems-based analysis of these topics through a combination of experiential learning, lecture, small group discussion, case investigation, team projects, and interdisciplinary clinical activities. HPS will seek to imbue students with invaluable problem-solving skills and positive attitudes toward lifelong learning. Furthermore, it will antagonize one of the most dangerous forces in our health care system: the delivery of fragmented care that is unsafe and inefficient.

The central premise of the HPS curriculum is interdisciplinary, problem-based learning. Many health professions schools are located in close proximity to each other and should collaborate whenever possible on HPS coursework. Schools may also seek to integrate other didactic sessions, in addition to HPS. Many schools have overlapping degree requirements and may benefit from creating opportunities for students to work together on similar coursework. For example, at Mayo Medical School, medical and physical therapy students work together on the small group dissection required in their first-year Gross Anatomy course.

Primary Care Focus

The value of primary care specialties in improving the quality and efficiency of health care delivery has been well documented.^18,19,20,21 It has been shown that each additional general practitioner per 10,000 population is associated with about a 6% decrease in mortality.²² Many leading countries in quality health measures have primary care-focused systems, but the U.S. has emphasized specialty care instead.^23,24 Specialists grossly outnumber generalist physicians, and some fear that soon, the growing supply of specialists will exceed demand for specialty care.²⁵ There is widespread agreement that these trends must be reversed.²⁶

Since 1992, the AAMC has embraced the goals of its Generalist Task Force, which has set forth strategies for increasing the number of medical students committed to careers as family physicians, general internists, and pediatricians.²⁷ AAMC policy clearly delineates the goal of having the majority of graduating medical students enter generalist specialty areas.²⁸

Our health education system must respond to calls for greater emphasis on primary care. Undergraduate medical education will need to make a concerted effort to educate students on the importance of primary care. Medical school leadership should host interest groups and provide strong mentors for those interested in generalist specialties. Clinical experiences in primary care should be integrated into the basic science coursework of years 1 and 2. In addition, advanced clerkships in family medicine, pediatrics, and internal medicine should receive greater emphasis and increased curriculum time in years 3 and 4. The vast majority of students enter medical school in order to help people. It is the duty of the school to teach and inspire these students to provide the primary care skills that patients so desperately need.

In graduate medical education, becoming primary care-focused may mean reducing the number of specialty training positions available. The AAMC supports this type of action, especially when market forces have proven ineffective in responding to America’s great need for generalists.²⁹ These types of cuts must be done carefully and should be based on the most sensitive and insightful predictions about our future.

A truly primary care-focused system will train students in clinical epidemiology, decision analysis, disease prevention, health care economics, and other topics that are extremely valuable in primary care and correspond to better outcomes for patients. These initiatives will be strengthened by the HPS curriculum discussed earlier. Becoming primary care-focused will also mean more training of students in diverse, outpatient settings. In order to understand generalist practice, students must follow patients through an entire course of illness (an experience not readily available in inpatient settings) and learn how to manage complex problems.

There are many benefits to a primary care-focused system. We can expect that quality and efficiency of care will be greatly improved. Professionals will be better equipped to provide care to those who are chronically underserved in inner city and rural areas. Furthermore, as more interest is fostered in primary care, it is reasonable to expect more research and practice aimed at eliminating health disparities.³⁰

Interdisciplinary Training

Currently, students train within their given profession without much contact with other disciplines. This is not ideal, nor is it realistic. Health care services are rarely provided in isolation. There is often much coordination across teams and time frames in order to provide care. Health care education should reflect the system students will be entering. Creating opportunities for health professions students to work together should be a major goal. I envision a system where students are engaged in clinical activities as members of an interdisciplinary team. The Johns Hopkins School of Medicine has provided an outstanding example of interdisciplinary coursework. In a first-year medical course, students were given the opportunity to work with intensive care nurses in order to understand and reflect on challenges to patient safety.³¹ This model could be reasonably expanded to include health students from multiple disciplines. For example, a care team might include a nursing student, medical student, and pharmacy student.

Integration of Basic Science and Clinical Training

Integration of basic science and clinical training is another underlying principle influencing the changes I have outlined, and it makes sense on many levels. It makes sense for our patients, who need providers with extensive exposure to real-world situations. It makes sense for students, who will receive relevant reinforcement of basic science principles. The great divide between pre-clinical and clinical training must be blurred, and all teaching, whether basic science or clinical, must be patient-centered.

Consequences of Proposed Model

The addition of HPS to health professions curricula will require much coordination. It will also force schools to make tough decisions about what is absolutely necessary in their curricula and which components can be replaced with HPS. Some schools may find that they are already covering many HPS topics, but simply need to reorganize their curricula in order to satisfy HPS objectives.

The consequences of a primary care-focused system are complex. Some view the primary care movement as anti-intellectual. They fear that basic science training will be undermined. However, the system I have proposed here will do anything but undermine intellectual rigor and scholarship. A greater understanding of basic science and other topics such as economics and epidemiology is needed in order to satisfy HPS and primary care objectives.

Primary care-focused training will require more generalist faculty, of which there are currently few. Recruiting and retaining more primary care faculty will be an important step. If we move to a system where specialty positions are gradually tapered, we must be innovative in maintaining scholarship and research that is currently dominated by specialists. Lastly, training students in ambulatory care settings is important to primary care initiatives, but it is more expensive and will require more federal dollars, which are currently allocated mainly for inpatient training.

Conclusion

Dr. William J. Mayo, co-founder of Mayo Clinic, said, “Instruction from teachers and books teaches a man what to think, but the great need is that he should learn how to think.” In this essay, I have proposed ways in which we can teach health professionals how to think: through the problem-based HPS curriculum, through greater emphasis on primary care, and through interdisciplinary training (see figures 1 and 2). We must believe that every American health student possesses the heart of a healer, and when taught how to think, he or she will impact our society in significant ways. It is most important for us now, as health education nears a crossroads, to guard against reform without real change. We must not compromise on our duty to create a health education system that is relevant to America’s patients. It will take our best efforts in order to achieve our loftiest aspirations.

Figure 1 – Summary of HPS model of education

Figure 2 – Composite View of Proposed Changes – High Value, Team Approach to Coordinated, Patient-Centered Care

References

1 Anderson, G.F., B.K. Frogner, R.A. Johns, and U.E. Reinhardt. “Health care spending and use of information technology in OECD countries.” Health Affairs 25 (2006): 819‐831.

2 Starfield, Barbara. “Refocusing the system.” New England Journal of Medicine 359 (2008): 2087‐88.

3 Hussey, P.S., G.F. Anderson, R. Osborn, C. Feek, V. McLaughlin, J. Millar, and A. Epstein. “How does the quality of care compare in five countries?” Health Affairs 23 (2004): 89‐99.

4 Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington: National Academy Press, 2001.

5 Council on Graduate Medical Education. Physician Education for a Changing Health Care Environment. Rockville, MD: Health Resources and Services Administration, 1999.

6 Calabretta, Nancy. “Consumer‐driven, patient‐centered health care in the age of electronic information.” Journal of Medical Library Association 90 (2002):32‐37.

7 Frosch, D.L., and R.M. Kaplan. “Shared decision making in clinical medicine: past research and future directions.” American Journal of Preventive Medicine 17 (1999):285‐94.

8 Mansell, D., R.M. Poses, L. Kazis, and C.A. Duefield. “Clinical factors that influence patients desire for participation in decisions about illness.” Archives of Medicine 160 (2000):2991‐96.

9 Wu, S., and A. Green. Projection of Chronic Illness Prevalence and Cost Inflation. California: RAND Health, 2000.

10 Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington: National Academy Press, 2001.

11 Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington: National Academy Press, 2001.

12 Greiner, A.C., and E. Knebel, ed. “Health Professions Education: A Bridge to Quality.” Committee on the Health Professions Education Summit. 2003.

13 Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press, 2000.

14 Vincent C. “Understanding and responding to adverse events.” New England Journal of Medicine. 348 (2003):1051‐1056.

15 Chassin, M.R., R.W. Galvin, and the National Roundtable on Health Care Quality. “The urgent need to improve health quality.” Journal of the American Medical Association 280 (1998):1000‐1005.

16 Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press, 2000.

17 President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry. “Quality First: Better Health Care for All Americans.” http://www.hcqualitycommission.gov/final/ Accessed March 16, 2009.

18 Starfield B., L Shi, and J. Macinko. “Contributions of primary care to health systems and health. “Milbank Quarterly 83 (2005):457‐502.

19 Vogel, R.L.. and R.J. Ackermann. “Is primary care physician supply correlated with health outcomes?” International Journal of Health Services 28 (1998):183‐96.

20 Shi, L. “The relationship between primary care and life chances.” Journal of Health Care for the Poor and Underserved 3 (1992):321‐35.

21 Gulliford, M.C., R.H. Jack, G. Adams, and O.C. Ukoumunne. “Availability and structure of primary medical care services and population health and health care indicators in England.” BMC Health Services Research 4 (2004):12.

22 Gulliford, M.C. “Availability of primary care doctors and population health in England: Is there an association?” Journal of Public Health Medicine 24 (2002):252‐254.

23 Starfield, Barbara. “Refocusing the system,” New England Journal of Medicine 359 (2008): 2087‐88.

24 Starfield B., L Shi, and J. Macinko. “Contributions of primary care to health systems and health.” Milbank Quarterly 83 (2005):457‐502.

25 Cohen, J. “Generalism in medical education: the next steps.” Academic Medicine 70 (1995):87‐89.

26 Macinko J, H. Montenegro, and C. Nebot. “Renewing primary health care in the Americas: a position paper of the Pan American Health Organization/World Health Organization (PAHO/WHO).” Washington, DC: Pan American Health Organization, 2007.

27 AAMC Generalist Physician Task Force, AAMC Policy on the Generalist Physician. Academic Medicine 68(1993):1‐6.

28 Association of American Medical Colleges. 1993 Institutional Goals Ranking Report. Washington, D.C.: AAMC, 1993.

29 Bondurant, S. Statement on the Health Security Act, S 1757: health professions workforce and academic health center provisions. Testimony presented January 26, 1994, to the Senate Labor and Human Resources Committee, U.S. Congress, Washington, D.C.

30 Shi, L., J. Macinko, B. Starfield, R. Politzer, J. Wulu, and J. Xu. “Primary care, social inequalities, and all‐cause, heart disease, and cancer mortality in U.S. counties, 1990.” American Journal of Public Health 95 (2005):674‐680.

31 Thompson, D.A., J. Cowan, C. Holzmueller, A. Wu, E. Bass, and P. Pronovost. “Planning and implementing a systems‐based patient safety curriculum in medical education.” American Journal of Medical Quality. 23 (2008): 271‐77.

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].

A practical study of the health care system has been largely neglected in even the most modern of curricula.  With the current model of medical education, newly trained physicians will find themselves adequately equipped to deal with medical conditions, but exceedingly few will have the knowledge and experience to devise, work and evaluate a system that provides coordinated, patient-centered care over an individual’s lifetime.  Providing this level of health care is possible if professionals are effectively integrated in a system centered around efficient communication and dissemination of information across disciplines[3].  In short, medical education of the twenty-first century must be restructured to emphasize a practical training that prepares future health care professionals to develop, utilize and evaluate systems of care that focus on providing coordinated, patient-centered care.

The Health Care Challenge

The American health care system is facing a monumental challenge in its attempt to deliver high quality care to all Americans [4]. Poorly structured care delivery systems and inefficient medical administration are contributing to negative patient outcomes and medical mistakes while also increasing costs [5].  Though the US has the highest per capita health care expenditures of any country, an estimated 45.7 million Americans remain without insurance [6, 7].  The system is strained by a fragmented delivery of care process, soaring administrative costs and ineffective payment schemes, all adding to increased costs without improving patient outcomes [8].  Using the Porter definition of value- health outcome per dollar of cost expended- it would seem that Americans are suffering from one of the worst values in health care in the developed world [9].

An archaic infrastructure is exacerbating our burgeoning expenses by harboring a payment system which does not prioritize the interests of the patient.  The majority of physicians still work in relative isolation of each other, the pharmaceutical industry, the health insurance sector, and even the public health arena.  These physicians are entrenched in a system that makes interdisciplinary communication difficult. Moreover, it actually encourages a sort of protectionism from each individual player.  Referring a patient to another doctor is synonymous with losing a customer in the business arena.   However, some physicians may be ill equipped to intervene with certain conditions and may be treating patients less efficiently and less safely than their peers.  In response to this skewed system of incentives, the payment system should be redesigned to ensure that physicians are embedded in a well coordinated system of reciprocal exchanges which maximizes individual physician expertise.

The dissemination of health care is increasingly expensive, fragmented and disorganized.  We are stuck in an archaic payment system that does not create incentives for a value-based approach to quality health care.  The numbers of Americans not covered by health insurance are astronomical in comparison to any developed country in the world.  Addressing all these systemic breakdowns at the same time would be the most effective manner to deliver patient-centered, high value, coordinated health care that covers everybody[10].  A fundamental shift in the practice and culture of health care delivery must be addressed by reforming medical education to adequately prepare physicians of the twenty-first century.

This paper argues for why an improved health care system will only prevail in the face of a medical education reform.  This study proposes a medical education model that will be based on the current challenges of the health care system.  While it is critical to reform the training of all health care workers, this paper will only address physician education, but the universality of the model allows it to be folded over to other branches of medical education as well.

The Dilemma

To realize a reformed US health care system, a new value driven payment system must be established in the context of a health care infrastructure that efficiently coordinates care among health care professionals. Central to reforming the payment system is the widespread publication of results[11].  Reporting results has been shown to dramatically improve outcomes as in the case of coronary artery bypass grafting procedures in New York [12].  Nevertheless, it still remains that very few physicians or institutions devise outcome measures and make the results public. This failure is largely a product of a protectionist culture fostered in medical education. As a result, physicians view the care of patients as a solo operation in which they alone stand to be personally judged by publishing results.  Starting very early in the premedical education, the focus is on individual test scores and GPAs as opposed to a highly diverse education emphasizing group interactions.  Interestingly, it is far more likely that the latter allows future physicians to relate and understand others more fluently[13].  Until physicians are taught to evaluate and be evaluated on their collective performance, a value driven payment system will not be achieved.  In essence, the current medical education creates a physician culture that discourages publishing and evaluating results, an essential component of a reformed value driven payment system.

A reformed payment system will advance health care in America, but it must be done in conjunction with a new model in which care is coordinated over the full care cycle [9].  The current medical education promotes a specialty-based, segregated clinical education that rarely sees medical students incorporated over the full care cycle for a single patient.  The core clinical years are a potpourri of clinical experiences, generally at academic medical centers, in which students are assigned to a physician for a short duration of time. In bouncing from one rotation to the other without ever being in a particular team for extended periods of time, students never develop the integral skills to design and work in coordinated teams over the full cycle of care for a single patient.  Equally detrimental is that students are rarely expected to measure the outcome of a particular episode of care and evaluate what could have been done differently.  The current education reinforces an isolated medical model in which physicians work as individuals to deliver compartmentalized and fragmented medical care.  In that sense, it is fair to assume that future physicians will be less capable and thus feel less comfortable to redesign the flow of patient care so that it is patient-centered, coordinated, results driven, and conducted over the full cycle of care.

The Medical Education Reform

In order to develop, utilize and evaluate a modern health care system that is both patient-centered and value driven, physicians of the twenty-first century must have a broader practical knowledge of health systems than that provided by the traditional medical education.  More specifically, a much more rigorous interdisciplinary knowledge base must be established before physicians-in-training are clinicians.  A longitudinal approach to increase the knowledge and practical applications of a wide variety of fields over the course of undergraduate, medical and graduate medical education must be emphasized in conjunction with the basic medical curriculum.

Figure 1: Traditional flow of knowledge in medical education

Figure 2: Flow of knowledge in the proposed interdisciplinary model of medical education

Undergraduate Studies

Undergraduate education must be viewed as an opportunity to broaden a future physician’s capacities as a creative, organized and interdisciplinary thinker as opposed to the current view in which it is a necessary stepping stone on the path to medical school.  Such a paradigm change requires the alignment of a new set of incentives for admission to medical school with the reformed approach to undergraduate studies [14].  Creativity, leadership and intellectual breadth of knowledge must be equally awarded with GPAs and MCAT scores.  The current standard makes the study of the sciences, especially biology, the de facto major even though the biological sciences will be largely duplicated in medical school.  The incentives in place for undergraduate education create a disturbingly homogenizing experience that are in stark contrast to the diversity of roles expected of future physicians as clinicians, researchers, educators, public health directors, hospital managers, health care consultants, politicians, and patient advocates.

In a reformed model, students who study a wide range of subjects will greatly influence and educate their peers when they arrive to medical school.  They will be better suited to undertake interdisciplinary projects and create new ideas.  As medical students, those who formerly studied economics, business or political science will debate the payment schemes within various fields of medicine. Computer engineers, public health and literature majors will discuss ways of creating helpful physician-patient web interfaces.  Ideas will flourish and interdisciplinary skills will be second nature for this new cohort of medical students.  Reform at the undergraduate level must be matched by a restructured medical school admission standard to ensure the selection of interdisciplinary students that will have the abilities needed in tomorrow’s physicians.

Medical School

Once students with a wide breadth of education and experiences are admitted to medical school, it is pivotal to enhance their interdisciplinary education by integrating them with professionals and students outside of medicine.  A problem based series of modules throughout the four years would allow medical students to acquire the necessary practical skills that will pave the way for reformed health care delivery.  Led by professionals from other fields, the problem based modules would be designed to provide medical students with a practical experience in assessing a health care system, designing an improved system, preparing a method for studying that change, and analyzing the results.  Under the guidance of professionals from other fields the medical students would develop vital communication skills pertinent to talking with professionals outside of medicine. They would be exposed to skills and knowledge implemented in other fields. They would gain practical experience in receiving and responding to feedback in dynamic group settings.  Medical students could be joined by graduate students in other fields to enhance the practical real world experiences for both groups. Ultimately, integrating medical students with professionals and students from other fields will have a significant impact on the ability of future physicians to better understand and participate in the interdisciplinary teams necessary for coordinated health care delivery.  The gains from each module for future physicians and the health care system can be seen in figure 3.

Figure 3: Expected outcomes from four fundamental modules emphasizing a practical education in health care systems

The problem based modules would be centered on the skills that physicians must learn to participate in improving the delivery of care throughout their career.  The series of modules would have a core syllabus addressing: 1) an improved payment system

2) coordinating care, 3) improving value and 4) insurance for everybody [10].  An example of the trajectory a typical course could follow is proposed in figure 4.  By creating group projects in which students will be evaluated as a whole, these modules will also facilitate the paradigm shift in which future physicians will be more likely to publish and evaluate their results in order to improve outcomes.  Health care reform will not be a single event with a defined end date. Instead, it will be a continuously evolving process which aims at optimizing health care systems given the current technology, economic situation and capacity. Physicians must be highly trained in practical skills enabling them to advance coordinated and patient-centered health care delivery models throughout their career.

Figure 4: Example of a problem based module in which a new payment scheme is assessed, redesigned, measured and evaluated.

Graduate Medical Education

Graduate medical education should allow residents to utilize their acquired knowledge from the problem based approach and apply it in real world scenarios.  Admittedly, graduate medical education poses a difficult challenge since residents have limited time for added responsibilities.  Nevertheless, the vast majority of physicians will have duties in addition to their clinical responsibilities.  Not training residents in the real world applications of health care delivery would be a disservice to them and to the patients that they will serve.  Graduate medical education should therefore encourage residents to participate in various levels of non-clinical roles as junior members.

Conclusion

Until now a traditional medical education has shied away from training physicians to prepare them to create a meaningful health care reform that prioritizes a value driven, patient-centered and coordinated health delivery system.  Physicians of the twenty-first century will have a spectacularly wide breadth of responsibilities and occupations throughout the flow of health care delivery.  In response to the rising demands, health education must realign itself with a practical and interdisciplinary education that encourages physicians to reevaluate the dissemination and organization of care models.  Undergraduate education must emphatically push students to take on a wide breadth of knowledge in fields other than medicine and biology in order to create multidisciplinary physicians.  Medical schools should align their curricula with the demands of tomorrow by creating a series of practical modules that put medical students face to face with professionals from other disciplines.  This reform would challenge students to develop new ways of thinking about how to deliver care while creating a future physician culture that will optimize health systems to deliver coordinated and patient-centered care.  Graduate medical education will encourage residents to participate in real world systems improvement to begin a practical training in their future non-clinical work.  Health care reform is no longer a choice but a necessity.  New ideas and inventions constantly emerge in medicine. To bring these developments to patients, systems of care will need to continuously evolve.  Physicians will play a major role in health care reform and therefore it is critical that they receive a practical education that prepares them for their interdisciplinary roles.

References

1.         Christakis, N.A., The similarity and frequency of proposals to reform US medical education. Constant concerns. Jama, 1995. 274(9): p. 706-11.

2.         Whitcomb, M.E., Redesigning clinical education: a major challenge for academic health centers. Acad Med, 2005. 80(7): p. 615-6.

3.         Leonard, M., S. Graham, and D. Bonacum, The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care, 2004. 13 Suppl 1: p. i85-90.

4.         Obama, B., Affordable health care for all Americans: the Obama-Biden plan. Jama, 2008. 300(16): p. 1927-8.

5.         Why Not the Best? Results from the National Scorecard on U.S. Health System Performance.  2008  [cited 2009 March 12]; Available from: http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2006/Sep/Why-Not-the-Best–Results-from-a-National-Scorecard-on-U-S–Health-System-Performance.aspx.

6.         Schoen, C., et al., How many are underinsured? Trends among U.S. adults, 2003 and 2007. Health Aff (Millwood), 2008. 27(4): p. w298-309.

7.         Household income rises, poverty rate unchanged, number of uninsured down [press release].   [cited March 3, 2009]; Available from: http://www.census.gov/Press-Release/www/releases/archives/income_wealth/012528.html.

8.         Spithoven, A.H., Why U.S. health care expenditure and ranking on health care indicators are so different from Canada’s. Int J Health Care Finance Econ, 2009. 9(1): p. 1-24.

9.         Porter, M.E. and E.O. Teisberg, Redefining health care : creating value-based competition on results. 2006, Boston, Mass.: Harvard Business School Press. xvii, 506 p.

10.       Building upon the cornerstones: Recommendations, action steps and strategies to advance health care reform, Mayo Clinic Health Policy Center: Rochester, MN.

11.       Porter, M.E. and E.O. Teisberg, Redefining competition in health care. Harv Bus Rev, 2004. 82(6): p. 64-76, 136.

12.       Chassin, M.R., Achieving and sustaining improved quality: lessons from New York State and cardiac surgery. Health Aff (Millwood), 2002. 21(4): p. 40-51.

13.       Gunderman, R.B. and S.L. Kanter, Perspective: “How to fix the premedical curriculum” revisited. Acad Med, 2008. 83(12): p. 1158-61.

14.       Thomas, How to fix the premedical curriculum. New England Journal of Medicine, 1978(298): p. 1180-1181.

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

A 2001 survey of 6,772 patients indicated that minorities are more likely to have trouble communicating with healthcare providers compared to non-minorities;^iv as many as twenty percent of Spanish-speaking patients do not seek medical attention due to language barriers.^v The healthcare student should be mindful of these growing disparities in our healthcare system and become an advocate for those who lack a voice.

At the community level, errors in communication have profound adverse effects. Within healthcare facilities, misinterpretation of prescriptions, poor interactions amongst health care providers, and inadequate patient education have estimated to harm approximately 1.5 million people annually, amounting to 400, 000 preventable drug-related injuries in hospitals, 800, 000 more in long-term care facilities and 530,000 in outpatient Medicare clinics.^vi

Increases in costs which resulted from these communication errors and inadequate clinical judgments prove to be most significant, as demonstrated in the table below:

Table 1. Increases in Cost due to Medical Errors.^vii

^{More emphasis should thus be placed on establishing stronger communication skills that would cultivate a more patient-centered approach to health care delivery to eliminate these costly errors. A proposed mechanism for this change would be to strengthen three specific tiers of communication in our medical training: provider-community, provider-provider, and provider-patient interactions.}

I. Provider-Community Communication: The Provider as a Community Leader

^{An essential aspect of patient care is understanding the needs of the community in which the patient belongs. Health professional students should be required to engage in a set number of community outreach events, such as volunteering at free clinics or organizing community health fairs to promote health prevention. Interwoven with these outreach activities would be mandated courses in public health and communication skills to strengthen the student’s leadership role in his or her community.}

The mode of health information dissemination is a crucial component of this interaction. Information that patients obtain at home has more recently shifted from media-based to internet-based and interactive software. Closer examination, however, reveals that there is a literary and “digital divide” amongst variant socioeconomic classes.^viii As health information is often written at the eighth grade level, low literacy members (those reading at grade two or below, often non-native members of the community) may have trouble understanding available information. Subsequently, studies have demonstrated these members have four times annual health care costs compared to those with higher literary skills.^ix Moreover, low literacy in elderly patients should not be disregarded. A recent study demonstrated that 81 percent of the elderly had difficulties comprehending basic healthcare information such as prescription labels.^x To better accommodate for these barriers, health professional students should be trained to communicate healthcare information in a manner that is accessible to everyone, be it using more visual stimuli such as on-line videos, skits, or showing health-related movies as part of community events. Furthermore, as immigrant communities emerge, it is imperative that health professional students be required to take additional foreign language courses to better understand the needs of those communities.

Yet a primary concern remains access to information in certain racial ethnic groups as well as low-income and rural communities. A study in 1998 reveals such growing disparities as shown below.

Table 2. Internet Access at Home by Race, Family Income, Geographical Location^xi

Compounded with low literacy and personal disabilities low-income, rural, and minority groups are at a clear disadvantage in terms of access to health information. More focus, then, should be placed on other mediums of disseminating health information. These could take the form of students traveling to remote areas to educate rural communities or journeying to schools in underprivileged neighborhoods to promote health prevention. Students could then articulate the needs of these communities to local leaders to enhance internet access for all.

In promoting more access to the community, the Health Promotion and Prevention Initiative recommends that students be made aware of the following:

Table 3. Presentation of Information to Promote Health & Prevention^xii

In addition to being a proponent for change in their communities, professional students could take additional technology courses and collaborate on designing websites and interactive programs that are easily accessed by all members of the community. Taken with community outreach opportunities and public health communications training, the technologically-conscious professional could better accommodate for the needs of his or her patient.

II.Provider-Provider Communication: Providers as a Collective Team

Working collaboratively and respecting the roles of other healthcare providers are an integral part of caring for the patient. However, research shows that communication barriers still exist between healthcare providers. For instance, amongst residents and attendings, varying age, disparate cultural backgrounds, and training often lead to tension when caring for patients. A few real life scenarios of these tensions along with ways to overcome them are outlined below.

Table 4. Tensions between Residents and Attendings & Mechanisms for Change^xiii

Miscommunications between nurses, pharmacists, and physicians are not uncommon in the hospital setting. A National Academy of Science’s Institute of Medicine report revealed that an excess of 7,000 people are killed each year as a result of poor handwriting by doctors misinterpreted by other providers and patients; less than 10% of American doctors also do not have access to the internet in their surgery.^xiv To mitigate these drastic statistics, all health professional students should be required to learn how to use electronic medical records as part of their medical training and schedule regular meetings with other providers to debrief about patients under their care. Fortunately, an e-prescription program is currently being implemented to help physicians and students become more aware of drug-drug reactions.^xv

More importantly, providers must mutually respect each other in the care of patients. For instance, in Nursing Against the Odds, Susan Gordon explores how nurses’ roles as empathetic health care providers are often strained by long work hours, insensible duties, and lack of acknowledgement from superiors. To promote better care, Gordon calls for a broad agenda that includes safer staffing, improved scheduling, and other policy changes that would give nurses and nursing students a greater voice at work. She proposes that the main stimulus for doctors and nurses to collaborate more effectively is respect-respect for each other’s presence, and respect for each other’s opinions in the care of patients.^xvi

Our health-care training should thus encompass a well-rounded knowledge of the potential impact that other healthcare providers may have on patients’ well-being be it dentists, doctors of eastern medicine, chiropractors, and perhaps most importantly, the role that interpreters may have on immigrant populations. Providers should be trained to interact with paraprofessionals in a respectable manner through attending one another’s annual conferences or community meetings where mutual intellectual exchange could take place. Students should also learn to work with medical interpreters at an early stage as often the biggest mistake that providers make is allowing interpreters to talk for the patients as opposed to letting patients talk for themselves. Below are key points implemented by the International Institute at Buffalo for effective usage of interpreters:

Table 5. Strategies to Communicate Effectively with Interpreters^xvii

^{Effective communication with interpreters, in turn, helps patients better understand their physicians and improve compliance. Taken collectively, a group healthcare providers who are cognizant and respectful of each other’s roles and who are willing to collaborate with one another could translate into more effective care for patients.}

III. Provider-Patient Communication: Global-Minded Providers and Well-Informed Patients.

The most essential component of caring for the patient is communicating effectively with the patient and understanding his or her individual needs. Because of the tremendous diversity around us, effective communication should encompass not only awareness, sensitivity, and knowledge of the patient’s condition but also transcultural and cross-cultural awareness. For instance, a culturally sensitive and aware student would realize that promoting the use of condoms by members of some African-American communities may be interpreted as a strategy to promote black genocide by limiting reproduction. The same mindful student would also not interpret a Native American patient’s lack of response or periods of silence as signs of resistance but as a common cultural means of communication amongst native members.^xviii

Yet gaining such valuable insights requires that health care students have a breadth of diverse cultural experiences. As statistics show that minorities compose only three percent of medical school faculty and sixteen percent of public health school faculty, professional schools should strive to increase these numbers to ensure that students gain multiple health perspectives in their training.^xix In addition to the required science coursework, professional schools should place more emphasis on a candidate’s depth and breadth of non-science coursework. Once in professional schools, students should be required to take a set number of electives in international health or medical humanities to gain an appreciation for other cultures. Moreover, students should also be given more clinical exposure to rural or underserved communities via precepting under physicians who care for these communities. Under such mentorships, students can take on research projects working to improve conditions for minority patients and their families. The table below outlines specific points to embrace in communicating with patients from diverse backgrounds.

Table 6. Strategies to Help Students Communicate More Effectively with Patients from other Cultures^xx

^{The common theme underlying these recommendations is an awareness and appreciation for patients’ personal beliefs and practices. These skills could only be cultivated through direct exposure, hence, students should begin their training with an conscious and receptive mind for these differences.}

Another imperative factor in establishing patient-centered care is involving the patient in health care decisions. The first step in this process is helping providers and students communicate more effectively through the elimination of medical jargon. Students can attain such skills through weekly classes with standardized patients and receiving feedback or role-playing with one another and engaging in community outreach projects. Patients would be empowered to collaborate with health-care providers to manage their illness without subsuming a more inferior role in the interaction.

The American Academy on Communication and Healthcare recommends the following three pronged approach toward healthy provider-patient interaction, which should be taught to all health professional students:

Table 7. Strategies toward Healthy Provider-Patient Interaction^xxii

Additionally, in the clinical setting, students could learn to focus more on the following key areas:

Table 8. Areas of Focus in Provider-Patient Interaction^xxii

^{The strategies and skills provided above simply could not be attained overnight, hence, professional schools should expose students to the clinical setting in the first semester of medical education and have students practice to reinforce these pertinent skills throughout their training. Effective provider-patient interaction translates into a more informed patient, better compliance, and an overall improvement in patient-centered care.}

Conclusion

Unifying the Three Tiers of Communication.

Patient-centered care really beings at the community level, where professional students learn to be mindful of the needs of their communities through direct work with those communities. Such an active role could only take form if students are trained on how to communicate effectively with patients and execute those skills in a variety of clinical settings, be it journeying to local free clinics or schools to promote health prevention. Having learned the needs of their communities, providers could work together in an environment of mutual respect and intellectual exchange to provide more cohesive care for patients. These could take the form of more frequent seminars and conferences or simply learning to the respect the important role that each provider may have on the well-being of patients. Any tension or miscommunication should be addressed in an open-manner and through peer feedbacks to improve upon disparate modes of health-care delivery.

Patient-provider communication could be strengthened through repeated exposure to patients from diverse backgrounds. Such interactions begin with a receptive and culturally conscious mind. It is imperative that providers also learn to communicate without medical jargon or cultural biases. Most importantly, providers should listen carefully to patients and engage patients and their families in the decision-making process. Providers should empathize and have open communications with patients to ensure that individual needs are met. Although some of these skills can be taught, the vast majority can only be cultivated through many years of clinical experiences. As Dr. Francis Peabody eloquently states in his final talk, “The Care of the Patient” in 1927:

“Medicine is not a trade to be learned but a profession to be entered. The treatment of a disease may be entirely impersonal, the care of a patient must be completely personal…the secret of the care of the patient is in caring for the patient.”^xxiii

If we embrace this philosophy, certainly we would realize that there is an intricate science and art to patient care. It’s not just about pinpointing a chief complaint and fixing it, it’s about understanding the human condition and recognizing the humanity behind every patient. If we are attuned to the needs of a patient, we would realize that although medicine can cure, only an attentive ear can heal.

ⁱ World Health Organization. (2009). Facts about Healthcare Inequaties. www.who.int.
ⁱⁱ “Health Insurance Coverage,” Current Population Reports, US Census Bureau, September 2000.
ⁱⁱⁱ Ibid,WHO.
^iv Collins, K. et al (2002). Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans. The Common-wealth Fund 2001 Health Care Quality Survey. The Common Wealth Fund.
^v Institute of Medicine, Committee on Understanding & Eliminating Racial & Ethnic Disparities in Healthcare (2002). Unequal Treatment Confronting Racial and Ethnic Disparities in Health Care, B.D. Smedley, A.Y. Stith & A.R. Nelson, eds. Washington, DC, National Academies Press.
^vi Ibid, Institute of Medicine, National Academy of Sciences.
^vii Encinosa, W. and Hellinger, F. Impact of Medical Errors on 90-Day Costs and Outcomes: An Examination of Surgical Patients.Health Services Research Journal. July 2008.
^viii Street, RL, Gold WR; and Manning T, eds. Health Promotion and Interactive Technology: Theoretical Applications and Future Directions. Mahwah, NJ: Lawrence Erlbaum Associates, 1997.
^ix Eng, T.R; Maxfield, A; Patrick, K; et al. Access to health information and support: A public highway or a private road? Journal of the American Medical Association 280 (15): 1371-1375, 1998.
^x Ibid, Eng et al.
^xi “Computer and Internet Use Supplement to the Current Population Survey,” Current Population Reports, US Census Bureau, 1998.
^xii Adapted from US Department of Health and Human Services. Healthy People 2010. 2nd Edition With Understanding and Improving Health Objectives for Improving Health. 2 vols. Washington, DC: US Government Printing Office, November 2000. http://www.healthypeople.gov/document/HTML/Volume1/11HealthCom.htm.
^xiii Scenarios adapted from: McCue, JD; Beach, KJ. Communication Barriers between Attending Physicians. Journal of General Internal Medicine, March 1994, Volume 9 Number 3. Springer New York. P.151-161.
^xiv Ibid, Institute of Medicine, National Academy of Sciences.
^xv Ibid.
^xvi Gordon, Susan, Nursing Against the Odds: How Health Care Cost Cutting, Media Stereotypes, and Medical Medical Hubris Undermine Nurses and Patient Care, Cornell University Press, New York, April 2006.
^xvii International Institute of Buffalo. http://www.iibuff.org/ 2009.
^xviii Kavanagh, K; Kennedy, P, Promoting Cultural Diversity: Strategies for Health Care Professionals, Sage Publications, Newbury Park, CA. 1992. p.39-40.
^xix Betancourt, JR et al (2002) Cultural Competence in Health Care: Emerging Frameworks & Practical Approaches. The Commonwealth Fund.
^xx Ibid, Kavanagh et al. p.46.
^xxi American Academy of Communication and Healthcare. http://www.aachonline.org/
^xxii Frankel, RM; Stein, Getting the Most out of the Clinical Encounter: The Four Habits Model, The Permanente Journal, 1999;3(3) http://xnet.kp.org/permanentejournal/fall99pj/frhabits.htm.
^xxiii Oglesby, Paul, The Caring Physician: The Life of Dr. Francis W. Peabody, Harvard University Press, Cambridge, MA 1991. p. 220.

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.

In its’ document “Building Upon the Cornerstones”, the Mayo Clinic outlines four areas of focus in recommends as being key considerations in health care reform. These cornerstones ask that the system be transformed to 1) Create Value, such that patient health outcomes and satisfaction with U.S. health care would be improved, and medical errors, costs, and waste would be decreased; 2) Coordinate Care, such that patient care services would be coordinated across people, function, activities, location and time, increasing the value of health care service provision. To do so, the cornerstones suggest that patients must be active participants; 3) Reform the Payment System, such that providers are paid based on value, using a payment system that provides incentives for providers to coordinate care, improve care, and support informed patient decision-making; and 4) Provide Health Insurance for All, such that all individuals are given choice, control, and peace of mind. ^(7). If embraced, these four tenets have the potential to transform our existing health care system into one that embodies a high-value team approach to coordinated, patient-centered health care.

The reconstruction of our current health care system into one that provides this coordinated, patient-centered health care will require a multi-faceted approach. In a recent discussion on this topic in JAMA, Patrick Conway and Carolyn Clancy suggest that a transformation should include the development of patient-centered quality measures, a payment system that is pay-for-performance and strays away from volume or unit-based imbursement, health information technology tools that capture quality measures, on-going measures of efficacy that compare quality of care, and the establishment of quality improvement collaborative and learning networks. ^(2). In that same issue of JAMA, Kaveh Shojania and Wendy Levinson assert that academic medical centers begin to incorporate quality improvement into the research and education they provide, so as to create an environment where practitioners work together to provide a standard of care that is constantly improving and adapting to meet the needs of its patients. ^(8). Therefore, a high value, coordinated, patient-centered health care system will require is the development of a multidisciplinary team that works together to together provide and constantly re-evaluate the integrative health care that is served. It will redefine health care that is provided more so as a bundle or a whole, and less so a series of individual units of care, that is much greater than the sum of its individual parts. In short, it will require teamwork, the ability to use the talents and skills of providers of all disciplines to work together to address the health needs of our population, one that is often times facing chronic health issues.

A team approach will require the development of team building skills. While traditionally our healthcare system has focused on the “patient-physician team”, coordinated patient-centered health care includes a large array of health care professionals that include the nurse, pharmacist, nutritionist, physical and occupational therapists, physicians, and other providers as equal team members, with the patient at its center.  Together, these professionals would work not as separate units, but together as a collective whole, or a team. A process that embodies this concept of a team must be integrated into our health care education system. Currently, our system of medical education does not emphasize a team-building approach, even in its preclinical education arena. Most curriculums focus on individual growth and learning. Students are often busy trying to achieve the highest scores in an effort to later have competitive residency applications. However, it is imperative that tenets of team-building are incorporated early on in medical education. As Katharine Treadway, MD stated during a roundtable discussion for the New England Journal of Medicine, “it must begin on Day 1 of medical school and continue in residency training.” ⁽⁹⁾ This begins with the introduction of teamwork early on, and building on that concept throughout the four year curriculum.

So where do we begin? How can medical school curricula that are already overloaded integrate team-building into their programs? This starts with a simple concept: helping students understand that helping each other will ultimately help patients. To do this, schools can employ a wide variety of teaching techniques, such as simulator sessions, small-group learning, and pairing trainees with senior faculty. Other ideas include a clinical skills laboratory using a clinical instruction model with a bank of patient volunteers, standardized patients, and the use of a bank of patient videotapes.⁽¹²⁾ Given that many students are grade driven, these exercises should offer collective grades, where the greater the collaborative effort represented by all members of the team, the greater the grade is for each person in the team. This approach would help future physicians to see themselves as equals and peers, and seek ways to integrate each person’s strengths and talent-sets. It is a good place for many institutions to begin.

The further development of a team approach is one that extends far beyond the student physician base to include practitioners from all disciplines. Therefore, it is critical that medical and other health professionals intimately learn the details of other disciplines, and have opportunities to work collaboratively with them as a team. Exercises that bring together nursing, dental, physical and occupational therapists, social workers, nutritionists, pharmacists, and clergy are critical in developing a mutually-supportive and respectful environment in which students learn to work together as a team. ^(9). Many institutions host a variety of health professional programs on the same campus, creating a perfect opportunity for such team-building. By working collaboratively, instructors can provide routine opportunities for students from various programs work together on case studies and scenarios, where they are required to utilize each others’ toolsets.  This type of integrative training has already begun to be used in some residency training programs. For example, the Mercy Health System of Southeast Pennsylvania in Philadelphia described a system-based practice program it introduced to its first-year internal medical residents. The Residency Director developed a two week systems-based practice for first-year residents, where they had first-hand experience with delivery of health care in home care, hospice, pharmacy, laboratory, utilization, and nutritional services. The use of pre-and post-surveys showed that after the two week interval, residents reported deeper theoretical understanding and a greater knowledge of specific policies around these health services.^(10). A plan such as this one is a good first step towards a multi-disciplinary team model. Further exercises could be developed where residents work collaboratively with multiple disciplines on specific patient cases, where the team consists of a larger number of health professionals based on individual patient needs.

While the above study documents attempts made within some residency programs, as Katharine Treadway suggests, there is an imperative need to establish competencies within medical school programs that help establish collaborative, patient-centered health care. In 2001, the Department of Health Policy of Johns Hopkins University School of Medicine conducted two studies. In the first they randomly sampled U.S. physicians that see patients with chronic illness for at least 20 hours a week. The results were astounding. Of those surveyed, 61% felt that their medical training did not prepare them to develop team work with non-physician care providers. 63% of the physicians also felt that their training had not prepared them to educate patients with chronic conditions, coordinate in-home and community services, provide end-of-life care, manage geriatric syndromes, manage psychological and social aspects of chronic care, manage chronic pain, assess care-giver and family needs, provide nutritional advice, or develop team-work with non-physician care providers. Today, chronic care is a major cause of disability and use of health care services, totaling 80% of all health care expenditures. This study suggests that many physicians feel both insufficiently trained to address the complex aspects of chronic disease, and difficulty in developing the necessary multidisciplinary team needed to address those needs. Another study done by the same group surveyed 70 directors of required clerkships and courses of 16 US medical schools. In the survey, they asked the directors to rate the importance of 49 different skills or practices deemed relevant to the management of chronic disease. Only 29 of the 49 skills were rated as moderately important, and none were rated to be essential. ^(11,12) This suggests that in order to create a system of health care that can effectively treat and manage chronic disease, we must begin by teaching our medical students to develop the skills necessary to manage the complex needs of chronic disease, which includes the development of team-building skills across multiple medical and nonmedical disciplines.

The transformation of our health system into one that offers our patients care with a high value that meets the multifaceted and diverse needs will require efforts from every corner of our current system. Our government will need to work with various sectors of our health system to restructure our current payment and administration system. Current providers will need to work together to modify the current way care is administered. Most critically, future health providers have the exciting opportunity from the first day of their medical training to develop the ability to work and think collaboratively, to invite their colleagues from other disciplines and health professions to work together as a whole, creating a true multidisciplinary team. It is through the greater development of a collaborative team model that as a country, we can effectively shape a model of care that defines not as an individual unit of service rendered, but rather a host of various services that work together collectively. Through a multi-disciplinary team approach, we may better be equipped to attain better patient outcomes, greater patient and physician satisfaction and reduced health care costs.^(11). And ultimately, through a multi-disciplinary team approach, our health care system may be able to place at its’ center the most important component: the patient.

References:

1. Moody J. “Health Care Reform: The Debate Ahead”. The Journal of Nuclear Medicine. 36(4). 1995:22N,38N.
2. Conway PH, Clancy C. “Transformation of Health Care at the Front Line”. JAMA. 301(7) 2009:763-765.
3. “National Health Expenditure Data: NHE Fact Sheet”. Centers for Medicare and Medicaid Services.
4. Keehan S, Sisko A, Truffer C, Smith S, Cowan C, Poisal J, Clemens MK, and the National Health Expenditure Accounts Projections Team, “Health Spending Projections Through 2017: The Baby-Boom Generation Is Coming To Medicare”, Health Affairs.
5. “World Health Organization assesses the world’s health system“. Press Release WHO/44 21 June 2000.
6. Health system attainment and performance in all Member States, ranked by eight measures, estimates for 1997, World Health Organization. http://www.who.int/whr/2000/en/annex01_en.pdf. Accessed on March 16, 2009.
7. “Building Upon the Cornerstones”. Mayo Clinic Health Policy Center Power Point. http://www.mayoclinic.org/healthpolicycenter/pdfs/building-cornerstones-final.pdf. Accessed March 16, 2009.
8. Shojania KG, Levinson W. “Clinicians in Quality Improvement”. JAMA 301(7). 2009:766-8.
9. Bodenhaimer T, Starfield B, Treadway K, Goroll AH, Lee TH. “The Future of Primary Care- The Community Responds”. New England Journal of Medicine. 359:25. 2008. 2636-2639.
10. Eiser AR, Connaughton-Storey J. Experiential learning of systems-based practice: a hands-on experience for first-year medical residents. Academic Medicine. 83(10. 2008: 915-23.
11. Holman HR. “The inadequacy of medical education” Chronic Illness 5. 2009: 18-20.
12. Pols, RG. “Chronic condition self-management support: proposed competencies for medical students”. Chronic Illness. 5. 2009:7-14.

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.

I do not believe that there is any intrinsic quality of primary care that makes it less attractive to most individuals. The amount of graduating medical students pursuing careers in primary care were once relatively higher than they are now, but began decreasing along with the ever increasing amount of debt that medical students now face after graduation. For example, 49 % of medical school graduates in 1997 began pursuing careers in primary care, but this figure dropped to 39% in 2003.¹ Furthermore, 32 % of medical students graduating in 2002 said that their level of financial debt in part dictated their choice of specialty.¹ This finding is not especially surprising when one considers that the average indebtedness of medical students graduating from private medical schools in 2007 was $157,000, and it would be considerably easier paying off that debt making the $400,000 per year salary of an invasive cardiologist than the $146,000 per year salary of a family practice physician.^1,6 However, since the decrease in amount of new doctors pursuing primary care is largely due to the extrinsic financial factors, medical schools are particularly well-position to affect this trend. Medical school tuition, after all, has been increasing well above the inflation rate, particularly for public schools that have lost state funding.¹ Medical schools can decrease the average indebtedness of graduating medical students by both directly lowering tuition and also by decreasing the amount of time it takes to acquire the M.D. degree. These may sound like unlikely sweeping reforms, but there are several successful examples of these very changes that could serve as models for future reforms of medical education.

The Cleveland Clinic Lerner College of Medicine (CCLCM) of Case Western University, for example, offers a full scholarship covering tuition and fees for the entire class of 32 medical students each year.³ The goal is not to produce primary care physicians, but rather physician scientists that intend to pursue research-oriented careers. Still, the impetus for their decision to provide full-tuition scholarships to each and every student is relevant to the present discussion; only 2 % of medical students pursue research-oriented career, and there is a resultant shortage of physician scientists in the United States. Similar to primary care, fewer physicians engage in research because it is often less lucrative than clinical practice and therefore makes paying back years of student loans more difficult. The CCLCM program is intended to shore up this shortage by relieving would-be physician scientists of student debt, effectively making the question of debt and financial compensation a non-issue while simultaneously attracting top students to the program.³

There are certainly some major difference between encouraging students to pursue a career as a physician scientist and a primary care physician, the main distinction being that there is probably a far greater shortage of primary care physicians than physician scientists. The method for attracting physician scientists may therefore be unfeasible when applied to the primary care physician shortage. The funds for the CCLCM full-tuition scholarship come via existing endowment as well as the clinical operations of the associated Cleveland Clinic Foundation hospitals. Many medical schools, however, would likely find it too costly to simply provide a free medical education to cover the predicted shortage of primary care physicians, which is predicted to be about 40,000 by the year 2025.¹¹ Still, such programs directed specifically towards students that have a desire to practice primary care could definitely help lessen the severity of the shortage. Significant partial reductions in present tuition, as opposed to full tuition scholarships, would probably be effective in attracting more students. Harvard Medical School has adopted this approach by contributing more of their endowment toward financial assistance for medical students from middle class families, resulting in a $50,000 reduction in student debt by graduation.⁷ The Yale School of Medicine has recently adopted a similar financial aid program to help offset the debt to lower and middle class students.⁶ The explicit purpose of both of these financial aid programs is to relieve the pressure on medical students to pursue higher paying medical subspecialties in order to pay off debt, as well as to remove financial barriers confronting students from middle and lower income families that wish to pursue a career in medicine.^6-7 Overall, reducing debt upon graduation seems to be a fairly direct approach to counteracting the detrimental effect increasing educational costs seems to be having on medical students’ decisions to enter primary care and, as shown, seems to be within the means of at least some large universities.

The time it takes to become a physician, beginning as an undergraduate and extending through residency, also seems to be barrier to developing more primary care physicians. Not only does the extensive educational process often delay repaying student loans until after residency, each additional year of education also represents more student loans and more debt by the end of graduation from medical school. Removing such time barriers would not only attract more students but also speed the development of future primary care physicians. The reductions in time could take place at various stages in the entire educational process including the undergraduate years, medical school, and residency. The Northeastern Universities Colleges of Medicine and Pharmacy (NEOUCOM), for example, offers a combined B.S./M.D. degree that guarantees high school students a spot in the medical school program after completing their undergraduate education in an accelerated 2-year program.⁵ It is one of 17 such programs in the U.S. that allow its students to finish their undergraduate and medical education in only 6 or 7 years. The Lake Erie College of Osteopathic Medicine (LECOM), by contrast, created an accelerated M.D. program in 2006 that allows students to complete medical school itself in 3 years.⁴ It focuses on developing primary care physicians, and prospective students must be committed to a primary care career path; the admission process requires prospective students to write an essay attesting to their commitment to primary care, and each student’s guaranteed one-year tuition scholarship is dependent on the student remaining in a primary care field for 5 years after residency.  The time-saving occurs largely as a result of eliminating advanced surgical, emergency, and internal medicine electives and replacing them with rotations more relevant to primary care.⁴ Programs such as NEOUCOM and LECOM seem perfectly geared toward helping develop primary care physicians, either by removing financial barriers or by explicitly recruiting medical students for that purpose.

A valid question concerning accelerated medical school programs is whether the reduced timeframe compromises the graduates’ abilities as physicians. One study examining results from both the American Board of Internal Medicine and American Board of Family Medicine found that students who participated in a program that combined the fourth year of medical school with the first year of residency had scores similar to students completing traditional programs.⁴ The potential quality of focused, accelerated training is also evidenced in other areas of the medical world. The Shouldice Hernia Centre in Ontario, Canada is one of the best medical centers in the world for abdominal wall hernia repairs.^8,9 Compared to similar surgeries at other large medical centers, hernia repairs at Shouldice have better outcomes, lower incidences of recurrence, take about half the time, costs less, and allow patients to return to work earlier.^8,9 The interesting part of their practice is that many of their surgeons did not complete surgical residencies; rather, physicians from disparate backgrounds have come to Shouldice and completed about a year of training solely in repairing abdominal hernias using a specific procedure.⁹ The implication is perhaps that comprehensive, traditional medical training is not necessary if one knows precisely their destined area of medicine. Becoming competent in hernia repairs versus a competent primary care physician are two very different things, but the existing accelerated medical programs such as NEOUCOM and LECOM show that primary care physicians can be trained more quickly than they are currently in traditional medical school curriculums, and the development of similar programs at other schools may be able to attract more primary care physicians to the field and replenish the shortage.

Despite spending more per capita on health care than any country in the world, the World Health Organization (WHO) has ranked U.S health care system as only being 37^th in world in terms of overall performance.¹³ The relationship between cost and quality is shocking, but it does not reflect any shortcoming in medical science. Rather, the major problem underlying the U.S. health care system can be viewed as one of properly allocating resources to areas of care most needed by the U.S. populace, and it seems that a shortage of primary care physicians is at the heart of the issue.^10,12 It has been estimated, for example, that nearly 75% of the 2 trillion spend on medical care in the US per year is attributable to the care of chronic illness.¹⁴ Studies have shown that regions that rely on primary care physicians for the management of severe chronic illness have not only better quality care, but also  lower Medicare spending.² It is therefore problematic that an estimated 56 million Americans do not have access to a primary health care due to a shortage and misdistribution of primary care physicians.¹² Increasing the amount of primary care physicians has the potential to not only bring basic and preventative care to these millions of individuals, it can also reduce costs and improve quality of service in a health system that focuses too much money and investment in  specialty care and too little in prevention and chronic disease management. Reform of the medical education system can affect such an increase in primary care physicians, not by changing the face of medical education as we now know it, but rather by implementing tested and proven programs on a grander scale.

References

1. Morrison G. (2005). Mortgaging our future–the cost of medical education. The New England Journal Of Medicine, 352(2), 117.
2. Wennberg J, Fisher ES, Sharp SM, Bronner K, McAndrew M, Bubolz T, et al. (2006). The care of patient’s with severe chronic illness: An online report on the Medicare Program by the Dartmouth Atlas Project.
3. Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (2009). Accessed March 15, 2009, from http://www.clevelandclinic.org/cclcm/.
4. Bell HS, ., Ferretti SM, .,  & Ortoski RA, . (2007). A three-year accelerated medical school curriculum designed to encourage and facilitate primary care careers. Academic Medicine: Journal Of The Association Of American Medical Colleges, 82(9), 895.
5. Northeast Ohio Universities Colleges of Medicine and Pharmacy. (2009). Accessed March 15, 2009, from  http://www.neoucom.edu/audience/applicants/succeed/admi/admiinfocurrentHS
6. Yale University Office of Public Affairs. (2008). “Changes Mean Fewer Loans, More Scholarships for Yale Medical Students.” Retrieved March 15, 2009, from http://opa.yale.edu/news/article.aspx?id=1463
7. Colen, B.D. (2008, March 21). “Harvard Medical School to reduce student debt burden.” Harvard Science: Science and Engineering at Harvard University. Retrieved March 15, 2009 from http://www.harvardscience.harvard.edu/culture-society/articles/harvard-medical-school-reduce-student-debt-burden
8. Bendavid R. (1997). The Shouldice technique: a canon in hernia repair. Canadian Journal Of Surgery. Journal Canadien De Chirurgie, 40(3), 199.
9. Gawande, A. (2002). Complications: A Surgeon’s Notes on an Imperfect Science. New York: Picador.
10. Mayo Clinic Health Policy Center (2009). Building upon the cornerstones: Recommendations, action steps and strategies to advance health care reform. Retrieved March 7, 2009 from http://www.mayoclinic.org/healthpolicycenter/pdfs/building-cornerstones-final.pdf
11. Colwill JM, ., Cultice JM, .,  & Kruse RL, . (2008). Will generalist physician supply meet demands of an increasing and aging population? Health Affairs (Project Hope), 27(3), w232.
12. Cross M. (2007). What the primary care physician shortage means for health plans. Managed Care (Langhorne, Pa.), 16(6), 24.
13. World Health Organization assess the world’s health system. Press Release WHO/44 21 June 2000.
14. Center for Disease Control and Prevention (2009). Chronic Disease Overview. Accesses March 13, 2009 from http://www.cdc.gov/NCCdphp/overview.htm.

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.

Health professionals now bear the responsibility of direct involvement in the development and incorporation of quality measurement tools into practice to improve patient outcomes. QI concepts are often overlooked as a component of professional medical education. Therefore, to improve health outcomes, there is an imminent need to transform the way quality is taught to healthcare students in the United States. Furthermore, Blumenthal (1996) articulates in a New England Journal of Medicine essay that political and economic groups will call the expertise of physicians into question until the physicians can truly lead the industry in QI. All members of the healthcare team must thoroughly understand the state of the science of QI activities and adopt evidenced-based practice as the standard of care. Furthermore, healthcare professionals must play an active role in the implementation of quality management practices.

Sustained quality in the healthcare system will not be possible until properly formulated interdisciplinary teams openly communicate and work together. Learning how to work in a team is not part of the curriculum in medical and nursing schools. As a result, many graduates are not taught how to foster teamwork, communication, co-operation and leadership (Kyrkjebo, Brattebo, & Smith-Strom, 2006). Until clinicians are taught these skills, they will not be able to participate in, much less lead, QI teams. The siloed approach to medical education is problematic for many reasons, but most notably because round table discussion and open communication should be the basis of healthcare professional education. Interdisciplinary communication that is required in QI should be introduced early in clinical education; this will build a solid framework of the underlying principles of teamwork and communication from which quality and patient safety can be improved (Silver, 2000).

Challenges

In the past, quality improvement (QI) and patient safety (PS) lessons have received only ‘honorary’ mention in medical and nursing education. The reasons for this practice were two fold: 1) it was assumed that by learning the medical knowledge and developing excellent clinical skills, young professionals would automatically deliver the highest quality and safest care, and 2) the science of QI and PS had been rather ill-defined. Today, it is apparent that the former assumption was false, given that expert clinicians do not always obtain expert results. Also, the science of QI and PS are now better understood. Nevertheless, proposals to implement these changes into the educational pathways continue to face numerous challenges, including practical limitations of an already full curriculum, unfamiliarity with or resistance to interdisciplinary learning, and cultural challenges of executing QI and PS principles in the live hospital environment.

Medical students are expected to learn more information now than at any point in the history of medical education (Institute of Medicine, 2003). Furthermore, in the last decade, the Liaison Committee on Medical Education (LCME) has imposed new curricula on medical schools, such as ED-10, that require teaching of communication and other “soft skills” (Liaison Committee, 2009). Simultaneously, many medical schools are reducing the length of their preclinical training in order to accommodate more research or elective experiences. Top ranked schools like Duke University, the University of Pennsylvania, and Stanford University follow condensed preclinical curriculum, completing all traditional coursework and the new LCME requirements in about 11 to 18 months. The curriculum crunch is not unique to medical schools; in recent years, the number of accelerated Bachelor of Science in nursing programs in the United States has increased by more than 600% (American Association of Colleges of Nursing, 2007).

Despite the aforementioned limitations, the application of QI and PS principles in daily medical practice must become a distinct part of the health professions’ required core curricula. Some have suggested that while the volume of factual information covered in undergraduate medical education is indeed burdensome, much of it is only marginally relevant to clinical practice and perhaps can be culled to make room for more clinically-relevant subjects such as QI and PS (D’Eon, Kosmas, & MacMillan, 2007).  Quality and safety are not electives.

For too long, siloed educational programs have prepared health professionals to enter a siloed healthcare system (Institute of Medicine, 2003). However, the status-quo of the latter is slowly changing, and the formation of evidence-based highly functioning, patient-centered, collaborative “care teams” is contingent on collaborative efforts early on in training (Schall, Sevin, & Wasson, 2009). Despite some promising endeavors, interprofessional medical education is neither universally accepted nor widely implemented in a substantive manner (Mayer, Klamen, Gunderson, & Barach, 2009).

Coordinating interprofessional educational opportunities can be an operational nightmare, compounding the curriculum limitations mentioned previously. Overcoming these difficulties will require cultural buy-in – learning about QI and PS is as important as learning about the Kreb Cycle or differential diagnosis. The basic science professors must see themselves as true stakeholders in the QI and PS education process and believe in it – a difficult task because they seldom have the opportunity to experience the workflow of clinical care. Curriculum should address this deficiency. Designing new assessment paradigms for these interdisciplinary courses will also require time and financial resources (Mayer, Klamen, Gunderson, & Barach, 2009).

The practice of QI and PS principles in everyday clinical workflow remains a formidable challenge due to cultural resistance and workload.  It is not the case that people do not want to do an excellent job; rather it is because they lack skills to overcome systemic barriers that prevent them from doing an excellent job. Fear of ‘blame’ remains a significant impediment to reporting near misses and having open fruitful discussions (Institute of Medicine, 2001).  Therefore, the curriculum should have provisions to include the practice of these principles during clinical clerkships.  Medicine remains a hierarchical profession whereby students might be easily swayed by a preceptor or supervisor who does not recognize the importance of quality or patient safety. Students must be empowered to practice safe, quality medical care in systems lacking a culture of quality and safety. This can be achieved through early practical application of newly acquired knowledge in an interprofessional environment.

Specific Aims

Aim 1: To identify an approach to interprofessional education of healthcare quality and patient safety.

Hypothesis: An interprofessional approach to educating health professions students on quality and patient safety will lead to positive effects on the healthcare system.

Aim 2: To identify a mechanism to integrate quality and safety into health professions education to achieve educational reform.

Hypothesis: Integrating quality and patient safety into health professions education will lead to better population health management and inclusion of the patient as a member of the team.

Vision for the Future

Our vision for the future includes an integrated curricular approach to healthcare professions education that prepares students to create and participate in a healthcare delivery system that facilitates a team-based approach and engages patients in the care delivery process. In an effort to meet this need, we propose a 26-week interprofessional course, Quality and Safety-Foundations and Applications, integrating didactic education, team-based case reviews, and practical real world assignments. The health professions students of today are the healthcare leaders of tomorrow. Engaging them in conversations about quality and patient safety now will drive improvement in the future. The course will provide an overview of QI and PS, basic tools to measure and analyze, and information about the organization of the healthcare system. Small group discussions about assigned cases will supplement the didactic lectures. A mix of students from different disciplines, such as medicine, nursing, pharmacy, administration and allied health will comprise the small groups. The goal of this exercise will be to improve communication and encourage students to view the healthcare system through each discipline’s lens. Each group will submit a weekly report identifying the case’s errors and system breakdowns and offer recommendations for corrective action.

Quality and Safety-Foundations and Applications is designed to be completed over two terms. A commonly cited challenge to integrating quality and safety education into health professions curricula is finding the time. While this course would be mandatory for all health professions students, when it is taken will depend on the discipline. The first 13 weeks and the second 13 weeks do not need to be taken in succession. The second half of the course is designed to be completed during the student’s residency, internship or other experiential component of training. Three modules will expand on information presented during the first 13 weeks of the course. Each module will be followed by a web-based discussion facilitated by an expert in the field. The students will be challenged to reflect on their thoughts during the first 13 weeks of the course and how their thinking has changed as a result of their experiences in training. In week 26, the students will engage in a conversation about the healthcare system of the future based on their experiences. Comparisons will be made to the commentary of the students during the first 13 weeks of the course. Medical students, nursing students, and pharmacy students will be encouraged to share their clinical experiences and QI suggestions. Public health and health administration students may suggest areas for process improvement. The students will be expected to reflect on their experience and how the course has helped them understand the importance of interprofessional collaboration to deliver safe, quality healthcare.

Despite the challenges associated with health education reform, a growing number of students recognize the importance of learning QI and PS in an interprofessional environment and believe that shared learning activities will lead to better working relationships (Horsburgh, Lamdin, & Williamson, 2001). Students are seeking programs like the IHI Open School for Health Professions to learn about healthcare improvement in an interprofessional educational community. Through this program, students from around the globe are collaborating and looking at the healthcare system through multiple lenses.

Our [the authors] collaboration on this essay is a direct reflection of the power of organizations such as the IHI to bring students together. While we may live in different states across the country, and study different disciplines, we shared our opinions and experiences, and then collaborated to define our vision for the future. It is the collective teamwork of a group of interdisciplinary health professionals that will help us decrease inefficiencies and better manage the health of populations leading to better management of chronic conditions and outcomes of care.

APPENDIX A:

Sample Syllabus
Course Name:        Quality and Safety-Foundations and Applications
Course Instructor:    Dr. Qualitysafetyguru
Hours per week:    1.5 hours
Term:             Fall semester supplemented by modules
Credit:            Three semester credit hours.
Prerequisites:        There are no prerequisites for this course.
Objectives/Goals:    To provide students with an understanding of defining and measuring healthcare quality and patient safety, the importance of a team-based approach and the need to include the patient in the care team.
Text:    Course materials will be provided. Supplemental texts will be recommended for reference.
Grading:
Weeks 1-13    Case studies (weekly assignment)      – 30%
Team Presentation            – 20%
Class participation and attendance    – 5%
Weeks 14-26:    Web discussions            – 15%
Final discussion            – 30%

References

American Association of Colleges of Nursing. (2008). Accelerated programs: The fast-track to careers in nursing. AACN Issue Bulletin. Retrieved March 11, 2009, from www.aacn.nche.edu/Publications/issues/Aug02.htm .

Blumenthal, D. (1996). Part 1: Quality of care. What is it? New England Journal of Medicine, 335, 891-894.
D’Eon, M., Kosmas, C., & MacMillan, J. (2007). Teaching syndromes: A response to learning syndromes. Medical Teacher, 29, 280-281. Retrieved March 11, 2009, from http://www.informaworld.com/smpp/content~content=a781268408~db=all~jumptype=ref_internal~fromvnxs=v29n2s46~fromtitle=713438241~cons=768375889.

Horsburgh, M., Lamdin, R., & Williamson, E. (2001). Multiprofessional learning: The     attitudes of medical, nursing and pharmacy students to shared learning. Medical Education, 35, 876-883.

Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press.

Kohn, L.T., Corrigan, J.M., & Donalson, M.S. (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.

Kyrkjebo, J. M., Brattebo, G., & Smith-Strom, H. (2006). Improving patient safety by using inter-professional simulation training in health professional education. Journal of Interprofessional Care, 20(5), 507-516

Mayer, D., Klamen, D. L., Gunderson, A., & Barach, P. (2009). Designing a patient safety undergraduate medical curriculum: The Telluride Interdisciplinary roundtable experience. Teach Learn Medicine, 21(1), 52-8.

Schall, M., Sevin, N.P., Wasson, J.H. (2009). Transforming Care Teams to Provide the Best Possible Patient-Centered, Collaborative Care.     Journal of Ambulatory Care Manage 32(1), 24-31.

Silver M. P., &  Antonow, J. A. (2000). Reducing medication errors in hospitals: A peer     review organization collaboration. Joint Commission Journal Quality     Improvement, 26, 332-340.

Liaison Committee on Medical Education. (2009). Standard ED–10. The curriculum must include behavioral and socioeconomic subjects, in addition to basic science and clinical disciplines. Retrieved March 11, 2009, from http://www.lcme.org.

The Commonwealth Fund Commission on a High Performance Health System (2008). Why not the best?: Results from the national scorecard on U.S. health system performance. New York, NY: The Commonwealth Fund. Retrieved August 11, 2008, from http://www.commonwealthfund.org/usr_doc/Why_Not_the_Best_national_scorecard_2008.pdf?section=4039.

Wakefield, M.K. (2008). The quality chasm series: Implications for nursing. In Hughes,     R.G. (Eds.), Patient Safety and Quality: An Evidenced-Based Handbook of      Nurses (2-35-    2-40). Rockville, MD: Agency for Healthcare Research and     Quality.

Acknowledgement

We would like to acknowledge John Chuo, MD, MS, Children’s Hospital of Philadelphia and Rod W. Hicks, PhD, RN, FNP-BC, FAANP, UMC Health System for their assistance with editing this essay.

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.

As a profession, it is critical that we re-establish the central role of primary care and affirm the value of a team-based approach.  The need for reform is evident both locally and nationally.  Currently, 97% of Louisiana parishes have areas classified as Primary Care Health Professional Shortage Areas (HPSAs)¹.  Nationally, nonmetropolitan areas, which include more rural areas, have substantially fewer primary care physicians per 100,000 people (55 per 100,000 vs. 93 per 100,000 in metropolitan areas)².  This shortage correlates with the low numbers of US medical school graduates choosing residency in primary care fields (an average of 8.4% of US medical school graduates chose Family Medicine for residency from 2005-2007)³.  Ultimately, the way to help meet the health care needs of this nation is to increase the number of primary care physicians.  We believe this should start at the medical education level, where we must engage students in meaningful community health initiatives and teach them the fundamental principles of primary care.

The reform of medical education has been the topic of numerous reports and forums^4,5,6 in recent years,  and multiple groups have been proponents of a diversification of the curriculum7,8, especially in the “pre-clinical” years.  It is now generally understood that the solution to improving medical education is a multi-faceted one, and begins with the incorporation of more social and political aspects of health care delivery into the medical school curriculum.  Crucial to the patient-centered approach is the recognition by the physician-in-training that the patient exists within a dynamic environment and that his/her determinants of health not only include genetic or biologic factors, but are also profoundly influenced by his/her familial relationships, socioeconomic status, level of education, and access to resources.  The growth from a primary care foundation begins with the very definition of “primary care” ― its inclusion of disease prevention, health promotion and maintenance, counseling, and patient education, all in addition to the diagnosis and treatment of illness.  We propose that teaching medical students to consider the patient as a whole must involve the pursuit of a longitudinal community health project, not unlike JumpStart Pierre Part, by each student in the course of his/her time in medical school.

In recent years, many medical schools have begun to shorten traditional didactic lecture-time for students, relying instead on small-group discussion, self-instruction, laboratories, and case-studies.  In addition, medical students have been increasingly offered more exposure to essential topics such as the doctor/patient relationship, medical ethics, nutrition, and population health9.  We propose formalization of these topics within the curriculum― changing their current “auxiliary” or “selective” status to “requirement” status.  To gain experience in clinical skills, students would shadow clinical nurses and EMTs, practice in a simulation laboratory, learn the relevance of computers in medicine from experts in medical technology, and compare firsthand how rural and urban health care settings deal with the difference in available resources.  As prevention plays a critical role in all disease states, students would have the opportunity to visit the local or state department of health, learn from a partnering dentist, teach a lesson at a high school or school clinic, and attend community-based health and wellness classes.  All students would gain exposure to the local Women, Infants and Children (WIC) and Planned Parenthood offices.  Another essential piece of medical education is to learn how physicians serve as advocates and influence policy change.  To acquire some of these vital skills, students would meet with a hospital CEO, a community health center or federally-qualified health center CEO, and health professionals serving as lobbyists.  Students would also be introduced to and have the opportunity to work with individuals who advocate for patients every day, including social workers and hospital case managers.  Exposure to medical-legal partnerships, and medical-business partnerships would help students better understand the issues surrounding malpractice and public versus private medical insurance.  Students would gain an appreciation of the basic sciences and research by spending time on the laboratory bench and would see the direct application of such work in pharmaceutical development.  In order to emphasize the role of public health in medicine, students could work with a state epidemiologist, meet with a global health specialist, and see patients at a local homeless shelter or prison.  We believe that each of these opportunities is pivotal in cultivating a well-rounded, patient-centered health care workforce in which physicians not only appreciate all the determinants of health, but are able to apply the lessons learned from each of these interactions to their future practice of medicine.

Although much time and consideration have been given to updating medical school education so that it more accurately prepares students for the current practice of medicine10, many institutions are finding it hard to achieve true change due to a variety of barriers: lack of staff to teach or funding to implement the newly designed courses, time constraints and problems with scheduling, and an overall resistance to change11.  We believe that the best way for students to internalize knowledge about the determinants of health learned in the pre-clinical years is for each student to embark on a longitudinal project over the course of their third and fourth years of medical school.  The student would first establish a potential area of interest within the medical profession.  The next step would involve the identification of a need within the specified field of interest.  Then, the student would begin to formulate an approach to solving the problem or meeting that need.  Students would receive mentorship from a practicing physician in the community.  The basis for the longitudinal project can be found in the following belief: each medical student should make a meaningful contribution to his/her field of interest in hopes of not only gaining valuable experience in that field, but also developing a better understanding of how all the components of the health care system are intertwined and interact with one another.

Figure 1.  Medical Education Model

As a representation of our curricular redesign, we have aligned our medical education model with the sprout of a great oak tree, common to the streets of New Orleans.  The soil, providing life and support to the nascent sprout, is composed of the foundation of the first two years of medical education: an appreciation and understanding of primary care and community health.  Also in this early stage of development, each physician-in-training would be exposed to the essential principles of basic sciences and research, clinical skills, prevention, advocacy, policy, and public health.  By the end of the first two years, students would have a strong foundation from which they could start to pursue their specific field of medicine.  Over the course of the next two years, students would begin to grow into a more mature tree, with their specific interests driving the choice of a hands-on project that offers the opportunity to apply the acquired knowledge and skills from the first and second years, as well as contribute to their potential field of study.  Ultimately, the student would develop into a grand oak, with the ability to matriculate into the specialty of their choice and hone in on the areas most relevant to their future careers, but with the understanding that the patient exists at the center of a dynamic environment.  This model would not only encourage more medical graduates to pursue a career in primary care, but would also propagate a new generation of physicians who are able to treat the patient as a whole instead of simply treating the disease at hand.

Although there are many variables that influence a medical student’s career choice, one of the most important changes that can be made in medical education to promote primary care specialties is to present the field as a central tenet of medicine, one that is very highly respected and valued.  By redesigning the curriculum so that primary care and community health are at the core and such that students are exposed early on to mentors in primary care disciplines, we believe that more people will maintain their original interests in primary care upon entering medical school as well as be drawn to the profession due to its emphasis in their training.

It is said that an oak tree can live for over one thousand years.  In order for the tree to survive, however, it must have its roots planted in a solid foundation and be able to withstand the ever-changing environment.  Similarly, in order for our profession to continue to evolve over time, we must begin our education with a foundation grounded in primary care and community health, encouraging students to not only treat the patient’s disease but to consider every determinant of health.  JumpStart Pierre Part was a success because we were able to apply and incorporate what would normally occur in one doctor’s visit into all aspects of the patient’s life.  Success came in the realization that in order for one patient to change his/her eating habits, we needed to do more than tell him/her so in our fifteen-minute clinic visit.  Beyond this interaction, we had to consider the patient’s shopping habits, family dynamics, and physical environment.  In learning to appreciate all of the influences on a patient’s health through JumpStart, we accomplished more in medical school than we could have ever imagined.  Each of the six medical students who were originally involved has chosen a career path in primary care, and JumpStart continues to inspire future primary care physicians.

In summary, we believe that medical education requires an entire paradigm shift, transferring the focus from the current disease-based model to a new foundation based on primary care and the ability to advocate for a patient and his/her community.  In this way, we will create a professional work force that understands that medical knowledge is only the first step in truly treating their patients.  By engaging in a longitudinal, community-based project, the future generation of physicians-in-training would not only be challenged to work as a team and think critically, but they would also see firsthand that physicians have incredible power outside of the clinic and hospital to effect change at the individual patient level, the community level and the policy level.

References:

1. Morgan, K.O. and Morgan, S. (Eds.) Health Care State Rankings 2003: Health Care in the 50 United States. (11th Ed.) Lawrence, KS.
2. Steinwald, AB. Primary Care Professionals. Recent Supply Trends, Projections, and Valuation of Services. Government Accountability Office Report, Feb. 12, 2008.
3. McGaha, AL, Schmittling, GT, DeVilbiss, AD, Pugno, PA. Entry of US Medical School Graduates Into Family Medicine Residencies: 2007–2008 and 3-year Summary.  Family Medicine 2008;40(8):551-62.
4.  Health Professions Education: A Bridge to Quality.  Institute of Medicine, 2003.
5.  Training Tomorrow’s Doctors: The Medical Education Mission of Academic Health Centers.  A Report of The Commonwealth Fund Task Force on Academic Health Centers.  April, 2002.
6.  Educating Doctors to Provide High Quality Care: A Vision for Medical Education in the United States.  Report of the Ad Hoc Committee of Deans, July 2004.
7. Whitcomb, ME. The general professional education of the physician: is four years enough time? Academic Medicine 2002;77:845-46.
8. Hoover, EL. A century after Flexner: the need for reform in medical education from college and medical school through residency training. Journal of the National Medical Association 2005. September 97(9):1232-9.
9. “The Medical Student Education Program.” 2009.  AAMC Curriculum Directory. 8 March 2009. <http://services.aamc.org/currdir/about.cfm>
10. “U.S. Medical Schools Teaching Selected Topics 2008 LCME Part II Annual Medical School Questionnaire” Hot Topics in Medical Education. 2008. AAMC Curriculum Directory. 8 March 2009. <http://services.aamc.org/currdir/section2/04_05hottopics.pdf>
11. Educating Medical Students: Assessing Change in Medical Education. The Road to Implementation. ACME-TRI Report.  1992.

Supplemental Figure 1: JumpStart Pierre Part photo journal. (a) Claire Fung (MS4) & Dr. Sherlyn Bell Larrison conducting a cooking/nutrition class on Fiber at the local library. (b) Green-Light Foods display at the Pierre Part Store. (c) Katie Hall (MS4) giving a lesson to students of Pierre Part Elementary for February’s “Healthy Hearts” challenge. (d) JumpStart Program Coordinator and Bayou Journal columnist, Linda Cooke, planting seeds in the school garden. (e) Randi Sokol (MS4) teaching kids “Healthy Habits”. (f) Jessica Schumer (MS4) introduces “Eat a Rainbow”-week. (g) Staff at the Larrison Family Health Center all dressed up for JumpStart team spirit! (h) Without any input from the JumpStart initiative, students at Pierre Part Elementary decided on a Healthy Food theme to this year’s Mardi Gras parade.

Supplemental Figure 2. The JumpStart Pierre Part Model