Rabinowitz, Howard K. MD; Babbott, David MD; Bastacky, Stanford DMD; Pascoe, John M. MD, MPH; Patel, Kavita K. MD; Pye, Karen L.; Rodak, John Jr. MS(Hyg), MS(HSA); Veit, Kenneth J. DO, MBA; Wood, Douglas L. DO, PhD
Dr. Rabinowitz is professor, Department of Family Medicine, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania; Dr. Babbott is professor emeritus, Department of Internal Medicine, University of Vermont, Burlington, Vermont; Dr. Bastacky is chief, Policy and Special Projects Branch, and Mr. Rodak is senior health professions education specialist and UME-21 project officer, Division of Medicine and Dentistry, Bureau of Health Professions, HRSA, Department of Health and Human Services, Rockville, Maryland; Dr. Pascoe is professor, Department of Pediatrics, Wright State University School of Medicine; Dr. Patel was formerly president, American Medical Student Association, Reston, Virginia, and is currently a resident in internal medicine at the Oregon Health Sciences University; Ms. Pye is president, KLPye Consulting, Landenberg, Pennsylvania; Dr. Veit is dean, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania; and Dr. Wood is president, American Association of Colleges of Osteopathic Medicine, Chevy Chase, Maryland.
Correspondence and requests for reprints should be addressed to Dr. Rabinowitz, Department of Family Medicine, Jefferson Medical College of Thomas Jefferson University, Suite 401, 1015 Walnut Street, Philadelphia, PA 19107; telephone: (215) 955-7416; fax: (215) 923-6256; e-mail: 〈Howard.Rabinowitz@mail.tju.edu〉.
The authors' positions and affiliations are listed at the end of this article.
For articles on related topics, see pages 598 and 606.
The UME-21 Project is funded by the Division of Medicine and Dentistry, Bureau of Health Professions (BHPr), Health Resources and Service Administration (HRSA), U.S. Department of Health and Human Services (HHS), Rockville, MD, under Contract #240-97-0038, and administered by the American Association of Colleges of Osteopathic Medicine, Chevy Chase, Maryland.
The authors thank the following individuals and organizations that have been important to the UME-21 Project: Carol M. Bazell, MD, MPH, Director, Division of Medicine and Dentistry, BHPr, HRSA, HHS; the Primary Care Organizations Consortium (PCOC); the American Medical Student Association representatives on the UME-21 Executive Committee (Simon Ahtaridis and Joshua P. Rising); the members and organizations of the UME-21 Advisory Committee (including Ellen K. Hamburger, MD, and Lindsey K. Grossman, MD, Ambulatory Pediatric Association; Perry A. Pugno, MD, MPH, and Norman B. Kahn Jr., MD, American Academy of Family Physicians; Timothy R. Schum, MD, American Academy of Pediatrics; Barbara Ross-Lee, DO, American Association of Colleges of Osteopathic Medicine; Simeon A. Rubenstein, MD, American Association of Health Plans; Samson A. Inwald, DO, American College of Osteopathic Family Physicians; James B. Reuler, MD, American College of Physicians—American Society of Internal Medicine; Harry S. Jonas, MD, American Medical Association; Robert W. Chisholm, American Medical Student Association; Roger L. Bulger, MD, and Marian Osterweis, PhD, Association of Academic Health Centers; Michael E. Whitcomb, MD, Association of American Medical Colleges; Mark Johnson, MD, Association of Departments of Family Medicine; Penelope K. Patton Tippy, MD, Association of Family Practice Residency Programs; Lewis R. First, MD, MS, Association of Medical School Pediatric Department Chairs; Robert J. Nolan Jr., MD, Association of Pediatric Program Directors; Maurice A. Mufson, MD, Association of Professors of Medicine; Susan D. Wolfstahl, MD, Association of Program Directors of Internal Medicine; David Ross Garr, MD, Association of Teachers of Preventive Medicine; David Theige, MD, Clerkship Directors of Internal Medicine; Nancy Kaufman, MD, Council on Medical Student Education in Pediatrics; Mary R. Cicarrelli, MD, Medicine/Pediatrics Program Directors Association; Louis W. Sullivan, MD, National Medical Association; Gordon T. Moore, MD, MPH, Partners for Quality Education; Alexander W. Chessman, MD, Predoctoral Director's Group of the Society of Teachers of Family Medicine; Steven A. Wartman, MD, PhD, Society of General Internal Medicine; Elizabeth Ann Garrett, MD, MSPH, Society of Teachers of Family Medicine); the National Program Evaluators (J. Jon Veloski, MS, Jefferson Medical College of Thomas Jefferson University, and Barbara Barzansky, PhD, American Medical Association); Richard E. Schmidt, PhD, RSA Ltd., evaluation consultant; and the staff at the American Association of Colleges of Osteopathic Medicine.
The authors also thank the Project Directors (and faculty) at each of the 18 UME-21 Partner and Associate Partner Schools who implemented these important projects: Catherine F. Pipas, MD, and Ardis L. Olson, MD, Dartmouth Medical School; Maxine A. Papadakis, MD, University of California San Francisco; Mark T. O'Connell, MD, University of Miami School of Medicine; David J. Steele, PhD, and Jeff Susman, MD, University of Nebraska College of Medicine; Malcolm Cox, MD, University of Pennsylvania School of Medicine; Steven L. Kanter, MD, and John F. Mahoney, MD, University of Pittsburgh School of Medicine; Susan E. Skochelak, MD, MPH, University of Wisconsin Medical School, Maryjean Schenk, MD, MPH, Wayne State University School of Medicine; Linda O. Lewin, MD, Case Western Reserve University School of Medicine; Christine C. Matson, MD, Eastern Virginia Medical School; Susan L. Rattner, MD, MS, Jefferson Medical College of Thomas Jefferson University; David S. Brody, MD, MCP Hahnemann University; Bruce E. Gould, MD, University of Connecticut School of Medicine; Donna G. Grigsby, MD, and Lois Margaret Nora, MD, JD, University of Kentucky College of Medicine; Michele Pugnaire, MD, University of Massachusetts Medical School; Gregory M. Vercellotti, MD, University of Minnesota Medical School; Gregory M. Vercellotti, MD. University of Minnesota Medical School; Robert E. White, MD, and Daniel Derkesen, MD, University of New Mexico Health Sciences Center; Robert E. Gwyther, MD, MBA, University of North Carolina.
During the past decade, the organization, delivery, and financing of health care in the United States have undergone unprecedented change.1 This has resulted in a health care system that, while often described by the single term “managed care,” actually consists of a large number of diverse management strategies and organizational structures.2,3 While many of these changes were originally driven by concerns about the cost and quality of health care, it is becoming increasingly apparent that the current system has failed to adequately address either the cost or the quality problems that exist. Thus, continued major changes in this system are likely to take place in the future.3,4 Within this context, serious concern exists that young physicians are not being adequately prepared to provide optimal health care in the system where they will eventually practice.
HEALTH SYSTEM CHANGE AND MEDICAL EDUCATION
Increasing Attention to Quality of Care
For more than two decades, researchers have documented a large degree of variability in the quality of health care that exists in this country.5,6 Recently, however, the issue of quality has received increased national attention, with information about inadequate care frequently being reported in medical journals and in the media. A recent television special, hosted by Hedrick Smith, was entirely devoted to the issue of quality, asking, “How good is health care?”7 And a group of the country's largest corporations recently announced plans to encourage their employees to obtain health care where specific quality issues were being addressed.8 Physicians have also expressed concern that the quality of care they have been providing their patients has deteriorated over the past few years.9
With the increasing attempts to measure outcomes of care in recent years, there has been more awareness of this “quality gap,” i.e., the lack of alignment between the actual outcomes of care and what is considered to be ideal care. These quality problems have been divided into issues of medical overuse, underuse, and misuse.10 Estimates of medical overuse range as high as 20-50%, and considerable scientific evidence now exists that many surgical and medical procedures that are being done are clinically inappropriate, and that antibiotics and other medications are frequently being overprescribed.10–13
Similarly, many studies have shown substantial underuse of proven medical treatments, occurring as frequently as 50% of the time or more. These include major clinical issues such as not providing preventive treatments that have proven benefits (e.g., pneumococcal and influenza vaccinations), and not providing proven procedures and treatments (e.g., coronary angiography, and the use of aspirin or beta blockers in patients after acute myocardial infarction).14,15 While many of these studies have focused on comparisons among states or between different types of health care organizations or hospitals, the overall level of underuse has usually been more prominent than the differences in the levels of underuse among these groups.
Finally, and most recently, the nation's attention has been focused on the area of misuse, specifically the issues of medical errors and patient safety. The recent Institute of Medicine (IOM) report, To Err is Human, has certainly raised this level of awareness, reporting that up to 98,000 Americans die each year as a result of medical errors.16 A second IOM report on quality has just been published and provides a more comprehensive report on these issues.17
Rising Cost of Health Care
At the same time that the nation is focusing on the substantial variability and other concerns related to the quality of health care, the increasing cost of health care is poised to reemerge as an equally critical issue. While health care costs have been rising for decades, in part because of the dramatic advances in medical technologies and therapies, the level of cost has nevertheless reached a point where it has received unprecedented notice. The absolute level of national health expenditures has grown from $73.2 billion in 1970 to approximately $1.2 trillion currently, and is expected to reach $2.2 trillion by 2008.18 Even more important, the relative rise in health care costs has been more than twice that of overall inflation, and now represents approximately 14% of the total gross domestic product (GDP).
These increased costs are clearly making it harder to pay for health care. This is true for American businesses that pay for the health care of their employees, since this represents one of their fastest-growing and most unpredictable costs, and because the global economy has forced them to compete with other countries that have lower health costs. Health care costs are also a major concern for federal and state governments, which pay for Medicare, Medicaid, and other health care programs. And, it is certainly becoming more difficult for individual people to pay for health care, with out-of-pocket costs increasing, as evidenced by the current demands for prescription drug coverage. With continued medical advances likely to take place, these cost pressures are unlikely to relent in the foreseeable future. In fact, after the past few years of stability of health care costs (for the first such time in more than three decades), they are once again starting to rise, with health insurance premiums now increasing at double-digit rates.4,19,20
Role of Medical Education in the Changing System
The U.S. health care system, therefore, is currently facing crises in the critical areas of both quality and cost, with little likelihood that these underlying forces will abate.21,22 Some have suggested that health care itself has become so complex that these serious problems cannot be solved without major systemic changes.13,16,23 While few expect managed care to survive in its current form, little consensus exists as to the specific nature of the future health care system. It does seem clear, however, that the major driving forces for change will continue to include improving the quality of health care and controlling its costs.3,4,16,20 It also appears likely that these forces will take place in an increasingly competitive marketplace environment, fueled by a marked increase in consumerism, patients' concern with individual choice, and the greater availability of medical information and improved communication made possible by the Internet. This will also occur among an increasingly diverse and aging population.
As health care continues to change in these directions, little is being done to prepare young physicians in training to provide optimal care to patients within the system where they will eventually practice.3,24–29 Physicians, managed care executives, medical educators, and health policy analysts have all indicated that current trainees are not being adequately prepared for the future health care environment.2,29–31 Even medical students rate their own education as inadequate with respect to issues of medical economics, cost, quality, and managed care.32 Some managed care organizations (MCOs) have spent considerable time and money in training new physicians to work more effectively in their practice roles.2
But despite the rapidity of the changes in health care, and the ever-increasing pressure it places on addressing these issues,33,34 few medical schools or residency programs have responded by adapting their educational curricula to teach students to practice in this evolving health care environment. A small number of residency programs have developed managed care curricula,35–38 and more recently the Partners for Quality Education (PQE) program has funded residency programs to address these issues, finding that participating residents feel better prepared in these areas.39,40 At the medical student level, some medical schools have been using managed care settings for training,41–45 although most of these experiences have taken place in group- and staff-model HMOs, a relatively small and decreasing segment of the managed care marketplace. More important, even when students are trained in these settings, the focus has been to learn traditional clinical skills, similar to what is learned in non-managed care settings, rather than those competencies that are unique to managing care.41 In response to these concerns, a number of recommendations have been made for medical schools, including working collaboratively with MCOs and health care systems to modify curricula and develop training experiences that will better prepare medical students to practice high-quality, cost-effective medicine.2,30,46–48
THE UME-21 PROJECT
To address these issues, in 1997 the Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services, developed a demonstration project entitled Undergraduate Medical Education for the 21st Century (UME-21). The goal of this $7.6 million national project was to identify ways that medical schools, in partnership with various other organizations concerned with health care, could effectively provide educational opportunities to help students acquire the knowledge, skills, and attitudes they will need to practice in the new health care environment. In the remaining part of this article, we provide a brief description of the UME-21 project, describe some of the demonstrations that have been implemented, discuss challenges to the program's innovations, and outline plans for future evaluation.
In 1998, eight U.S. medical schools were competitively selected to participate in the UME-21 project and undertake comprehensive projects as Partner Schools, funded at $125,000 yearly for three years (from 1998 to 2001). Ten additional schools were funded as Associate Partner Schools at $20,000 a year for the same three-year period to implement smaller, more focused curricular changes. (The names of all 18 schools are shown in List 1.) As such, the UME-21 project represents the largest national demonstration program focusing on teaching clinical medical students to practice in the evolving health care system, affecting 12.5% (18/144) of all allopathic and osteopathic medical schools located across the United States. (For more information about the project, see 〈http://www.aacom.org/UME/〉.)
The curricular innovations of UME-21 were based in the three major primary care disciplines, and involved integration across these disciplines. All of these changes took place in the ambulatory setting, and most had substantial involvement at sites serving underserved populations, in both rural and inner-city areas. Each of the major innovations was focused in the core required primary care clinical clerkships, usually in the third year of medical school. Faculty development was also an important component of the UME-21 projects, and was undertaken by each of the schools.
A key component of the UME-21 project was to involve organizations outside the medical schools to collaboratively develop and implement these demonstration projects. These included managed care organizations, health plans, multispecialty physician groups, physician—hospital organizations, Area Health Education Centers (AHECs), community health centers, and local health departments. List 1 presents the names of the more than 50 external partners that were integral to planning and implementation of the UME-21 project. Each of the UME-21 schools has also developed a plan for evaluating its own project that complements the comprehensive national evaluation of the project (see below).
The eight medical schools funded as Partner Schools in the UME-21 project were required to include learning objectives from each of the following nine content areas that have been described as important for practice in the changing health care environment, while the ten Associate Partner Schools each addressed only one or more of these areas2,49:
▪ Health systems finance, economics, organization, and delivery
▪ Practice of evidence-based, epidemiologically sound medicine, with particular emphasis on a population-based perspective
▪ Development of effective patient—provider relationships and communication skills
▪ Quality measurement and improvement, including cost—effectiveness and patient satisfaction
▪ Systems-based care
▪ Medical informatics
▪ Wellness and prevention
Similar lists of competencies have been developed by others, and have been shown to be valued similarly by both residency directors and managed care medical directors.27,29,50–52
Unlike earlier national projects that were developed to broadly reform the medical education curriculum (e.g., the Generalist Physician Initiative,53 the Interdisciplinary Generalist Curriculum54), the UME-21 project was a demonstration project to determine ways to achieve its overall goals. Although some of the nine content areas (e.g., ethics, prevention) and some of the external organizations involved in this project (e.g., AHECs) had previously been part of medical students' education, their prior role had been to foster the teaching of traditional aspects of medicine. In contrast, the nine topics and the various organizations were included in the UME-21 project for the unique and specific focus of teaching students to practice medicine in the changing health care environment.
Structure of UME-21 Activities
In implementing the UME-21 demonstrations, some medical schools undertook major restructuring of their core primary care clerkships, while others chose to integrate UME-21 content into their existing clerkship structures. Examples in each category follow.
Restructuring core primary care clerkships
The main clinical component of the four-year Managing Care Curriculum at Wayne State University School of Medicine is the new six-month longitudinal Continuity Clinic Clerkship. This consists of one-half day per week in the same community-based primary care ambulatory practice, which takes place concurrently with the three primary care core clerkships. In order to link these clinical experiences with the UME-21 instructional curriculum in years one and two, clinical learning exercises have been developed that involve interaction with electronic resources (for more information about these exercises and the clerkship, see 〈www.med.wayne.edu/ccc〉). Examples of these exercises include performing a community health assessment; applying clinical guidelines to a patient cared for by the student; obtaining telephone follow-up of patients regarding their care, compliance, and satisfaction; meeting with administrative and financial staff in their offices; and following a patient through the health care system, including determining the total cost of care. In order to standardize, monitor, and evaluate the students' experiences and performances, students develop, discuss, and review a learning contract with their preceptor throughout the Continuity Clinic Clerkship.
The University of California, San Francisco, School of Medicine completely restructured its third-year clerkships, dividing the academic year into two 24-week blocks: the outpatient Longitudinal Block and the Inpatient Block. A major component of the new Longitudinal Block is an ambulatory care placement held half a day per week for students at one of the external partner MCO's primary care sites. Throughout the Longitudinal Block, a series of interdisciplinary managed care instructional sessions is taught in small groups one-half day per month.
The University of Pittsburgh School of Medicine has implemented its new, multidisciplinary Community/Ambulatory Medicine Clerkship, a 12-week requirement for third-year students. The clerkship includes core clinical experiences in each of the three primary care disciplines, as well as one additional ambulatory selective. Each week throughout the entire clerkship, half-day instructional sessions take place that are integrated and interdisciplinary and that incorporate UME-21 competency areas. Each student also completes a series of “training problems” (e.g., back pain, abdominal pain) related to important outpatient issues, incorporating relevant UME-21 principles. For each issue there is an associated information resource on the Web, which can be accessed via 〈http://www.hsls.pitt.edu/curric/camc/〉.
Integrating UME-21 within existing primary care clerkships
Dartmouth Medical School enhanced what it calls its Student—Preceptor Learning Dyads at each teaching site during the community-based integrated primary care clerkship, which is required for 16 weeks during the third year. As part of these dyads, each student participates in a wide range of activities in collaboration with his or her preceptor, including projects related to evidence-based medicine (EBM), population-based medicine, and continuous quality improvement (CQI). Students study the treatment and management of clinical problems utilizing guidelines, practice data, and managed care resources. PalmPilot hand-held computers are used to facilitate many of these learning activities.
The University of Wisconsin Medical School has introduced managed care modules into each of its third-year primary care clerkships. The pediatrics clerkship focuses on medical ethics and ethical decision making; internal medicine has developed a Web-based EBM curriculum (see below); and the primary care clerkship (which includes family medicine) uses Web-based clinical cases incorporating UME-21 principles (these cases can be accessed at 〈http://www.fammed.wisc.edu/pcc/〉). A core managed care lecture series takes place during one-half day between the clerkships, when all students return to the main campus. A managed care curriculum has been developed for the required community preceptorship during the fourth year. Each student is required to complete one managed care activity related to each of the nine UME-21 curricular areas, from among a list of options that are available at the specific preceptorship site.
The University of Nebraska College of Medicine has developed a comprehensive and integrated managed care curriculum, Education for Managed Care Competencies (E = MC2′), which spans 18 months during the third and fourth years of medical school. This program includes (1) four self-paced Web-based modules (found at 〈http://www.unmc.edu/Pediatrics/managedcare/〉); (2) a series of formal workshops called Challenges in Managed Care, including issues related to credentialing, utilization review, and informatics; (3) the systematic inclusion of UME-21 issues in various formats throughout the core clinical clerkships, e.g., community assessment projects and utilization management rounds; and (4) managed care mini-practicums involving direct experiences in managed care settings (see below).
The University of Pennsylvania School of Medicine has developed a comprehensive program to teach and integrate the principles of UME-21 throughout its entire four-year curriculum. The core clinical clerkships in primary care have been expanded to include community-based experiences, and during these clerkships interdisciplinary problem-based seminars have been modified to incorporate managed care concepts, and have been expanded to include the use of disease-management protocols. A new interdisciplinary, small-group seminar series on communication, professionalism, and medical ethics has also been instituted. An indepth course that covers clinical evaluative science, EBM, resource allocation, health care economics, and managed care has been added to the preclinical curriculum, and a series of student-organized plenary sessions on managed care topics has been developed for the entire medical school community.
Case Western Reserve University School of Medicine has implemented a series of case-based small-group discussions focusing on UME-21 concepts. These sessions are part of a longitudinal experience across the core clerkships for all third-year students. This curriculum, entitled Contemporary Learning in Clinical Settings (CLICS), occurs once during each four-week block of the third year.
Jefferson Medical College of Thomas Jefferson University has restructured one week of its six-week ambulatory subinternship for fourth-year students whose clerkships take place in the Philadelphia area. This mini-clerkship consists of interactive seminars on provider relations, ethical issues in managed care, finance and contracting issues, strategic planning and network development, information services, disease management, and EBM. Each student spends a half day at a local MCO, working one-on-one with a medical director. A Web-based version of this mini-clerkship is being developed.
Specific Curricular Innovations
The eight Partner Schools and ten Associate Partner Schools are implementing a wide range of specific curricular changes. Some of these involve working directly with managed care and other external organizations, while many focus on special demonstration projects. In this section, we describe specific curricular changes that the 18 UME-21 schools have instituted, and focus on those changes that are generalizable and important to educators and policymakers.
Working directly with managed care organizations
While each of the UME-21 medical schools works closely with its external partners, some provide their medical students with extensive contact with the administrative structures of those organizations. Students participate in activities with managed care medical directors, utilization review (UR) coordinators, quality assessment/quality improvement (QA/QI) coordinators, insurance coordinators, and others.
For example, as one part of its comprehensive four-year UME-21 curriculum, the University of Miami School of Medicine has developed a structured practicum whereby third-year students spend one day at the administrative offices of their external partner, AvMed Health Plan. This experience takes place during the 12-week interdisciplinary primary care clerkship, and involves exposure to several aspects of the internal operations of an MCO, including medical management, population care, practice guidelines, affordability, and quality of care. Students also observe AvMed staff in a number of administrative units as they coordinate care with members and providers.
One component of the University of Nebraska College of Medicine program is a managed care mini-practicum working with their five managed care partners. Each student is required to spend three hours in a call center, observing actual case management and utilization review. In addition, students participate in three additional activities of their choosing at a managed care partner site, from among formal managed care activities related to credentialing, drug utilization, utilization management, subscriber appeals, benefit interpretation, accreditation, and quality assurance.
The University of Minnesota School of Medicine has developed a project whereby all students participate in a two-hour managed care colloquium with a panel of two MCO executives. This colloquium involves direct discussions of issues in managed care, including health plans' vision and purpose, design of a health care system to serve an overall population (including culturally diverse groups and individuals with special needs), the use of physician incentives, and the portrayal of managed care in the media.
Specific UME-21 demonstration projects
Many of the UME-21 schools have developed special projects to teach one or more of the nine proposed learning objectives, discussed below.
Continuous quality improvement (CQI) projects
The University of Connecticut School of Medicine has developed a CQI project that medical students complete during their half-day continuity practice, which they attend during the first three years of medical school. Second-year students and their preceptors receive formal training on CQI, medical error prevention, and record abstraction, and are provided with information regarding national guidelines of care. Students then perform chart audits on a random sample of patients from their practice with a chosen clinical condition (e.g., diabetes mellitus, hypertension, asthma in children) using validated clinical collection instruments developed by Qualidigm (formerly the Connecticut Peer Review Organization). After these baseline performance data are entered and analyzed by research assistants, a quality report, including peer, aggregate, and benchmark data, is given to each student and his or her preceptor. The student and the preceptor then choose and implement one improvement intervention in the practice, e.g., a disease-tracking form or a consultation-review form. After six to 12 months, the same students (now in their third year), repeat their audits, collecting post-intervention data to assess the impacts of the interventions. Details of this process may be found at 〈http://www.commed.uchc.edu/preceptor/choice.htm〉.
The University of Miami School of Medicine requires all second-year students to perform a quality assessment (QA) of a primary care practice. Students use an assessment instrument derived from HEDIS (Health Plan Employer Data and Information Set), NCQA (National Committee for Quality Assurance), JCAHO (Joint Commission on Accreditation of Healthcare Organizations), and AMAP (American Medical Accreditation Program) criteria. Upon completion of the QA project, students discuss their results with faculty.
Evidence-based medicine (EBM) projects
Eastern Virginia Medical School has developed a nine-month elective for fourth-year medical students, who work as a group with their MCO partner on an EBM project throughout the year. This group is responsible for developing and validating a written and Web-based version of an EBM practice monograph (for example, a monograph on the topic of hyperlipidemia), as well as a practice guideline, to be used by physicians who work with the MCO. Students also participate in formal instructional sessions on the principles of EBM, and work on an individual EBM project related to a clinical issue of their choosing.
The University of Wisconsin Medical School has developed and implemented a self-instructional, computer-based program, EBM Roadmap, whereby students can learn the basics of EBM. This program may be found at 〈http://www.infocare.medicine.wisc.edu/ROADMAP/〉. The program guides them through an EBM approach to medical questions, helps provide a general interpretation of the evidence, and calculates the “core numbers” used in EBM. Additionally, there is a computer-based “decision walk-through” that takes students through the steps necessary for decision analysis (see 〈http://infocare.medicine.wisc.edu/informatics/DECISIONS/walkthrough/intro.html〉).
Population-based medicine projects
At Dartmouth Medical School, each student is involved in a number of population-based medicine projects, including an assessment of health care in the community and the collection and analysis of patient population data to look at practice variations. Students use their PalmPilots to record the documentation of their clinical experiences. Interim summary reports guide mid-course adjustments, assuring that course objectives are met.
Wayne State University School of Medicine is using a population-profiling program, developed in collaboration with its College of Urban, Labor, and Metropolitan Affairs, which students use with the patients they have seen during their six-month longitudinal ambulatory care rotation.
The University of Minnesota School of Medicine has developed a population-based computer project for all students, using an actual Medicare claims database with blinded information about 4,000 patients.
Computer-assisted instruction and Web-based learning
The University of North Carolina School of Medicine has developed clinical problem-solving exercises that are online and interactive. These self-instructional cases provide immediate feedback to the students, and have a built-in self-assessment program. The cases are built around clinical problems; cases concerning diabetes mellitus (family medicine), asthma (internal medicine), and the presence of a breast lump (obstetrics-gynecology) have been implemented (see 〈http://webct.unc.edu〉; click on “Course Listing,” “Special Courses,” and “MED 001 001.” The user name is “guestaccount” and the password is “guest”). A case on precocious puberty (pediatrics) has also been developed. Cases are supplemented by an interdisciplinary seminar relating to the students' actual clinical experiences. In family medicine, these seminars take place at AHEC sites around the state, frequently co-led by the AHEC clerkship director or AHEC faculty and a medical director of Blue Cross/Blue Shield of North Carolina.
The University of Kentucky School of Medicine is developing three computer-assisted patient management problems incorporating the principles of managed care, one of which has already been implemented. These cases involve patients covered by CHA Health or KenPac health plans, and were developed with input from the University's CHA partner, which directs both plans. In addition to diagnostic and treatment options, emphasis is on issues related to pre-authorization, formulary use, and primary and secondary prevention issues affecting medically underserved populations.
The standardized family
The University of Massachusetts Medical School has developed small-group problem-solving sessions in the primary care clerkships, focusing on the care of the same multigenerational standardized family, the “McQs.” This project expands the prior experience in family medicine with the McQs55 by adding new family members, by expanding the breadth of medical issues involved, and by incorporating managed care principles. The McQ family is insured by a representative managed care plan, and the project uses supplementary materials such as a drug formulary and practice guidelines. Currently students use printed curriculum materials, including patient charts, readings, and reference lists, although expansion to a Web-based format is under development.
Jefferson Medical College incorporated a series of managed care monographs into the required third-year curriculum in the primary care disciplines. During these rotations, students complete and are evaluated on the content in five self-instructional modules in The Physician's Study Guide on Managed Care.56 These modules are The Key Principles and Definitions in Managed Care; How to Maintain Autonomy While Using Clinical Practice Guidelines; Using Cost-Effectiveness Principles While Maintaining Quality in Clinical Care; Medicare and Medicaid in a Managed Care Environment; and Strategies for Success in a Managed Care Environment.
The University of New Mexico School of Medicine has revised its problem-based tutorials and created new tutorials during the three primary care clerkships, in order to establish a population-oriented curriculum emphasizing managed care knowledge and skills. Each tutorial covers at least two of the nine UME-21 competencies, and teaches care management as an integral part of clinical practice.
Integration of UME-21 into the history-taking process
The University of Pennsylvania School of Medicine provides formal instruction to its students on how to expand the medical interview process to include financial and economic information and incorporate issues related to disease management, clinical pathways, and guidelines. During the core primary care clerkships, students are required to routinely include these areas in the medical history, and their fulfillment of this requirement is monitored on a regular basis.
The MCP Hahnemann University School of Medicine has developed a structured clinical encounter form that third-year students use during their four-week rotation in ambulatory internal medicine. Each student completes this form for one patient each day, focusing on such issues as the patient's insurance coverage, cost-effective decision making, prevention, psychosocial problems, and the patient's goals for the visit.
A critical part of the UME-21 project is to evaluate the educational innovations that it initiated and to identify and assess the project's outcomes. A National Program Evaluation (NPE) contract was awarded to the Center for Research in Medical Education and Health Care at Jefferson Medical College, working with the Division of Education of the American Medical Association. In addition to working with each school's local evaluator, the NPE team will describe the baseline status for each Partner School, describe the UME-21 curricular development, document the process of institutional change, and describe the outcomes of the project.
In order to accomplish these goals, the NPE is obtaining qualitative data from a number of sources (e.g., periodic progress reports, site visits, and meetings with local school evaluators). In addition, annual analyses of quantitative data are being undertaken, obtained from (1) the Association of American Medical Colleges' (AAMC's) Graduation Questionnaire (GQ), (2) a UME-21-developed questionnaire administered to graduating medical school seniors, (3) a survey of residency program directors, and (4) data from the schools' internal evaluations. This comprehensive evaluation will be completed in 2002 and will provide outcomes regarding the impact of this demonstration program.
CHALLENGES AND BARRIERS
Many of the innovative demonstrations of the UME-21 project are comprehensive, and all include substantial changes to the traditional undergraduate medical curriculum. Thus, it is not surprising that a number of challenges have arisen in implementing these projects. Many similar issues exist across schools, and are related to program implementation, student acceptance, faculty development, working with external partners, and the rapid changes taking place in the overall health care environment.
Change in medical education requires the involvement of a large number of individuals at a variety of locations, some of whom have considerable investment in the status quo. In addition, many of these changes are occurring during a time of considerable instability in the health care environment. As such, organizing and introducing these changes, integrating them within the current curriculum, obtaining wide faculty support, developing the various teaching instruments and computer-based components, and finding ways to rein-force the instructional components within the clinical setting have all provided similar challenges for the UME-21 schools.
In addition, medical students, already overwhelmed with the need to understand an increasingly expanding scientific knowledge base and range of therapeutic modalities, have had mixed reactions to these curricular changes. While many students have been keenly interested in learning about the health care environment in which they will practice, others have found the focus on “non-medical” issues distracting, and at some schools students have expressed concern that their curricula have been changed without their input. A number of faculty have also been resistant to expanding their own knowledge related to the issues of managing care, especially at a time where they have been facing increasing pressures and time constraints.
While one of the major strengths of the UME-21 project has been bringing together academic health centers with external partners involved in managing care, it has at times been a challenge trying to merge their two very different cultures. However, in many instances the ideas and perspectives of the managed care partners have provided for some of the most innovative curricular changes. Finally, the rapid changeover in personnel and organizations that is taking place in both the academic environment and the managed care industry continues to provide significant challenges to this project. During the first two years of implementation of the project, a number of UME-21 medical schools experienced significant financial problems, and encountered changes in project directors, key faculty, or school leadership. Similarly, within the managed care environment there have been numerous mergers and acquisitions, as well as a number of changes in medical directors or senior administrators who were intimately involved in and committed to the proposed UME-21 projects.
At each school, the commitment of the leadership of the medical school, the project directors, and the external partners have been key to the success of the UME-21 project. Major project successes have also resulted from including the relevant groups and personnel in the decision-making process, fostering interpersonal relationships, achieving organizational commitment, and having frequent discussion and negotiation. However, the process of change continues to require considerable ongoing time and effort.
Despite all of the challenges and barriers that exist, however, the UME-21 project has already catalyzed a number of curricular changes within 12.5% of all medical schools. We look forward to the results of the ongoing national evaluation, which will provide information as to which of this important project's curricular demonstrations worked and what institutional changes resulted.
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