OHSU

Background and Rationale

There is national consensus that undergraduate, and especially graduate medical education need urgent reform not only to produce more primary care physicians and allied health professionals but to ensure that this primary care workforce is equipped with the skill sets that will be required to effectively provide safe, high quality, evidence-based care to an increasingly diverse and aging population. While the ultimate structure of the U.S. healthcare system is not fully known, there is little argument for the need of dramatic reforms in both the health care delivery and medical educational systems (1-4). Policymakers have grown increasingly frustrated at the Graduate Medical Education (GME) enterprise’s inability to more quickly transform itself to meet these contemporary expectations for physician training (1, 3).

As poignantly highlighted by Frenk and colleagues, competency-based medical education requires that educators start with the needs of the population and health system first (Figure 1). These needs then define the outcomes, or competencies, of the healthcare workforce (5). Only then is a curriculum developed, one that meets the needs of the targeted population in the context of the health care delivery system. In its second of two reports examining the future of graduate medical education, The Josiah H. Macy Jr. Foundation recommended the “GME system should be proactive in responding to and anticipating significant changes in health care delivery and practices,” and the sites and content of training should expand to reflect future patient care and system’s needs. (6)

A look at the current state of United States healthcare finds a system that provides suboptimal quality, is too expensive and too often unsafe. In addition to longstanding quality problems, the country is experiencing a dramatic demographic shift in conjunction with changing needs among patient populations (e.g., curable infectious diseases, new morbidities such as obesity and escalating numbers of patients with mental health issues as well as growing numbers of patients with special health care needs as a result of technologic advances and new drug therapies). Training programs, and by logical extension, faculty must design training to prepare future physicians to meet these changing needs. Frenk and colleagues also contrasted the explosion of medical knowledge and technology and the skills needed to manage these profound changes, with the stagnant investment in education through faculty training, time and resources, equating to less than 0.5% of the total health care expenditures in this country. (5)

Finally, while it seems logical that in order to acquire high levels of knowledge, skills and attitudes a medical student and resident must train in a setting that provides high quality and safe care, evidence is beginning to accrue to support this hypothesis. (7-8) Therefore, any faculty development initiative must tackle the tall task of equipping faculty to both teach important new primary care competencies while concomitantly working to improve the clinical system in which the care is delivered. For example, much investment and hope is being placed on the patient centered medical home, but what constitutes the optimal “version” of the PCMH for training programs has yet to be fully defined. As Larry Green eloquently articulates,  “We have to train our residents for a system and model of practice that doesn’t currently exist.” This places an added imperative on skills that enable one to innovate in medical education and care delivery systems as well as lead and manage change.

 

Figure 1-Background

Figure 1: Changing mindset – Competency-based medical education (ref 5).

 

Several fundamental barriers currently exist that will impede, if not prevent, the transformation of training across all primary care training programs:

1)    Faculty, both physicians and non-physicians, are critical to the development of trainees in the ambulatory environment through teaching, role modeling, assessment of trainee’s knowledge, skills and attitudes, and feedback. (1, 4) Formative assessment and its attendant feedback are perhaps the most important elements in helping trainees learn and improve (9-10). Yet, substantial research highlights that too many faculty lack competence in assessment and feedback skills related to quality improvement, teamwork and systems-based practice, especially in the ambulatory setting. (11-14) As recently noted by Dr. Tom Nasca, CEO of the Accreditation Council for Graduate Medical Education (ACGME), the lack of a sufficiently trained faculty workforce in assessment and evaluation may be the largest impediment to successfully transforming medical education to a competency-based system. (15)

2)    In order to most effectively learn how to practice in advanced models of primary care with an emphasis on teams, trainees should experience such models during their training (2-16). However, far too many ambulatory training sites lack effective systems to provide the necessary environment for training in primary care. (2,16-17)  Nelson and colleagues have laid out nine key success factors for effective ambulatory microsystems (18), including leadership and interdependence of the care team. Both require competent faculty, staff and strong working relationships between faculty, trainees and clinic staff. Yet, several studies suggest this is not happening in primary care, including residency clinics. (2, 16, 19)

3)    There is a lack of a nationally coordinated effort to train faculty and other key providers who work in ambulatory training sites. To date, most faculty development programs have been housed and delivered within single departments or training programs and given as one-time “bolus” workshops (20). This one-time approach to faculty development fails to acknowledge that the acquisition of expertise occurs longitudinally and experientially. All of the “new” competencies, such as interprofessional teamwork, quality improvement, care coordination, evidence-based practice and informed decision making, require ongoing practice and reinforcement. (21-22) The lack of coordinated and longitudinal efforts results in too much heterogeneity that leads to unwarranted and unnecessary variation in both performance and teaching practices. Faculty development should seek to integrate the lessons learned and expertise across the primary care specialties using a longitudinal and interprofessional (e.g. physicians, nurses and other allied health professional) approach.

4)    Many primary care training sites serve underserved populations with a multitude of complex medical and social problems. Current GME financing polices and reimbursement is not sufficient to cover faculty time and effort and faculty are being required to see greater volumes of patients to generate their salaries. A major unintended consequence is less time for teaching, assessment and feedback with little to no time for their own faculty development. As recently highlighted in the Carnegie Foundation report, Educating Physicians, teaching, assessment and evaluation require training, practice and feedback in these skills; they are not simply innate characteristics of clinicians appointed to faculty positions. (4)

5)    The ever evolving health care delivery system and the contrast between the independent physician of the past and interdependent physician of the future calls for a new mindset. The traditional notions of physician autonomy must give way to the importance of professional relationships and interprofessional teams. The vast majority of current faculty were not “socialized” into a interprofessional culture; this represents a major change for faculty who must role model team-based care. 

Historical Context of Primary Care Residency Education

The movement to enhance the quality of primary care began prior to the passage of the Affordable Patient Care Act (APCA) through work by several medical organizations to define and promote demonstration pilots of the Patient-Centered Medical Home (PCMH). (23) The Patient-Centered Medical Home (PCMH) is primarily based on evidence compiled by Barbara Starfield’s work about the favorable effects of primary care, specifically improved patient outcomes at lower costs. (24-29)  As currently conceived, features of the Patient-Centered Medical Home include: 1) an ongoing relationship between the patient  and  a personal physician;  2) continuous and comprehensive care; 3) collaborative care  by teams  and coordination with others as needed; 4) patient’s and their families directly engaged in their own care planning, so care is coordinated and/or integrated across all elements of the health care system and the patient’s community; 5) care that is facilitated by information technology, such as electronic health records and disease registries; 6) information exchanges about health and healthcare  according to patient need, such as the use of asynchronous communication (e.g., e-mail) and enhanced access to healthcare through expanded hours and open-access scheduling; 7) quality and patient safety  as foundational  principles of the medical home, based on patient advocacy, care planning, and the use of evidence-based medicine and clinical decision support tools; and 8) payment reform that appropriately recognizes the added value provided to PCMH patients.

Supporting Residency Training Redesign

The scope, scale, and pace of developments in healthcare have not been matched by adaptations in the training of primary care physicians.  The three primary care disciplines have launched separate initiatives within each discipline to catalyze change. Most notable is the Preparing the Personal Physician for Practice (P4) sponsored by the American Board of Family Medicine and the Association of Family Medicine Residency Directors that has been active for over five years in 14 programs, and this initiative has helped to identify a number of faculty development needs (30). In internal medicine, the ACGME sponsored the Education Innovations Projects (EIP) providing substantial flexibility to 21 internal medicine programs to try innovations in the program. Several programs targeted training in the ambulatory setting, including use of milestones and quality teams (31).  The American Board of Pediatrics launched the Initiative for Innovation in Pediatric Education, with 18 programs currently involved in innovations around handovers, individualizing training to meet career goals, longitudinal quality improvement team-based training and improving competency-based assessment.  However, to date no faculty development program has systematically involved all three disciplines in collaboration. There is national interest in securing a modernized foundation of primary care for a new health care delivery system for all, and the American Boards of Family Medicine, Internal Medicine, and Pediatrics, along with HRSA and the educational community are working together to effect this change by combining expertise and resources to  create a national faculty development program building on empiric evidence of “what works” in faculty development and early pilot efforts to improve training in the ambulatory setting.

To best design a pilot faculty development initiative, we pursued three key activities. We:

1)    Performed a semi-structured literature review to uncover key design principles for a faculty development program. 

2)    Performed a needs assessment of all training programs in the three disciplines.

3)    Hosted a national stakeholders meeting in January 2012 to get robust input from a broad group of stakeholders: medical educators; consumer and purchasers; primary care physicians and educators; trainees; allied health professionals; private and public health system leaders; and regulators.

Literature review:

While much has been written on faculty development for teaching, the literature is less robust around faculty development in the newer competencies. However, combining this literature with lessons from quality improvement, systems and cognitive science, some over-arching design principles can be highlighted.

Faculty Development should:

1.    Be experiential, relevant and interactive. The training has to help the faculty member solve a “problem” and incorporate the recent advances in the neurobiology of learning (32-33).

2.    Be longitudinal. While “bolus” type workshops and courses have value, the lessons learned from the initial bolus have to be reinforced and refined over time. This will be particularly critical given that some of the changes involved in this initiative will evolve over time. Learning is an iterative, cyclic process. 

3.    Involve effective group process. This training should not be done alone, and in fact, one of the key operating principles of the training is to create an interdisciplinary learning community to enhance impact and promote sustainability. 

4.    Be evidenced-based to the greatest extent possible given the competing need for flexibility that takes advantage of local strengths. A one-size fits all approach will likely not work for all participating programs and clinics. (34)

5.    Focus on faculty competencies that parallel those that are critical for graduating residents. The faculty development should have the same philosophy as the training program – strive for changes in KSA among the faculty to empower them to effect change consistent with self-efficacy and self-determination theory. (35-6)

6.    Build iterative evaluation into the program, using the principles developed by Kirkpatrick, realist and developmental program evaluation models. (37-8) It is important to detect early signals so as to enable real-time adjustments during training and maximize the learning for scaling a larger intervention.

7.    Must occur in the context of a training site embarking on change and redesign. Training faculty that do not have a “receptor site” after completion of the faculty development will have a low chance of success. All participants should come with a commitment from their local leadership and administration.

8.    Recently published results from the P4 project in family medicine have also provided additional insights for faculty, specifically the need for (30):

a.    Collaboration with other residencies
b.    Faculty cohesion and commitment
c.    Periodic faculty retreats
d.    Ongoing curriculum management
e.    Providing adequate administrative and financial support

 

References:

1.    MedPAC Website MedPAC June 2009 Report to the Congress. Improving Incentives in the Medicare Program. Medical Education in the United States: Supporting Long Term Delivery System Reforms.http://www.medpac.gov/documents/Jun09_EntireReport.pdf. Chapter 1.  Accessed January 5, 2010
2.    Bowen JL, Salerno SM, Chamberlain JK, Eckstrom E, Chen HL, Brandenburg S. Changing habits of practice. Transforming internal medicine residency education in ambulatory settings. J Gen Intern Med. 2005; 20(12): 1173-78.
3.    Lucien Leape Institute. Unmet Needs: Teaching Physicians to Provide Safe Patient Care. National Patient Safety Foundation. Boston. 2010.
4.    Cooke M, Irby DM, O’Brien BC. Educating Physicians: A Call for Reform of Medical School and Residency. Jossey-Bass. San Francisco. 2010.
5.    Frenk J, Chen L, et. al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010; 376: 1923-58.
6.    Josiah Macy Jr. Foundation. GME Report 2: Ensuring an Effective Physician Workforce for the United States, May 2011.
7.    Asch DA, Nicholson S, Srinivas S, Herrin J, Epstein AJ. Evaluating Obstetrical Residency Programs Using Patient Outcome. JAMA. 2009;302(12):1277-1283.
8.    Sirovich B, et al. When less is more:  A new measure of appropriately conservative management (abstract). Presented at the Society for General Internal Medicine annual meeting, 2005.
9.    Hattie J, Timperley H. 2007. The power of feedback. Rev Educ Res 77(1):81–112.
10.    Eva KW, Regehr G 2008. "I'll never play professional football" and other fallacies of self-assessment. J Contin Educ Health Prof. 28(1): 14-9.
11.    Vukanovic-Criley JM, Criley S, Warde CM, Boker JR, Guevara-Matheus L, Churchill WH,  Nelson JP, Criley JM.. Competency in Cardiac Examination Skills in Medical Students, Trainees, Physicians, and Faculty A Multicenter Study. Arch Intern Med. 2006; 166:610-616.
12.    Braddock CH, Edwards KA, Hasenberg NM: Informed decision making outpatient practice. Time to get back to basics. JAMA 1999; 282:2313-2320.
13.    Kogan JR, Hess BJ, Conforti LN, Holmboe ES. What Drives Faculty Ratings of Residents’ Clinical Skills? The Impact of Faculty’s Own Clinical Skills. Acad Med. 2010; in press.
14.    Lynn LA, Hess BJ, Conforti LN, Lipner RS, Holmboe ES. The Relationship between Clinic Systems and  Quality of Care for Older Adults in Residency Clinics and in Physician Practices. Acad Med. In press; 2009.
15.    Nasca T, The CEO’s First Column-The Next Steps in the Outcomes-Based Accreditation Project. ACGME Bulletin, May 2008, p2-4.
16.    Green LA, Jones SM, Fetter G Jr, Pugno PA. Preparing the personal physician for practice: changing family medicine residency training to enable new model practice.  Acad Med. 2007:82(12):1220-1207.
17.    Reddy SG, Babbott SF, Beasley BW, Nadkarni M, Gertner E, Holmboe ES. Prevalance and Functionality of Electronic Health Records in Internal Medicine Continuity Clinics. Acad Med. 2010 Aug;85(8):1369-77.
18.    Nelson E, Batalden PB, Godfrey MM. Quality by Design: A Clinical Microsystems Approach. Jossey-Bass. San Francisco. 2007.
19.    Chesluk BJ and Holmboe ES. How teams work in primary care: An ethnographic perspective on teamwork in internal medicine practices. Health Aff (Millwood). 2010;29(5):874-9.
20.    The Future of Family Medicine Project Leadership Committee.  Future of Family Medicine: A Collaborative Project of the Family Medicine Community. Ann Fam Med. 2004; 2:S3-S32.
21.    Green ML, Aagaard EM, Caverzagie KJ, Chick DA, Holmboe ES, Kane G, Smith CD, Iobst W. Charting the Road to Competence: Developmental Milestones for Internal Medicine Residency Training. J Graduate Med Educ. 2009; 1: 5-20.
22.    Carraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin C. 2002. Shifting paradigms: from Flexner to competencies. Acad Med 77(5)361–367.
23.    American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association.  Joint Principles of the Patient-Centered Medical Home. March 2007. (http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home). Accessed July 27, 2008.
24.    Dartmouth Atlas of Health Care, Variation among States in the Management of Severe Chronic Illness, 2006.
25.    Starfield B, Shi L, Macinko J, Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Affairs. 2001;20:64-78.
26.    Starfield B, Shi L, Macinko J. Contributions of primary care to health systems and health. Millbank Quarterly 2005;83:457-502.
27.    Starfield B, Shi L, Grover A and Macinko J.  The effects of specialist supply on populations' health: Assessing the evidence.  Health Affairs Web Exclusive, March 15, 2005 (W5-97).
28.    Starfield B, Presentation to The Commonwealth Fund, Primary Care Roundtable: Strengthening Adult Primary Care: Models and Policy Options, October 3, 2006.
29.    Beal AC, Doty MM, Hernandez SE, Shea KK, Davis K.  Closing the Divide: How Medical Homes Promote Equity in Health Care: Results From The Commonwealth Fund 2006 Health Care Quality Survey, The Commonwealth Fund, June 2007.
30.    Eiff MP, Waller E, Fogarty CT, Krasovich S, Lindbloom E, Douglass AB, Pugno P, Green LA, Carney PA. Faculty development needs in residency redesign for practice in patient-centered medical homes: A P4 report. Fam Med. 2012; 44: 387-95.
31.    Warm EJ, Schauer DP, Diers T, Mathis BR, Neirouz Y, Boex JR, Rouan GW. The ambulatory long-block: an accreditation council for graduate medical education (ACGME) educational innovations project (EIP). J Gen Intern Med. 2008 Jul;23(7):921-6.
32.    Steinert Y, Mann K, Centeno A, Dolmans D, Spencer J, Gelula M, Prideaux D.A systematic review of    faculty development initiatives designed to improve teaching effectiveness in medical education: BEME Guide No. 8. Med Teach. 2006 Sep;28(6):497-526.
33.    Forsetlund L, Bjørndal A, Rashidian A, Jamtvedt G, O'Brien MA, Wolf F, Davis D, Odgaard-Jensen J, Oxman AD. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD003030. DOI: 10.1002/14651858.CD003030.pub2
34.    Stevens DP, Shojania KG. Tell me about the context, and more. BMJ Qual Saf. 2011 Jul;20(7):557-9.
35.    Bandura A. Self-efficacy: Toward a Unifying Theory of Behavioral Change. Psychological Review. 1977; 84:191-215.
36.    Ryan RM., Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 2000; 55: 68-78.
37.    Kirkpatrick DL, Kirkpatrick JD. (2006). Evaluating Training Programs (3rd ed.). San Francisco, CA: Berrett-Koehler Publishers
38.    Pawson R, Tilley N. (1997) Realistic Evaluation. San Francisco, CA: Sage Publications.