Editor’s Note: This is a commentary on Chen C, Petterson S, Phillips RL, Mullan F, BazemoreA, O’Donnell SD. Toward graduate medical education (GME) accountability: Measuring the outcomes of GME institutions. Acad Med. 2013;88:1267–1280.
The article by Chen and colleagues1 in this issue suggests that the context in which clinical medical education is executed matters, especially if we intend to meet the projected future physician workforce needs in the United States. Currently accepted models of clinical medical education for both students and residents depend on interfacing in real time with patients during health care delivery, yet integrating education with health care delivery presents significant challenges. Placing learners in the highest-performing medical settings seems intuitive if the goal is to produce the highest-performing physicians. However, efficient and effective models of care are built around the patient, not the learner. The very presence of students and residents may threaten the perception of efficiency, and educational goals may clash with productivity goals. Overcoming these challenges to integrate the education and patient care missions in academic clinical settings is critical in developing the next generation of physicians.
The settings in which clinical medical education occurs today are remarkably broad and complex. Historically, clinical learning occurred in the hospital, often because this setting provided abundant inpatient experiences. With current pressures to reduce length of stay and optimize utilization of resources, the inpatient learning environment must be supplemented, and perhaps one day supplanted, by other clinical settings, such as ambulatory offices, patient-centered medical homes, and skilled nursing facilities. These settings, which are becoming increasingly interconnected through accountable care organizations and sharing of electronic health records, are crucial to quality patient care and must be incorporated into training because of the insights they can provide.
Geisinger Health System is an integrated health care institution including a 1,300-member multidisciplinary group practice, primary through quaternary hospitals, ambulatory surgery centers, skilled nursing facilities, a network of community practice clinics, and a health insurance plan that offer coordinated care across specialties and facilities to people in the 50 mostly rural counties of central and northeastern Pennsylvania. Geisinger’s mission is to enhance quality of life through an integrated health service organization based on a balanced program of patient care, education, research, and community service. In our move away from traditional fee-for-service health care, our clinicians and stakeholders collect and assess data to define quality and performance drivers that lead to redesign of the care delivery model. A formal integrated longitudinal curriculum is used to deliver systems-based practice principles to nearly 400 residents and 100 medical students who are assigned to our clinical campus for their entire third and fourth years of clinical training. Here, we draw on our experience at Geisinger to explore the challenges and advantages to integrating the education and patient care missions of academic clinical sites for learners, patients, faculty, and the future of the workforce.
Barriers to Integrating Clinical Education With Care Delivery
Integrating medical education with health care delivery can be disruptive to the patient care interface, especially in high-performing health care delivery systems that strive to orchestrate each step of the patient experience, creating and executing a highly reliable process of care. Efficiency is an important driver of value in health care, captured in the common goal of providing “the right care to the right patient at the right time.” Access to care can be increased when practice efficiency is improved; this may be especially important for populations who experience disparity in access to health care. Although advanced primary care residents contribute to patient access, the presence of novice learners in these settings may decrease clinical efficiency by increasing the time needed for patient flow or increasing space needs to accommodate educational activities. The physician–patient relationship is also altered by the presence of learners, with potential effects on both the physician’s and the patient’s satisfaction with the experience. As patients have become more informed regarding health care delivery, quality, and safety, patients are often less willing to accommodate drop-in learners. Students may be increasingly disconnected from the physician–patient relationship. This relationship is no longer just face to face—physicians and learners must manage patient data and electronic communication in addition to the traditional patient visit.
Traditionally, clinical and educational processes have not been analyzed to determine how to maximize both clinical and educational outcomes. Inefficient systems resulted in gaps in productivity in which learners could be accommodated. Now that efficient clinical care delivery is being developed, learners are labeled as a disruption to clinical care.
Some educators may believe that efficiency in patient care is the enemy of clinical medical education. Graduate medical education (GME) faculty lament the lack of time to teach. Education roles and goals may be both unspoken and underrecognized in the clinical setting. Clinicians obsess about meeting relative value unit benchmarks for productivity that serve as a driver for compensation, in part because of models of payment incentives tied to units of work rather than to patient or learner outcomes. Concerns about devoting time to education duties are compounded by clinicians’ concerns that they are not being prepared to teach the new competencies of practice-based learning and systems-based practice required to manage patients within a medical home and with electronic communication (Geisinger Academic Affairs Program Director and Faculty survey, unpublished data, 2002–2012). Faculty knowledge and skill in quality improvement, systems of care, and interprofessional teamwork are underdeveloped.
Aligning Vision Locally and Nationally
Aligning medical education leadership, mission, vision, strategy, and tactics with the high-reliability health care delivery system can be a starting point for integrating education and patient care missions. The Geisinger Academic Affairs Mission statement, crafted in 2000, includes a commitment to “enhance the region with physicians focused on systems-based practice and practice-based learning.” In our experience, explicit physician workforce goals and a focus on specific competencies led to developing targeted strategies and tactics. We applied the following principles for integrating education with health care delivery when building and executing our curriculum:
* Integrate across the system.
* Consider the continuum of education and provide longitudinal experiences.
* Be interprofessional whenever possible.
* Build and teach team-based approaches.
* Minimize disruptions at the patient care interface.
* Protect the clinician from disincentives.
National efforts are beginning to address the context of clinical medical education as well. The Accreditation Council for Graduate Medical Education’s (ACGME’s) Clinical Learning Environment Review (CLER) focuses on the qualities of care delivery in the training institution.2 The Association of American Medical Colleges’ Teaching for Quality initiative is providing curriculum and faculty development support for teaching and learning quality improvement in the clinical environment.3
Outcomes Depend on Integrating Education and Care Delivery Systems
At Geisinger, embedding learners in systems focused on patients and value-based care may have influenced our learners’ choice of future practice as described by Chen and colleagues. The quality of care delivered in the clinical learning environment has been shown by others to correlate with the quality of care residents provide after graduation.4 As our residents plan their careers, they often voice concern about migrating to systems without a well-developed electronic health record or the care management systems they have come to rely on.
However, simply being in a well-functioning, highly reliable health care delivery system focused on systems of care and directed at improving quality and safety is not enough for learners. Boker and colleagues5 found that residents who were embedded in inpatient and ambulatory interprofessional teams with other health care professionals could not identify, define, or apply quality concepts. Self-reported gains in competence occurred with directed instruction, followed by hands-on experiences in the clinical learning environment. To ensure knowledge and skill acquisition, learners need explicit curriculum reinforced by dedicated experiential learning opportunities in a mentored clinical learning environment. Linkage of the educational and clinical delivery systems is a mandatory component for successful GME and subsequent outcomes.
Existing Curriculum Tools Can Provide Tactics for Education Interventions
Effective integration of medical education with high-performance health care delivery can be enhanced with conventional curriculum development tools applied in unconventional ways. At Geisinger, for example, innovations associated with breakthroughs in practice serve as the curriculum focus (see List 1). Systems engineering principles can be used to map key processes in the clinical learning environment with special notation of potential educational interfaces. New concepts of systems of care can be taught through workshops, and learners can then be integrated into the points in the health care system where the concepts are implemented. Learners can practice with simulation and be assessed with real-world metrics.
Many program leaders are now designing clinical curricula to prepare primary care residency graduates to seamlessly enter patient-centered medical home sites. For example, Geisinger primary care residents’ continuity clinics integrate the ProvenHealth Navigator program, a multidimensional medical home introduced at Geisinger to improve quality, efficiency, and patient experience, resulting in fewer hospital admissions and readmissions.6 The system is designed to ensure that residents are named as primary care providers in the “header bar,” an electronic health record term for designating key information and responsibility. Resident continuity clinics are supplemented by a longitudinal curriculum on quality, reliability, team-based care, and case management. Residents receive monthly reports of productivity and patient outcome metrics, such as percentage of resident’s patients receiving all recommended diabetes care. By leveraging the available educational tools, we hope to prepare residents to function in other high-performing clinical care environments upon graduation.
Faculty Must Be Supported
The core of any academic health care delivery system is its teaching physicians. Successfully integrating education and patient care missions requires the elimination of disincentives to teaching. Recognizing faculty teaching time can relieve the productivity stress. At Geisinger, under the direction of the program director, “Core Faculty” are recognized for contributions of at least three hours of nonbillable, not concurrently clinical teaching time each week for the good of the program. Actual salary and benefits are provided to the faculty member’s clinical unit in exchange for achieving explicit educational goals directly linked to incentives for teaching quality assessed by residents.7 Dedicated faculty development aimed at closing faculty’s real and perceived knowledge and skills gaps is necessary to relieve their anxiety and validate their teaching role.8
Toward Efficient Systems of Clinical Education Within High-Reliability Health Care Delivery Systems
Integrated health care delivery systems are uniquely structured to provide efficient clinical education. Barriers can be overcome, but only if educational infrastructure is intentionally designed for the desired results. Educational experiences must be planned, organized, and strategically aligned with clinical operations to ensure seamless integration with highly reliable health care delivery systems. In these systems, the majority of physicians and other health care professionals are employed by the health system so that their work plan and incentives can be aligned and, equally important, disincentives to teach can be removed.
In addition, the health care delivery system’s identification and cultivation of a stable patient population can overcome the fragmented relationships learners experience when only engaging with hospitalized patients. Analyzing and minimizing unjustified variation in care delivery ties learners to evidence-based practice. The ACGME’s recognition of the power of the clinical learning environment through the CLER initiative can direct the community to focus on quality and value rather than on compliance and regulation. As U.S. GME focuses on answering the Josiah Macy, Jr. Foundation’s call for accountable outcomes to meet the needs of the public,9 integrated health care delivery systems must also respond. Our experience at Geisinger demonstrates that accountable care organizations—health care delivery systems that integrate continuum of care facilities, physician practice groups, and insurance operations geared to population health—can provide the necessary context to align educational initiatives, overcome the barriers, and answer the nation’s call for improved GME outcomes.
The author would like to thank Dr. Veronnie Faye Jones and Dr. Karen Hughes Miller for their continued guidance.
1. Chen C, Petterson S, Phillips RL, Mullan F, Bazemore A, O’Donnell SD. Towards graduate medical education (GME) accountability: Measuring the outcomes of GME institutions. Acad Med. 2013;88:1267–1280
2. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system—Rationale and benefits. N Engl J Med. 2012;366:1051–1056
4. Asch DA, Nicholson S, Srinivas S, Herrin J, Epstein AJ. Evaluating obstetrical residency programs using patient outcomes. JAMA. 2009;302:1277–1283
5. Boker J, Thompson M, Raup C. Resident and nurse curriculum on quality improvement and interprofessional teamwork. Am J Med Qual. 2012;27:18S–20S
7. Famiglio LMRVU vs. GME. . Presented at: AAMC Group on Resident Affairs Spring Development Meeting April 29–May 2, 2012 San Diego, Calif
8. Neher JO, Gordon KC, Meyer B, Stevens N. A five-step “microskills” model of clinical teaching. J Am Board Fam Pract. 1992;5:419–424
9. Josiah Macy Jr Foundation. . Ensuring an Effective Physician Workforce for America: Recommendations for an Accountable Graduate Medical Education System. Presented at: Josiah Macy Jr Foundation, Conference Summary; October 2010 Atlanta, Ga