Wednesday Breakout Question
A century ago, “health care reform” encompassed such concepts as 1) the medical school organized around scientific research, and 2) the teaching hospital as the site of physician education. One can argue that these innovations came at a price – the development of an “elitist” culture in medical schools that favored specialization and technology, and a resulting in inattention to health promotion, general practice, and the cultural aspects of health care.
What role should “community-based medical education” play in an ideal, American health care system? (Give examples from your own experience that you believe should be replicated elsewhere.) What incentives could be developed to increase its impact on that system?
Breakout Group 1
Clasen, Leader; Boltri, Scribe; Cobb, Haughton, Kimball and Troy
Breakout Group 1 Scribe Notes”
Tape Marc Babitz – he has the best answer
Examples: RPAP Program in Minnesota: student spends nine months in 3rd year
Program shows Flexnerian model is not necessary. Better board scores; better able to deal with complex patients.
Teaching hospitals do not routinely provide experiential teaching for many aspects of skills of community care for primary care.
Example: Longitudinal outpatient curriculum.
Instead of two weeks or one month block, rotation residents do three months rotations
Day of Week M Tu W Th F
Cardiology X X
Neurology X X
Provides: 1) longitudinal experience
2) more continuity
3) develop relationships with preceptors and patients
4) learn referrals better
1) has a psychiatry advice line
2) family doc can call the psychiatrist to get immediate advice over phone on how to care for outpatients
3) both docs (family doc and psychiatrist) can bill for the call
4) saves consult, allows for immediate care of patient.
1) you do not have to do community-based education at the cost of other things
2) it’s a matter of building the system
3) shifting dollars from one system to the other
1) everyone should contribute to training of doctors
2) everybody wants the product but nobody wants to pay for it.
3) In many countries medical education is much more subsidized.
Submitted by John Boltri, Breakout Group 1 Scribe
Breakout Group 2
L. Burnett, Leader; Murray, Scribe; Christman, Clover, Flinders and Jafri
Breakout Group 2 Scribe Notes:
1) group agreed there is a big difference hospital and ambulatory experience and focus for education.
2) Believe outpatient education and teaching in “harder” than inpatient
We all agreed that community-based education should be the ceterpiece. We feel it is not so currently secondary to history and money. The curriculum should be driven by community health needs.
We hope that the Primary Care Medical Home (PCMH) development will help in ambulatory education and believe there should be increased use of decentralized education tools/methods (on line, computer-based modules, telemedicine and televideo consults, etc.)
There is need to explore more non-hospital sponsorship of residencies.
The incentives were difficult to define. Suggestions:
1) change reimbursement/incentives for outpatient care
2) need “closed system” like national health plan to operationalize #1 effectively.
Submitted by Kevin Murray, Breakout Group 2 Scribe
Breakout Group 3
Bejinez-Eastman, Leader; North, Scribe; Flores, Freeman, Kasovac and Lee
Breakout Group 3 Scribe Notes:
Calgary Canada has model adopted by A. T. Still University School of Osteopathic Medicine in Mesa.
Partners with CHCs are all over the country (in 9 states). Classroom at each site
1700 adjunct faculty or preceptors
Use communitiy based health ?___ts? and advocacy groups as learning sites for students, residents
D__s?/races/first aid stations
Community centers (after school with elder groups)
Patient’s homes (home visits)
Bring in community-based organizations to teach students
Provide support for students who want to work in communities
Use health science center allied health professional students to team with students/residents to work on community projects
Regulatory t?___Ss? to funding, accreditation and watch resident specialty increases under concomitatnt increase in primary care residency slots
Required rotational service
Loan repayment programs for work in primary care and communities
State, NHSC, HIS, medical school based
Submitted by Charles North, Breakout Group 3 Scribe
Breakout Group 4
Fowkes, Leader; Henderson, Scribe; Maudlin, McCanne and McKennett,
Breakout Group 4 Scribe Notes:
AHECs are a success model for community education partnerships
Varies widely by state/community
Helping communities to do healthcare needs assessments
Doing more training in CB non-hospital settings is constrained by ACGME requirements, but new 2013 ACGME requirements will help to change that
Concern: More CB training tends to isolate trainee from other colleagues and core faculty
WWAMI – great model
Issue: How to “engage” community effectively in terms of supporting/sponsoring a student
How to “engage” trainees effectively in the “community” experience
Finite number of community teaching sites for all the different health professions
Many sites are feeling overwhelmed
Paying “preceptors” leads to a good incentive, but schools =dpn’t have the dollars
Paying “preceptors” leads to inconsistent.
In some cases, also the “students” and need to make sure quality of experience is present
Need to expand resources/use more resources more efficiently_
+AHECs, CHCs, private practices, NHSC, community colleges
+ Funding fmore community sponsors
Submitted by Tim Henderson, Breakout Group 5 Scribe
Breakout Group 5
Hines, Leader; Coleman, Scribe; W.H. Burnett, Erickson, Frey and Hara,
Breakout Group 5 Scribe Notes:
An impetus to change from the teaching hospital towards better primary care came from the military in World War II, which was surprised at the physical and mental condition of many of its recruits.
There has been an evolution from a need for infectious disease treatment appropriately in a hospital setting to a community-based model where the focus is on chronic diseases and preconditions, which matches societal needs.
Kaiser is increasing the number of family medicine residencies
Dr Jack Geiger imported the idea of the community center from South Africa.
There is a need to structure undergraduate medical education to attract students into primary care.
It might make sense for there to be two types of medical school and not insist that all medical schools be research-based, but students may not buy into different models of medical schools.
Professional turf seems to get in the way, even with natural alliances. Power and prestige affect decision making. A focus on outcomes might break down barriers.
A reduction in family physicians causes family physicians to refer more, creating an exaggerated need for specialists.
If medical students knows that the revenue streams of some specialties is high with fewer hours than other specialties, everyone else does too.
A study of the referral patterns of family medicine residencies demonstrated that the referral specialists’ acceptance of the ability of a family physician to care for a patient is related to the prospects for reimbursement for that patient.
We can’t let people with a vested interesting in a field determine payment and need.
If we could pay family doctors 70% of specialty salaries, the shortage of family doctors would dissipate.
Submitted by Mary Coleman, Breakout Group 5 Scribe
Breakout Group 6
LeRoy, Leader; Ross, Scribe; Fernandez, Hansen and Peck
Breakout Group 6 Scribe Notes:
“Back to Flexner”
Elitist medical education devalued preventive community/longitudinal care
Increase 3rd and 4th year exposure outside the university
In Pharm D, move the education to community pharmacy.
Artificial experience in large university
Need to haul rigourous training outside university settings
UW example of inconsistency – vertically oriented schools that have a number of families assigned to follow through med school
More PBL like McMaster where vertical integration is paramount as ___? Horizontal , i.e., traditional medical school.
Do not want to go back to the Apprenticeship model
Many institutions want to or are considering shutting residencies
They are no longer cheap labor and are being replaced by NPs/PA/hospitalists
Studies show that non-continuity is more dangerous.
House of medicine has been “raided “ by outside entities that destroy our professionalism
Little personal motivation to become a “doctor” if professional students want a job and work for a large corporation.
Students need to be exposed to practice and professionalism outside of “systems” and large tertiary care centers that devalue professionalism, personal care
Medical education has become a “sideline” in medical schools.
Models from Flordia: FSU Tallahassee virtual campus. Multiple site hospitals with Regional Associate Dean appointed. Florida Int. University Student Clerkships that follow patients throughout hospitalization/care path. Gives individual patient continuity but scarifices “service” continuity.
More investmentin PD____ and web technology. Standardized central education through web/_Problem Based Learning/“Blended learning”
Submitted by Rob Ross, Breakout Group 6 Scribe
Breakout Group 7
Prislin, Leader; Babitz, Scribe; Garcia-Shelton, Smith and Sundwall
Breakout Group 7 scribe notes:
MSU example (Dr. Smith) – Dean directed new training method, specifically chose Dept. chairs to support mission, established community based training sites with their own Deans, very primary care oriented, support from other Chairs (e.g. surgery). Model alive and well, but some movement back to main center (recently only 30/200 entering primary care).
How could MSU’s program be re-engineered? Current Dean tried to remove Primary care from mission statement. System dependent on Dean. Pioneering dean introduced problem based learning and other innovations. MAFP supported line item funding for primary care, but later Dean was able to remove that. MAFP had become less involved in legislative process.
Natural trajectory of social movements: energy, innovation, change, success, protection of success, resist change, subject to next “wave” of change.
Important issue of who gets into medical school. Many potential students no longer consider medicine as a career. Even interested students may change interests during medical school. Medical school classes becoming more homogeneous; similar backgrounds, majors, etc. All do community service, research.
Primary care mentors can be sub-specialists. There are “caring” sub-specialists.
Book “Genius on the Edge, the strange life of William Halstead.” Johns Hopkins professor.
Mentorship issue: primary care, practicing family docs (harder to find, less willing to take the time). Influence of sub-specialists on students, some support, many “bash.”
Role of Humanities in medical school education. Being diminished or eliminated.
UC Irvine – task force to look at putting “humanities-type” courses into medical school. Having a “town meeting” to look at this option. School generally removing those types of courses in favor of classes that lead to success on Boards.
Is there evidence that “humanities” classes make a difference? Not enough exposure to really test. Evidence that Problem based learning exposure does change the way students learn to approach problems.
History of creation of UC Irvine, primary care mission? +/- MSU founded and funded to produce primary care physicians, and had initial leadership to support that. Had curriculum with early patient contact, discussions about families, home visits, etc.
U of UT experience: VP built research legacy and clinical empire with minimal interest in medical school. Cut medical school class size by 20%. Touts rank as #1 Academic Hospital in US.
Unintended consequences of Flexnerian reform: role of medical school faculty, role of research funding, role of faculty practice, have diminished emphasis on teaching and on primary care.
Need to separate line item funding for education. Currently not explicit or transparent. Need to have faculty to write grants to get indirect dollars. Can’t afford to use funded FTEs to teach. Teachers are on soft money (clinical practice).
Student concern/focus on topics that will be on Board exams. Students want what they want which may not be what they need.
How to address increasing demand for primary care? By mid-levels? Must change economics/payment reform to make a difference. Sub-specialists use mid-levels (have economic motivation). Primary care will survive as “team leaders” managing a team that provides services. Majority of mid-levels doing sub-specialty care.
Submitted by Marc Babitz, Breakout Group 7 scribe.