Reporting
from the 2002 AAMC Annual Meeting
Session Reviews from the AAMC Annual
Meeting: Improving the Nation‘s
Health
November 8-13, 2002, San Francisco
Reports from the following sessions:
Thanks to the following for contributing reports:
- Linda Heun, Ph.D.
- Mary P. Hoy, Ph.D.
“Consumer Driven Health Care: What
is it and What are the Implications for Academic Medicine?” November
11, 2002
Mark Smith, MD,
PhD
President & CEO
California Healthcare Foundation
Consumerism is the new managed care. It’s about money. Consumerism
is the newest answer to the question of how we will control the cost of health
care.
Historically, unmanaged health care was when you went anywhere you
wanted for care, doctors did whatever they wanted, and charged whatever
they wanted. Managed care was an attempt to change one or more of these
three features. And yet managed care doesn’t really significantly
control any of the following causes of high health care costs?
- Technology, devices, procedures
- Regulation and litigation
- Earning expectations of highly paid professionals
- Societal expectations for inpatient care
- Broadening social definition of what we consider health
care
Smith’s working definition of consumerism is:
- People will pay more out of their pocket for health care,
- there will be a greater relationship between what they
pay and what they get, and
- greater attention to quality.
Currently, he said patients are actually paying less and less out of their
pockets. Costs aren’t transparent and most of us don’t know how
costs compare from one hospital to another. This is about to change.
Starting next year Congress has called for national report card for health
care that will focus on how safe, equitable, effective, timely, efficient,
and patient-centered it is. They have discovered that patients’ definition
of quality isn’t about whether doctors can do their trade, patients expect
that. Patients focus on the quality of their experience. They hold health care
providers responsible for quality care and the quality of their experience.
21st century consumers will be different. They will be price conscious and
informed. Health care facilities will have to be flat, lean, responsive,
and customized with costs transparent. Services will be arranged for the
convenience of the consumer. For the bread and butter health care items,
like gall bladder surgery, there will be price comparisons. And because people
will be paying more out of their pocket, they will expect quality. The winners
in the new health care relationships will be health care givers that are
responsive to consumer demands.
Reported by:
Linda Heun, Ph.D. <meded@aacom.org>
Vice President for Medical Education
American Association of Colleges of Osteopathic Medicine
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“Perspectives on Leadership”
John Gavin, MD, PhD, GIA General Session, November 10, 2002
Gavin suggested that there was a crisis in leadership in academic
health centers as there is in the business world and offered the
following comments and suggestions. Basic to his comments was the
clear distinction he made between management which focuses on events
and day-to-day procedures and leadership which focuses on people
and the vision that guides the institution.
The challenge to those leading academic health centers, he suggested,
is setting the vision and determining the path to get there. This
must happen within the context of an increasingly diverse patient
population and the changing gender balance among physicians. Leaders
must also recognize that information technology is changing the
way we educate students and take care of patients. Leaders must
confront the status quo in mature organizations that have developed
dysfunctional processes. We cannot continue with “business
as usual”. Leaders must be agile agents of change with the
emotional strength to support individuals and institutions as people
unlearn old behaviors and change the cultural dynamics and properties
of the organization.
Those in leadership positions must pursue transformational leadership
which recognizes that leadership is about a process of motivating
and helping people to grow. Such leaders:
- are concerned with making people feel
good about themselves, not about you
- build on people’s strength,
- do not fear delegation of authority,
- enable people to transcend their own issues for the sake
of the whole.
Gavin urged new ways of thinking in academic medical cultures
that have become bloated and too comfortable. He encouraged leaders
to move with and create a sense of urgency to jump start change.
Complacency, he underlined, is the enemy of positive change. People
can be very creative in their attempts to avoid change that takes
them outside their comfort zone.
Academe should be modeling best leadership practices. At the core
of leadership is credibility. Based on data gathered from 2600
senior level managers, Gavin started that the following ranked
list of characteristics were perceived as the five most important
for effective leadership:
- honesty
- competence
- visionary
- inspiring
- intelligent
Gavin said that a person is considered honest if you do what you
say you are going to do. Personal integrity is not an act of testimony;
it is a pattern of behaviors. Followers look at full spectrum of
behaviors to see consistency. Gavin concluded with the following
specific behaviors that leaders do when they are at their best?
- Challenge the process and change the
status quo.
- Inspire a shared vision, set of beliefs, and community.
- Enable others to act; empower, build teams.
- Model the way with behavior that earns respect.
- Articulate values and live them.
- Encourage the heart.
Q&A: How can a leader inspire shared vision?
Most important is frequent and effective communication.
Reported by:
Linda Heun, Ph.D. <meded@aacom.org>
Vice President for Medical Education
American Association of Colleges of Osteopathic Medicine
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Family Medicine Curriculum Resource
(FMCR) Project
Using The Acgme Competencies As An Overarching Framework For Educating Medical
Students
Group on Educational Affairs Small Group Discussion Session
November 13, 2002
Alexander Chessman MD, Moderator
Kent Sheets PhD and David Steele PhD, Discussants
DISCUSSION SUMMARY
This summary is prepared in two parts. The first
part is a text summary of the discussion points. The second part
is a transcript of the flip chart notes recorded during the session.
PART I: TEXT SUMMARY
To set the stage for this 90-minute Small Group Discussion, Alexander
Chessman MD, FMCR Project Codirector and session Moderator, gave
an overview of the federally funded FMCR Project (a four-year contract
from the Health Resources and Services Administration to the Society
of Teachers of Family Medicine) noting that this small group’s
discussion focus was to be on the use of the ACGME competencies
as an overarching framework.
Why use the ACGME competencies as a framework? The group raised
some initial questions about the use of the ACGME competencies.
The following points were raised:
Is the ACGME new? Not for residency education, but when the FMCR started in
2000, there was nothing in the literature we could find which took the ACGME
framework down to the first day of medical school. One participant said that
at her institution, the students have asked that they be given skills in these
competencies since they are so much a part of residency training. One area
which students had noted they are particularly lacking in upon entering residency
training is Systems of Care.
Dr. Chessman moderated the discussion around three discussion
questions which related to Structure, Sequencing, and Assessment.
Discussion points raised in answer to each question are summarized
below.
Question 1. STRUCTURE.
Does the ACGME competencies as a
framework for structuring medical student
curricula make sense? Is it helpful? Is it
problematic?
Discussion Points:
- Advantages include links between education
of residents and students.
- How does ACGME relate to MSOP? We have an opportunity to
link the two together, and potentially broaden the impact
of the MSOP work.
- Some institutions noted that, if you are not specific enough,
one response from faculty and administration can be “we
are already doing that” or “that is not applicable
to our setting”. If you look at what they are really
doing, however, often it is very cursory.
- With competencies such as ACGME, we may need to teach the
teachers first. The teachers need to learn it and then how
to teach it. For example, faculty in a county hospital setting
may not know much about systems of care except that the system
does not work – just imparting this negative message
to students is counterproductive.
- Systems of care is a big faculty development area for all
faculty
- A key issue in the flow from medical student to residency
training with ACGME is faculty development.
- In some areas, like Practice-based Learning and Improvement,
faculty may already be teaching this but not label it as such.
(i.e., in surgery) The faculty may have studied a problem
such as slow turnover of OR rooms, made a change, and analyzed
the results, to incorporate a system-wide improvement, but
may not have called it Quality Improvement.
- One person suggested lumping Systems of Care and Practice-Based
Learning and Improvement together
- It makes sense to use the ACGME competencies – because
they are reflective of the best practices in medicine today.
It makes logical sense to look backwards along the continuum
of the ACGME competencies to Day 1 of medical school.
- Students definitely see the logic of using the ACGME framework,
especially in the fourth year, as they move toward residency
training. One participant noted that a survey of their students
attributed much importance to learning about ACGME competencies.
- A potential seventh competency is cultural competence.
- Clerkship Directors think it makes much sense to use the
ACGME – and the more clerkships which address these,
the better. At the preclerkship level, the logic may be less
compelling simply because the competencies as listed are so
broad.
- Regarding a seventh competency, the FMCR Project decided
not to add one, because it would destroy a clean connection
with the ACGME competency list. It was debated to add a seventh,
on self-awareness. The FMCR decided to stress self-awareness
within the six competencies.
- Is ACGME just a fad? Could be a problem but the RRC and
GME rigidity will not allow ACGME to go away any time soon.
It is even conceivable that CME could begin to be categorized
by the ACGME competencies.
- Another disadvantage of presenting a new curriculum structure
to the faculty and emphasizing new areas such as Systems of
Care – the faculty may feel stretched to incorporate
a great deal more into an already packed curriculum. It was
clarified with regard to the FMCR resource, that with cross-indexing,
the material could be integrated so that it is not “more” but “richer”.
For example, within one topic such as geriatrics, competencies
could be richer and have a broader meaning when tied to the
ACGME – with an indexed resource, one could search by
content area and/or ACGME competency.
QUESTION 2. SEQUENCING.
How does use of this framework play
out over a four-year period of medical education?
What is the basic level of competency that
we expect at the completion of each stage
of learning? What is the evidence for the
optimal sequence of clinical curricula?
Discussion Points:
- Sequencing gets at a major problem
with ACGME competencies. They have an
integrative complexity. They will need
to be reworked to be user-friendly for
students and they need discreteness for
applicability for students. The FMCR
Project will contribute a lot by doing
this level of work which is necessary
to make them useful in medical student
education.
- Another complexity with sequencing is that not all schools
are alike. In each year, students have a variety of entry-level
experiences. This differs from institution to institution.
How to make the FMCR resource so that it can be adapted by
different institutions will be key. With the example of systems
of care, learning setting is critical – so the FMCR
resource could suggest generically how varied learning settings
can be used to teach the competency of Systems of Care.
- Interesting question about curricular integration – when
does it become the responsibility of the student to integrate?
Maybe a special curriculum piece should be developed which
helps students learn how to integrate.
- There are many things we learn “incidentally.” If
you put students into a variety of clinical settings, they
are going to learn some intangibles. Creating situations in
which the student must learn about the system by being placed
in it may be one of the best ways to teach about systems.
- Fourth year is very appropriate place to focus on Systems
of care.
- For fourth year students, might be good to come up with
a tool for them to assess his/her own competence.
- A hierarchy for the objectives will be helpful: e.g. Must
know, should know, be nice to know.
QUESTION 3. ASSESSMENT.
What are some of the challenging behaviorally based objectives which are critical
to teach and evaluate (which may not be amenable to strict, rigorous assessment?)
What objectives might be the most important from a strategic standpoint?
Discussion Points:
- Do students learn from mistakes? Good
way to assess Practice-based Learning
and Improvement.
- Some ACGME competencies students must know to graduate;
others would be nice.
- What would you be embarrassed by if one your graduates was
not competent in? Answer – interpersonal communication
and professionalism
- The trip getting to the diagnosis is often more important
than getting the right diagnosis, in spite of the correct
answer. “Showing the thought process” is very
important in terms of getting at assessment of some of the
patient care competencies.
- We should sit down with students and ask them what they
are getting and what they think they are going to need to
know upon entering residency.
- Systems of care skills are every bit as important as traditional
knowledge – if students cannot function in the system,
then they cannot use the knowledge. If we were to graduate
a new crop of students who could function in the system, we
would be far along. Knowledge has changed three-fold since
most of us graduated. What is key is that students know how
to access new knowledge (informatics) and that they can function
in today’s systems of care.
- Another issue with regard to sequencing and assessment is
when does it stick? When do you assess? Do you expect to repeat
things before they stick?
- To the extent the FMCR resource is integrated, the more
useful it will be – it will not burden users if one
can search by topic or competency and then see integration.
PART II: TRANSCRIBED FLIP CHART NOTES
USES OF ACGME IN AUDIENCE
- Using ACGME competencies to plan undergraduate
medical education
- Expanding competencies to reflect undergraduate needs
- Preparation for graduate medical education
DOES IT MAKE SENSE?
- Linkage between medical student and
residency training
- “we are doing that already – do
not need to get involved” (possible
response from end-users)
- “this topic area, (i.e., Systems based care) is
not appropriate to MY clerkship” (possible response)
- Faculty are not training in several of the ACGME competencies
would need significant development
- Students think it makes sense
- Need to tie school level objectives to ACGME competencies
SEQUENCING ISSUES
- ACGME competencies are complex. How
do we define them for medical student
at varying levels?
- Integrative complexities
- ACGME competencies need to be rephrased for the medical student
- Variability of medical schools’ influences in sequencing
decisions
- Curriculum “implosion” – only so much we
can teach; only so much students can learn
- What are appropriate goals – competence OR awareness/consciousness
raising?
- “Minimal” competence may need to vary by specific
competency - Communication skills and Professionalism are critical
- Need to get input from students about where they think these
areas are for their own education
ASSESSMENT
- When will the learning stick? Finding
the right time and place to optimize
learning
Report Provided by:
Mary P. Hoy, Ph.D.
Associate Dean for Medical Education and Assessment
The University of Health Sciences
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Sunday, November 10,
Match Scholar Presentation, “The
Role of Assessment in Medical Education
Reform”
Susan D. Block, MD, Speaker and Award Recipient
Chief, Adult Psychology Oncology Program
Harvard Medical School
Dr. Block used her professional interests in ‘Care of the
Dying’ and ‘Exploring the Hidden Curriculum’ to
describe her work in Assessment. She has come to focus on humanism,
compassion, empathy, and attention to the patient’s and student’s
lived experience and psychosocial care. In this context, she observed
that there are many neglected and ignored opportunities for learning
that could lead students to transformative development if people
focused on assessment. She also sees end-of-life care as a paradigm
for teaching the core humanistic competencies given that in this
area “it’s hard to stand back and be neutral”.
She explained that although she was an educator first and an evaluator
second, whenever she designed a new program to meet an educational
objective, she would take care to be reflective as she implemented
it. She viewed her small group teaching experiences as ongoing
focus groups within which she could do assessment. To develop good
teaching programs, she suggested that we must look at the existing
education program, design an intervention, and assess its impact.
She observed that her dream paper was to write about an educational
intervention that used classic experimental design and the data
showed that it was significant in developing physician humanity
and compassion, enhanced physician satisfaction, and reduced burnout.
She commented on three actual studies that she has been involved
in.
- New Pathway Evaluation which focused
on ‘can we teach humanism without
undermining biomedical competency’.
It used a random control method and a
combination of quantitative and qualitative
measures. Given that there is no valid
measure of humanism, an aggregate of
multiple measures as outcome measures.
(see Academic Med ’94: 60: 983-989)
Compassion increased in first two years
and decreased during clinical years
She questioned if evaluation data
really matters as she indicated that
Harvard adopted the New Pathway Program
before her data was even analyzed.
Of the study he said, ‘we learned
that we can measure humanism and
teach it; and that students unlearn
it in clinical years, even when it
is strongly part of the formal curriculum.
There appear to be strong barriers
in the informal and hidden curriculum,
especially in the clinical years.
- Generalist Physician Initiative: The
question was ‘did it support primary
care careers’. Nationally stratified
samples and multiple indicators of culture
for primary care were used. The outcomes
showed that we can measure culture quantitatively
across multiple institutions and that
the measures are sensitive to change.
Data showed that the climate was chilly
for primary care; and while there was
a positive trend from 1994-97, there
have been steady erosion since.
- In a study of doctors and death, she
and others did an in-depth study of the
hidden and informal curriculum in this
area. The focus was the impact of patient
care on physician emotions and identity;
what learning experiences surround end-of-life
care, and how faculty and residents impact
students learning. Team care members
for randomly selected deaths were identified
and semi-structured interviews were conducted.
The ‘Impact of Event Scale’ was
used as a quantitative measure and the
synthesis of stories which interviewees
told about their personal experience
with the death were used as a qualitative
measure. There was a response rate of
80%. Interviews that were to be 40 minutes
became 80-minute interviews. She concluded
that people want to talk about this.
While medical students were part
of the care team, in most cases they
were not included in any retrospective
processing about the case. Faculty
reported that they were not included
because the cases were too complicated
or patients were so near death that
there was nothing to learn. Medical
students were protected and deprived
of opportunities to learn from caring
for the dying. Students reported
the need for support, but that they
didn’t get any.
She reported that the local impact
of the study actually changed the
culture. It brought the issue out
of the closet and Intern Grief Rounds
were initiated.
Her next study was the development of a national survey regarding
educational experiences related to end-of-life care. The outcomes
were
- positive faculty views about the responsibility
for teaching in this area
- negative faculty views about the quality and quantify of
teaching in this area
- faculty reported feeling that dying patients are not good
teaching cases
- only 20% of trainees had exposure to Hospice – consider
the best national model for end-of-life care
- faculty are unprepared to teach in this area
She reported the following lessons learned about assessment of
medical education programs:
- Reformers are viewed ambivalently.
- External evaluators often don’t have an in-depth understanding
of what is going on.
- Internal evaluator have a personal investments in the outcome.
- It is critical that your study methods are transparent and
have been subjected to peer review.
- There is an iterative process between research and teaching;
qualitative and quantitative measurement, and innovation and
evaluation.
- There are tradeoffs between having a broad impact and conducting
rigorous science.
- Discomfort is inherent in doing evaluation of issues you
care about.
- Unexpected findings, even disappointing ones, are gifts.
She cited the following benefits of doing effective evaluation:
- Validation of one’s efforts
- Justification of continued investment of resources
- Encouragement of others
- Demonstration of the commitment to values of science and
discovery
- Enhanced credibility of the profession
She concluded by saying that to know how to make change, we have
to know where we are: what is explicitly taught and what is hidden.
Further, we must:
- use good measures.
- stay in the field of measurement for the long haul.
- show patience and persistence in collecting data.
- collaborate with other professions.
- be committed to reflection and critical thinking. and
- use unexpected findings as windows to understanding.
Q&A: When asked how to present
professional qualities in ways that students wouldn’t perceive
as ‘hokey’, she indicated that the best methods she
had found were to use real patients as teachers and intensive small
group interaction.
Reported by:
Linda Heun, Ph.D. <meded@aacom.org>
Vice President for Medical Education
American Association of Colleges of Osteopathic Medicine
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