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A Synthesis of Nine Major Reports on Physicians' Competencies for the Emerging Practice Environment

Halpern, Ralph MSW; Lee, Mary Y. MD, MS; Boulter, Philip R. MD; Phillips, Rosalie R. MPH

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Author Information

Mr. Halpern is director of content development and program evaluation, and Ms. Phillips is executive director, Tufts Managed Care Institute (TMCI); Dr. Lee is dean for educational affairs, Tufts University School of Medicine, and faculty development director, TMCI; Dr. Boulter is senior vice president and chief medical officer, Tufts Health Plan, and medical director, TMCI.

Correspondence and requests for reprints should be addressed to Mr. Halpern, Tufts Managed Care Institute, 136 Harrison Avenue, Boston, MA 02111; telephone: (617) 636-1000; fax: (617) 636-0429; e-mail: 〈Ralph_Halpern@tufts-health.com〉.

For articles on related topics, see pp 587 and 598.

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Abstract

Medical education and training programs generally have been slow to introduce curriculum content that reflects important changes in practice organization and health services delivery. However, impetus for curricular reform is gaining momentum as national organizations endorse new content for both medical school and residency education.

The authors and colleagues at Tufts Managed Care Institute reviewed nine reports by key national organizations to assess their positions on curricular reform in light of changes in practice and the system of care. The reports agree generally on the evolving nature of practice, the need to address these changes during medical school and residency training, and the description of the new curriculum content that they advocate. The authors grouped these reports' specific recommendations under ten curriculum domains: health care system overview; population-based care; quality measurement and improvement; medical management; preventive care; physician—patient communication; ethics; teamwork and collaboration; information management and technology; and practice management. They describe the reports' rationales and cite specific knowledge and skills that these national organizations identify within each domain. This domain-based framework synthesizes and complements the recommendations of these national organizations.

The authors conclude that implementing curricular reform remains a challenge. The information and competencies need to be organized and sequenced for stage of training and specialty, and barriers to change require strategic and operational planning. Having a common nomenclature and framework will facilitate the introduction of new content within schools and programs, across departments, and among institutions nationwide.

Two revolutions have affected medical practice in the United States during the last 15 years: first, the continued explosive growth of biomedical technology for diagnosis and treatment of illness; and second, significant and widespread change in the payment for and organization of health services. Medical education and training programs have maintained a core curricular focus on the diagnosis and treatment of illness, incorporating key advances in biomedical knowledge and technology over time. However, by and large, they have not paid systematic attention to preparing graduates for changes in the practice environment.1–4 This practice context is critical to the professional lives of physicians as well as to their ability to positively affect the health and well-being of patients.

One manifestation of the revolution in the health care environment in the United States is the growth of “managed care,” characterized by prospective payment and medical management processes. In 1980, after decades of existence, managed care was limited in scope and geography and was restricted primarily to the presence of staff- and group-model health maintenance organizations (HMOs). The great majority of U.S. physicians were untouched by its presence and unfamiliar with its tenets. In contrast, by 1998, approximately 90% of physicians participated in at least one managed care contract; and approximately 85% of patients insured by their employers were enrolled in some form of managed care plan.5,6

Rather than referring to particular insurance plans or arrangements, in this article we use the phrase “managed care” as an umbrella term to describe a set of general characteristics and trends in today's health care environment. More specifically, we use the term to suggest any environment that

▪ acknowledges constraints on health care resources and values cost-effective care;

▪ sees patients not only as individuals but as members of a population to be cared for and, therefore, supports health assessment, patient outreach, and illness-prevention strategies;

▪ fosters the systematic assessment and improvement of quality indicators for physicians, hospitals, and patient populations; and

▪ coordinates and delivers care through organized systems.

The leadership of the Tufts Managed Care Institute (TMCI) is especially interested in assessing changes in medical education and training in response to the environmental forces reviewed above. The TMCI was founded in 1995 by Tufts University School of Medicine and Tufts Health Plan with the mission of “helping physicians and other health care professionals to practice more comfortably and effectively” in the emerging environment through the development and dissemination of relevant educational tools, programs, and curricula. The TMCI's original curriculum framework was derived from interviews with more than 50 practitioners, faculty, medical students, residents, and others, largely within the greater Tufts community.7 At that time, while one could find occasional articles and editorials about medical education and managed care, there was little organized discussion or consensus to guide us at the TMCI regarding the appropriate content for our course materials.

More recently, as a prelude to developing Web-based learning resources about managed care, we (the authors) revisited this curricular framework. This time when we researched the literature, we discovered that, in the years since 1995, several prestigious national medical education organizations and professional societies had published reports and recommendations for curricular reform that address the preparation of physicians for this evolving practice environment; see Table 1 for a list of these reports and the groups that prepared them. In this article we summarize our findings from analyzing those nine reports.

Table 1
Table 1
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The appearance of these reports is significant for three reasons. First, it demonstrates a growing recognition among physician—educators and leaders that the content of medical education and training must reflect changes in the health care environment and the organization of medical services. Second, the reports are consistent in their characterizations of the environment and the evolving nature of practice. Third, there is significant confluence among the reports in the nature of the new curricular content they recommend.

We being with a brief overview of the reports' assessments of the practice environment. We then present a synthesis of the key content areas they recommend for inclusion in medical education and training programs. We conclude with reflections on the challenges that lie ahead as academic medicine responds to these forces and endeavors to incorporate the new curricular components.

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OVERVIEW OF REPORTS

Two of the nine reports mentioned above and listed in Table 1 focus on curricular revisions for medical students, six for residents, and one for training in general. Some are, by design, high-level statements citing key curriculum topics; others offer greater detail and specificity about learning and performance objectives, practical strategies and tools, and knowledge and concepts. Together these reports present significant new perspectives on medical education and training in the United States. Most striking are their unanimity on the state of health care and medical practice and their shared assessment of the forces shaping the future.

The nine reports, to varying degrees, describe the forces affecting the overall health care system and the emerging practice environment as a context for their curricular recommendations. One dominant theme is a dual focus on quality and cost. The reports characterize an environment in which multiple parties are demanding increased monitoring of quality and demonstrable quality improvement. At the same time, they uniformly reflect the need for greater attention to cost effectiveness and efficiency.

As a second theme, the reports further depict a delivery system in which the composition of the provider sector is becoming increasingly organized and integrated. The nature of professional practice has changed fundamentally as physicians have aligned themselves within larger groups and networks. Paralleling this development among physicians is the grouping of individual patients into panels and populations, reflecting both insurance structures and new approaches to promoting health and treating disease.

A third major theme referenced in the reports is the explosion of new knowledge in biomedical sciences, epidemiology, and health services research. An essential tool to manage knowledge in this environment is information technology. In virtually every industry and profession, information technology is seen as a key to progress and improvement, and medical practice is no exception. In a related development, patients have greater access to information than ever before, with tremendous potential impact on the patient—physician relationship.

These developments might be seen by some as threats to the ability of physicians to fulfill their traditional professional roles and responsibilities towards their patients. The nine reports we examined strike a different tone: in their view the changes in the environment and in practice are undeniable, physicians have no choice but to adapt in order to be as effective as possible, and, indeed, this evolution presents opportunities to improve the care of patients and the functioning of the overall health care system. As a result, physicians need to acquire new knowledge and skills to perform roles that may not have been required of them in the past. Physicians are pivotal players in every aspect of health care, and their education and training must prepare them to meet these challenges.

All of the reports refer to some aspects of health care and medical practice that have come to be associated with managed care, i.e., enrolled populations, prospective payment, financial accountability, utilization management, quality assessment, coordination of care, and organized provider systems. The reports that do reference managed care per se do not seek to defend or justify the managed care industry as it now exists, nor do they suggest that the current structures and relationships involving purchasers, payers, and providers are necessarily salutary or permanent. They are concerned, rather, with achieving effective and high-quality medical practice. To cite a few examples, the Population Health Perspective Panel convened by the Association of American Medical Colleges as part of their Medical School Objectives Project stated,

The fundamental principles supporting efforts in population health training exist independently of the managed care delivery system, and yet the education mission and managed care mission are conflated in the minds of some. This misconception impedes education efforts to expand such training because faculty fear they are responding to a managed care imperative rather than preparing future practitioners for the medicine of the next century.8

The report of the Council on Graduate Medical Education concludes that “many of the skills required to practice sound medicine in a managed care context are also those required for being a capable and responsible physician.”9 The Pew Health Professions Commission, writing of the challenge of “truly managed care,” states: “‘Managed care’ has become the by-word for all that is wrong with today's health care system, and that is unfortunate. The Pew Commission understands managed care to be those processes that work to rationalize the use of health care resources at the lowest possible cost and the highest possible quality…. The techniques of managed care can be used to improve quality, expand access and enhance population health.”10

A statement introducing the initiative named Undergraduate Medical Education for the 21st Century (UME-21) captures much of the thinking of these collected reports:

Medical schools must teach and train graduates for the 21st century to practice effectively in systems that will be predominantly organized around the principles of the management of care and will focus on generalist, interdisciplinary team practice, promotion of the health of defined populations, and delivery of medical care that is outcome- and evidence-based and contains costs while preserving high quality.11

In sum, there is consensus that the practice environment has indeed changed and will continue to change, requiring that physicians adopt new competencies in order to fulfill their professional obligation to their patients and to society. These competencies are described in the following section.

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CURRICULUM DOMAINS

We conducted a detailed analysis of the content of the curricular recommendations in each of the nine reports. Since the terminologies and groupings were not always consistent, we reviewed each report at the finest level of detail that it offered and developed a nomenclature and a classification system that we believe remain true to the intents of the original reports. We then regrouped the individual topics under ten broader curriculum domains and assigned recognizable labels to each domain, as follows:

▪ Health care system overview

▪ Population-based care

▪ Quality measurement and improvement

▪ Medical management

▪ Preventive care

▪ Physician—patient communication

▪ Ethics

▪ Teamwork and collaboration

▪ Information management and technology

▪ Practice management

All the reports—either directly or by implication—recommend curricular content associated with nine of the ten curriculum domains. The exception is the practice-management domain, which was cited in only half of the reports. Presumably the authors of the other reports felt that practice management is best learned after training is complete, when the content is more relevant and immediate. Both the broad domain headings and representative topics under each one are discussed later in this section.

The analysis of reports is useful at the level of the domains to indicate broad areas that should be addressed in medical education and training. As we look beyond these general headings to the more specific knowledge and skill sets, however, it becomes more difficult to draw collective conclusions about what precisely should be taught. First, the reports vary in how much detail and guidance they offer regarding learning objectives. Second, the reports have different purposes, ranging from providing broad frameworks to giving detailed blueprints. Third, the reports acknowledge that within the broad headings, the ultimate curricular content will vary depending on the learner's prior training and the specialty field.

The list of curriculum domains emerging from this analysis includes some topics that are new to most medical education and training programs, such as population-based care. A number of the domains, however, contain topics that already are widely taught but need to be adapted to reflect pertinent issues in the new environment. For example, students and residents generally learn physician—patient communication skills, but they may not be trained to address contemporary issues, such as negotiating treatment plans with patients when there is disagreement about whether a specific service is necessary.

Below we review each of the domains in turn. For each we summarize the context presented in the reports as well as the specific topic areas recommended.

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Health Care System Overview
Context

Physicians practice in an increasingly complex and dynamic health care environment. Health care involves a complex interplay of payers, insurers, health care professionals, institutions, suppliers, vendors, and consumers. The health care system itself is the subject of increased scrutiny and expectations on the part of the public, legislative and regulatory bodies, and the media. Physicians must be grounded in the system in which they practice and understand how their decisions and actions are influenced by larger forces. By understanding these forces, physicians can meet their responsibilities towards individual patients and participate in systemic changes that can have an impact on health and health care beyond their personal sphere of influence. The curricular goals in this domain refer to both of these dynamics: how the system affects physicians, and how physicians can affect the system.

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Topics

Specific topics in this domain that are recommended in these reports include

▪ health system organization; practice structures and delivery systems;

▪ health system components and an understanding of how elements of the system affect medical practice;

▪ health system finance and economics; reimbursement systems; methods of controlling health care costs and allocating resources;

▪ key actors and organizations;

▪ use of system resources to provide care that is of optimal value; and

▪ advocacy for system change for the benefit of patients.

This area of instruction is largely contextual and descriptive. It sets the stage for competencies that are developed in other curriculum domains.

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Population-based Care
Context

The grouping of consumers into subpopulations and panels, previously identified with managed care plans, is becoming a defining characteristic for the entire health care system. Along with health plans, delivery systems are striving to provide truly managed and comprehensive care for populations for which they and their physicians are accountable. For physicians, there is a synergistic relationship between the perspectives of care for the individual and care for the group:

A population health perspective encompasses the ability to (1) assess the health needs of a specific population; (2) implement and evaluate interventions to improve the health of that population; and (3) provide care for individual patients in the context of the culture, health status, and health needs of the population of which that patient is a member.8

For the practicing physician, population-based care is applied at the level of his or her patient panel, as differentiated from the public health focus on whole communities and large populations. Patient panels can be identified and categorized along various dimensions, such as demographics, socioeconomic factors, insurance coverage, or health status. As reflected in several of these reports, the first learning objective is to foster recognition and understanding of this perspective in the provision of health care—a “willingness to accept at least partial responsibility for the health of populations.”8 The second objective is to develop competencies in using the tools and techniques for serving both patients and populations so that these responsibilities are complementary and not conflicting.

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Topics

Specific topics in this domain that are recommended in these reports include enabling physicians to

▪ define and describe populations as they relate to health status;

▪ organize and establish databases to assess risk factors or prevalences of specific diseases among subpopulations;

▪ apply population-based strategies to identify and reduce risk factors;

▪ apply population-based strategies to improve patients' use of and access to appropriate services and providers;

▪ allocate resources to maximize the defined population's health, recognizing implications for the care of each individual patient; and

▪ accept responsibility towards enrolled members of a health plan or underserved members of a community who do not initiate visits or present for care.

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Quality Measurement and Improvement
Context

The reports consistently recommend that more work is needed in health care to improve quality, reduce errors and inefficiency, and enhance service to patients. Continuous quality improvement techniques have affected some aspects of health care, particularly administrative operations. Now the front lines of medical care are beginning to apply these techniques in an effort to improve the entire process of care. In addition, employers, regulators, and health plans are more active in defining, measuring, and publicizing the quality of care and the performances of physicians, practices, and health care organizations. Accordingly, physicians need to learn both how the larger system is affecting them and how they can improve those elements that are within their control.

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Topics

Topics in this domain that are recommended in these reports include multiple aspects of quality in health care:

▪ definitions of quality and outcomes;

▪ methods for measuring performance and assessing quality of care;

▪ organizational strategies for quality improvement as applied to health care settings;

▪ analyses of the practice and implementation of practice-based improvement activities, using systematic quality improvement strategies;

▪ continuous quality improvement in clinical practice to improve the process and outcomes of care, including application of empirical data in a systematic fashion; and

▪ measurement of patient satisfaction and interpretation of these measures and their ratings.

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Medical Management
Context

All the reports reference limits on health care resources, and the need for cost-effectiveness and efficiency in the use and distribution of resources. Far from being immune to these pressures, physicians are seen as key players because they control, directly or indirectly, the vast majority of health care spending. The reports either cite cost concerns in the context for the specific functions of physicians, or they address cost control more explicitly as a criterion in clinical decision making (e.g., “residents are expected to practice cost-effective health care and resource allocation that does not compromise quality of care.”12). Nowhere do these reports state or imply that physicians should serve their patients without regard for the costs of care.

Complicating the physician's role as a provider of care and manager of resources is the rapid advancement in biomedical science affecting the diagnosis and treatment of disease. Moreover, epidemiologic and behavioral sciences continue to identify new opportunities to improve the health of populations and individuals. Physicians, individually and collectively, must learn how to select, develop, and implement interventions and practice protocols that achieve high-quality outcomes cost-effectively.

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Topics

Medical management is a broad category, encompassing knowledge, strategies, tools, and techniques for managing utilization and providing cost-effective care without sacrificing quality. The content recommended in these reports includes both general orientation to the topic and familiarity with specific tools and techniques:

▪ the medical management infrastructure—supports to physicians, groups, and networks in organizing and delivering high-quality and cost-effective care, for individual patients and for groups of patients;

▪ clinical decision making—considerations for deciding the optimal course of action at each point in the care process;

▪ evidence-based medicine—the ability to locate, appraise, and assimilate evidence from scientific studies from a variety of sources, including current research findings and recommendations, and apply these appropriately to the diagnosis and treatment of their specific patients' health problems;

▪ guidelines—developing, modifying, applying, or rejecting guidelines in specific practice situations;

▪ cost-benefit analysis—the ability to analyze the costs and probable benefits of different treatment plans that use varied mixes of inpatient/outpatient procedures and/or specialist services to manage a patient with a specific condition; cost-analytic approaches and information in prioritizing the use of resources;

▪ utilization management in general—understanding the potential contributions and pitfalls of various approaches to determining and delivering units of service and components of care during all phases of an episode of illness;

▪ disease management—methods to collect and monitor data from a group of patients with a chronic condition and use these data to develop and implement management plans;

▪ referral management—clear communication of expectations to a consultant; approaches to improving communication between generalists and specialists;

▪ case management—understanding case management techniques for patients with complex disease processes to assure access to necessary clinical services and efficient use of resources; and

▪ care coordination—coordination and advisory roles for a physician relative to a panel of patients.

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Preventive Care
Context

The long-standing medical model of care and treatment of acute illness by physicians may retain its central position, but, as the reports point out, health and health care now connote much more. The focus on health, as differentiated from illness, places greater emphasis on prevention, health promotion, and disease management. The benefits of preventive care are reinforced in a population-based or care management practice environment. As stated in the Pew Commission report, the best managed care arrangements emphasize education, healthy lifestyles, and early detection and treatment of disease. In fully integrated delivery systems, practitioners assume responsibility for the long-term health of their patients. Healthy individuals, families, and communities enjoy a higher quality of life and consume fewer health care dollars. Health professionals can help people and communities learn self-management skills that promote and protect their health.10

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Topics

Specific topics referred to throughout these reports include

▪ delivering health care services intended to prevent health problems or maintain health;

▪ understanding and applying principles of disease prevention and behavioral change appropriate for specific populations of patients;

▪ understanding the link between healthy lifestyles, prevention, and the cost of health care;

▪ implementing strategies for reaching those who do not present for care on their own; and

▪ employing non—office-based approaches to keeping patients healthy.

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Physician—Patient Communication
Context

The topic of physician—patient communication skills is a mainstay in medical school and residency curricula. The new practice environment adds new learning objectives to this existing base. Just as physicians need to revise their sense of professional responsibilities and develop new competencies, so do patients need to adjust their expectations and familiarize themselves with new care-delivery systems and processes. The interactions between physician and patient are made more complex under these circumstances.

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Topics

Specific topics include

▪ managing patient and family expectations regarding referrals and procedures;

▪ responding to a patient's demand for inappropriate or unnecessary services;

▪ communicating with groups of patients as well as with individual patients, including those who do not present for care; and

▪ applying behavioral change strategies relating to lifestyle factors of both individuals and populations.

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Ethics
Context

Analysis of the ethics issues involved in care is a standard component of the medical curriculum. The new challenge, cited in all the reports, is to integrate into the curriculum the ethics issues raised by changes in practice related to a physician's accountability for costs as well as quality, and for a population as well as the individual.

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Topics

Specific topics cited in these reports reflecting the changing environment include

▪ recognizing, analyzing, and addressing the physician's responsibilities to patients in the face of sometimes-conflicting pressures;

▪ understanding and responding to patients' concerns regarding potential conflicts of interest because of reimbursement method or organizational structure;

▪ understanding distributional ethics and the physician's responsibilities to a population as well as to the individual; and

▪ exposing ethics issues in choices about treatment and use of limited health care resources.

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Teamwork and Collaboration
Context

To a growing degree, physicians work within organized systems of care. Physicians must learn about organizations and how to be most effective within them. Further, the reports suggest that knowledge of teamwork that has proven effective in other fields and professions can and should be applied to health care. The benefits will be felt by physicians and their colleagues as well as by their patients. Teamwork and collaboration are instrumental in improving the work environment for physicians and others, and in yielding better results for patients.

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Topics

Specific topics in this domain that are recommended in these reports include

▪ applying team-based techniques to assess, coordinate, and improve overall health care;

▪ learning individual roles and processes required to work collaboratively with other health care professionals, including those from other disciplines, to provide more patient-focused care;

▪ valuing the unique contributions of different members of a health care team;

▪ learning and applying skills in team leadership, group dynamics, cognitive styles, and delegation; and

▪ using team approaches in patient education.

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Information Management and Technology
Context

The impact of emerging information technologies is pervasive throughout society. In health care, which has been relatively slow to apply these tools, providers and consumers alike will be affected. The reports emphasize that physicians and their delivery networks will need sophisticated information systems to guide clinical decision making, to keep track of and help manage their practices, and to assess their utilization patterns and outcomes. Consumers also have increased access to information about health and illness. In response, physicians need to act as information consultants to their patients and to adjust to serving a more informed clientele.

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Topics

Specific topics in this domain that are recommended in these reports include using information technology to

▪ access and manage medical information;

▪ support clinical decision making;

▪ profile practice patterns;

▪ collect and disseminate patient population profiles;

▪ support physicians' education; and

▪ enhance patient education.

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Practice Management
Context

Practice management topics are cited in five of the nine reports, suggesting some ambivalence as to whether this information belongs in the curriculum for students and residents, or whether it is an area to be learned after training is completed. The content can include both internal practice operations and external environmental factors and relationships affecting the practice.

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Topics

Among those reports that do reference practice management, specific topics include

▪ rudimentary knowledge of basic business skills and the business aspects of managing a medical practice;

▪ evaluating, negotiating, and implementing managed care contracts;

▪ management of financial risk;

▪ implications of managed care delivery models for the daily practice of medicine;

▪ appropriate selection and employment of medical personnel;

▪ time management and patient flow; and

▪ practice systems, e.g., telephone, appointment, triage.

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CURRICULUM ORGANIZATION AND SEQUENCING

The ten curriculum domains and their related teaching topics reviewed above present a new conceptual framework for both medical school and residency training and practice. The analysis of the medical education literature reflects a rapidly changing medical profession and leaves little doubt that this broad set of knowledge areas and competencies is essential for the successful practitioner.

The ongoing challenge is twofold: (1) converting the domains and their numerous topics to specific lessons and experiences; and (2) determining at what stage of training each component is most appropriate. Some content is most appropriately learned by the practicing physician rather than the student or resident. For the other topics, the next phase of curricular reform will probably establish norms regarding the organization and sequencing of the domains and their content, integrated within medical schools and residency training programs.

A number of initiatives in curricular reform are under way, already acting on this call to action:

▪ A five-year, national medical education demonstration project, Undergraduate Medical Education for the 21st Century (UME-21), is funding initiatives at 18 U.S. medical schools to encourage educational partnerships and curricular innovations to teach students about practicing high-quality, cost-effective medicine for individuals and populations.13

▪ The clerkship directors in internal medicine have rewritten their core curriculum guide to address some of the curricular topics and competencies cited above.14

▪ At the graduate medical education level, the residency review and institutional review committees are mandated to incorporate the new general competencies of the Accreditation Council for Graduate Medical Education into their requirements.12 The specialty boards are adapting their criteria for professional certification to include the same set of competencies, as relevant for each specialty.

▪ Between 1996 and 1999, the Partnerships for Quality Education (PQE) program, funded initially by The Pew Charitable Trusts and currently by The Robert Wood Johnson Foundation, supported 66 partnerships between residency training programs and managed care organizations to incorporate managed care skills into primary care resident education. Subsequently the PQE also funded 50 partnerships to develop and implement educational programs for primary nurse practitioners as well as medical residents.15,16

There is sure to be a groundswell of curricular changes at medical schools and residency programs over the next several years. While the organizations whose reports and initiatives are referenced in this article influence what happens at every institution, academic medicine still comprises myriad entities—teaching hospitals, schools, programs, departments, chairmen, directors, faculty—with a good deal of independence and discretion in curricular matters. In this complex yet fragmented environment, curricular reform can be facilitated by a shared vocabulary. A common nomenclature for curricular content will help departments and programs within the same school or teaching hospital to coordinate their courses and training activities. It will provide learners continuity and consistency as they absorb information from different faculty and sites. Shared definitions will also make it easier for schools and programs to learn from the experiences of other institutions elsewhere in the country and to draw upon existing courseware and instructional models.

We propose that our synthesis of major medical education reports presented above offers a nomenclature and definitions that capture the essential content put forth for training future generations of physicians. Our titles for the ten domains are compatible with the current leadership and scholarship on this topic. As categories of curricular content, the ten domains are a useful and logical framework for organizing the recommended body of knowledge and sets of competencies. We believe that the distribution of specific topics among the domains is consistent with the collective intentions of the authors of the nine reports.

Academicians who wish to develop and implement curricular changes at their institutions are likely to encounter one or more of these nine reports. The domain-based framework we have presented here provides a context for and a complement to the individual reports. Our summary indicates the relative consistency and strength of the support for each domain, and it specifies content and detail in topic areas related to the reports' recommendations. This framework can help the curriculum developer to make the transition from the reports and their recommendations to a program of study and the various syllabi involved.

As schools and programs undertake steps to reform and redesign their curricula, they will encounter a number of barriers to change. These barriers include

▪ competition with numerous other topics for scarce curricular time,

▪ lack of departmental “ownership” of the new competencies or curriculum topics,

▪ lack of adequate texts and instructional materials in the new or expanded topics,

▪ faculty inexperience, lack of knowledge, and negative attitudes about the recommended principles and practices, and

▪ little teaching experience at sites that are most appropriate to partner with schools and programs in teaching the new knowledge and skills.

Strategies for deans, program directors, faculty, and others to meet these challenges include

▪ integrating these curriculum domains and content within existing courses, clerkships, and rotations, rather than inserting a new course into an already crowded curriculum;

▪ involving the highest levels of leadership at each school and institution to promote the new curricular components and provide direction and support to the groups and individual faculty that will implement the changes;

▪ drawing from the growing body of available instructional materials and new Web-based educational programs in these domains;

▪ strengthening faculty members' knowledge of and ability to teach these topics through their own continuing medical education experiences and train-the-trainer programs; and

▪ stimulating collaboration between established academic programs and new teaching sites, such as effective community practices and health plans.

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LIFELONG LEARNING

As stated earlier, we believe that a common nomenclature and a framework such as we have proposed are valuable for identifying and adding curricular content to the current base of training and instruction in medical schools and residencies. The next steps in curricular reform will be converting this content to educational courseware, materials, and experiences, and deciding what content to teach at which stage of training. We emphasize again that strategies for success need to involve key people at all levels: deans, programs directors, and faculty.

For practicing physicians, continuing medical education (CME) will be a key resource for learning the new content and skills they need. Already, medical education in the United States has fostered an admirable commitment to lifelong learning within the profession. Physicians recognize their need to keep pace with developments in biomedical science, and they develop skills to acquire this new information expeditiously and apply it appropriately. Similarly, they will need to keep pace with the organization and financing of health services and approaches to care management, as these aspects of health care also continue to evolve. Thus, CME education and training programs, like those on the medical school and residency levels, must revise their curricula to help physicians understand their current practice environment and acquire new competencies to provide and manage high-quality and cost-effective care for their patients and panels. The commitment to lifelong learning must extend to these nonclinical spheres throughout the continuum of medical education if physicians are to realize their full potential, both for their own professional fulfillment and to promote health and combat disease on behalf of their patients and society.

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