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Medical Education and Health Care Delivery: A Call to Better Align Goals and Purposes

Sklar, David, P., MD; Hemmer, Paul, A., MD, MPH; Durning, Steven, J., MD, PhD

doi: 10.1097/ACM.0000000000001921
Perspectives
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The transformation of the U.S. health care system is under way, driven by the needs of an aging population, rising health care spending, and the availability of health information. However, the speed and effectiveness of the transformation of health care delivery will depend, in large part, upon engagement of the health professions community and changes in clinicians’ practice behaviors. Current efforts to influence practice behaviors emphasize changes in the health payment system with incentives to move from fee-for-service to alternative payment models.

The authors describe the potential of medical education to augment payment incentives to make changes in clinical practice and the importance of aligning the purpose and goals of medical education with those of the health care delivery system. The authors discuss how curricular and assessment changes and faculty development can align medical education with the transformative trends in the health care delivery system. They also explain how the theory of situated cognition offers a shared conceptual framework that could help address the misalignment of education and clinical care. They provide examples of how quality improvement, health care innovation, population care management, and payment alignment could create bridges for joining health care delivery and medical education to meet the health care reform goals of a high-performing health care delivery system while controlling health care spending. Finally, the authors illustrate how current payment incentives such as bundled payments, value-based purchasing, and population-based payments can work synergistically with medical education to provide high-value care.

D.P. Sklar is distinguished professor emeritus, University of New Mexico School of Medicine, Albuquerque, New Mexico, and editor-in-chief, Academic Medicine.

P.A. Hemmer is professor of medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.

S.J. Durning is professor of medicine and pathology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, and deputy editor for research, Academic Medicine.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the Uniformed Services University, the Department of Defense, or other federal agencies.

Correspondence should be addressed to Paul A. Hemmer, USUHS-EDP, 4301 Jones Bridge Rd., Bethesda, MD 20814; telephone: (301) 295-9411; e-mail: paul.hemmer@usuhs.edu.

Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.

The current U.S. health care system is more expensive than that of other developed nations, yet it does not provide the highest quality of care and has well-described gaps in access to care.1 As our population ages, future health care expenses are anticipated to increase, leading to a health care financing crisis.2,3 At the same time, transformative changes in the health care delivery system—facilitated by new technologies and changes in the relationships between physicians, insurance companies, and hospitals—have disrupted traditional physician professional practices and the business models they use. With all of the changes in health care delivery and the growing costs of care, physicians, who many say account for 80% of health care spending, have been the major focal point for governmental efforts to control health care spending through programs that provide penalties and incentives related to costs and quality of care.4–7

Physicians’ behavior is complex and can be affected by a variety of social, economic, psychological, and cultural factors as well as through education.8 We believe that medical education has largely been ignored as one potential contributor in addressing the impending health care financial crisis and the new challenges and opportunities for transforming care delivery because education and training have been viewed as separate from, rather than integral to, patient care and health care systems.9 Medical education provides the foundation for physician practice and has the capacity to change physicians’ decisions and actions that have an impact not only on health care spending but also on quality of care.10,11 We believe that medical education could work synergistically with payment and regulatory reforms to lower increases in health care spending, produce higher-quality health care, and better prepare medical students and residents for a health care system undergoing rapid transformation. However, for this to occur, the goals and purposes of medical education and the health care delivery system need to be better aligned. In this essay we will describe how changes in medical education not only could be used to change physicians’ behaviors in clinical practice but also could facilitate delivery system transformation in a reinforcing cycle. We hope that our article (1) will help medical schools to understand the important role that delivery sciences play in the overall educational program and how to balance its content with that of other important topics, and (2) will influence those who assess medical students and medical schools.

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Goals of Medical Education

Medical education prepares future physicians by instilling the knowledge, skills, and attitudes to deliver high-quality care to the population. Typically, medical students in undergraduate medical education progress through programs designed to give them a unique and sophisticated understanding of complex basic and clinical sciences as the necessary foundation for transitioning to carrying out actions for the benefit of individual patients and society. They make this transition through a series of experiences in which they learn how to apply knowledge and develop skills within the context of authentic relationships with patients and their families, nurses, and other members of the health care social system under the guidance of faculty physicians. This is continued in graduate medical education (GME) with increasing patient responsibilities within a given discipline of the trainee’s choice to prepare the trainee for independent practice. Students and residents demonstrate competence in defined areas through performance on standardized knowledge-based examinations; workplace-based assessments by faculty; assessments (some of them simulation based) of competencies; and evaluations from patients, peers, and superiors about communication and professionalism.

While current assessment methods provide a valuable picture of an individual’s ability to practice independently, there is no common or explicit expectation for the newly trained physician to understand or meet the goals of the clinical delivery system that increasingly includes teams of advanced practice nurses, social workers, physician assistants, pharmacists, and other health professionals with inputs from patient advocacy groups and individual patients empowered with information from the Internet. While in GME there has been attention to competencies that do incorporate the care delivery system—systems-based practice and practice-based learning and improvement12—these competencies are diffuse and difficult to evaluate, and medical education (and arguably other types of health professional education such as nursing and dentistry) has remained focused largely on developing an individual’s expertise in patient care and medical knowledge through deliberate practice.13,14 While individual competence is essential, it is not sufficient for success in future practice.

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Goals of the Clinical Delivery System

The clinical delivery system provides the means to deliver health care services to the population, but there are concerns about the quality of care, the uneven access to care, and the cost of care.15 Berwick et al16 have suggested that the goals of the overall health care system should be improving the individual experience of care, improving the health of populations, and reducing the per capita costs of care (the Triple Aim); this is often described as better health, better health care, and lower cost. Viewed in this way, health promotion, medical information, disease prevention, injury prevention, identification of waste and unnecessary care, and innovations in care delivery through use of big data and other health information systems advances should become important partners with the provision of high-quality curative care and management services. Health care spending has also become a legitimate responsibility of the delivery system, and payment mechanisms to provide incentives to achieve more rational spending have been developed.17 These payment mechanisms have attempted to alter physicians’ behaviors so that there would be rewards for efficiency, chronic care management, and quality of care rather than for the volume of physician activity and procedures, which has been the emphasis in the fee-for-service system.18

Unfortunately, there has been limited effort or incentive to incorporate these new perspectives about health care delivery into the education system or to use tools from the education system to improve the delivery system. Just as medical educators could use the expertise of individuals from the delivery system to broaden medical education, delivery system experts could use the expertise of educators to change physicians’ behaviors to achieve their goals. It is time to move to a more unified approach, and medical education theory provides a way to help achieve the goals and purpose of the care delivery system and vice versa.

One way to consider the implications of better alignment would be to imagine better integrating the Triple Aim of the care delivery system with the goals of medical education. We argue that the Triple Aim does not replace the goal of medical education—ensuring that an individual possesses the requisite expertise to advance—but rather that medical education should incorporate the Triple Aim into its goal.

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Current Misaligned Goals

To redesign medical education based on the Triple Aim, we must first identify and overcome the obstacles to alignment of the education and the clinical care systems. For example, to date, medical education has not been focused on providing the knowledge or experience about how to limit and reduce health care spending for individuals and populations. We believe that knowledge about the actual costs of care could make physicians and patients more effective advocates, since patients pay a considerable portion of their bills through deductibles and co-payments, which do not represent the full costs of care. Often, trainees and faculty have little or no knowledge of the costs of the various tests or medications they order, nor are they taught how to consider costs as part of decision making with patients about alternative options for care,19 despite evidence that knowledge of charges can reduce test ordering.20

The Choosing Wisely21 program initiated by the American Board of Internal Medicine Foundation encourages an examination of low-value and potentially unnecessary tests and treatments and has demonstrated the potential synergistic effects of education and care delivery change in improving quality of care and reducing costs. Also, prevention of illness and injury have been largely the responsibility of public health; previously, failures to prevent an illness or injury generally had no explicit negative consequences for physicians or hospitals, although this is changing with the monitoring of 30-day readmission rates for certain problems. Medical education has focused on the teaching of procedures with the latest technology (e.g., angioplasties for coronary artery disease, bariatric surgery for obesity and diabetes) rather than education about nutrition or exercise (such as through use of a “teaching kitchen”22). There has been limited recognition and integration of patient advocacy networks (e.g., patientslikeme23) powered by the Internet that provide advocacy, knowledge, and community support to groups of patients who had previously been isolated and dependent on health professionals for information and advice. We believe that previous priorities in medical education reflected the emphasis on the individual trainee’s expertise as opposed to interactions among all participants (including patients24) in the health care delivery system and the environment or system itself. McGinnis et al25 have described the impacts of various factors on preventable mortality and suggested that determinants such as environmental exposures, behavioral patterns, and social circumstances had far greater influence than did improvements in the quality of medical care. We would argue that medical education needs to pay sufficient attention to the living environment, the social and behavioral influences on patients, and their effects on the care delivery system. We believe that creating an awareness of a population health perspective while maintaining a focus on the individual patient would provide students and residents with the needed mix of competencies for a transformed health system.

Payment regulations in the clinical care system are also misaligned with the medical education system, creating confusion and waste. Although the Centers for Medicare and Medicaid Services pays for both GME and health care services for Medicare and Medicaid beneficiaries, it attempts to separate the activities physicians provide for education from those that are provided for patient care in the same setting. Current regulations also inhibit the gradual progression of independence of students because of requirements related to billing. Most medical students’ activities and documentation cannot be used for billable activity regardless of faculty presence or supervision,26,27 despite the foreseeable marginalizing effects this has on the education and patient care activities of students. This leads to unnecessary duplication of documentation that forces trainees and faculty to spend more time documenting in the medical record than in seeing the patients.28,29 The result is that medical students are ill prepared to assume resident responsibilities at the completion of medical school. Dividing a patient care encounter into education and clinical care is both arbitrary and artificial and does not recognize concepts such as entrustment30 that form the foundation of faculty–learner relationships or the continuing professional development that is stimulated when learners work with health professionals.

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Aligning Education and Care Delivery—The Way Forward

If education and care delivery had the same goals and a shared conceptual framework (i.e., mental model or frame of reference) for achieving the goals of better health, better health care, and lower cost, we could address the areas of misalignment and find new areas of synergy. Current transformational forces in the health care delivery system would then be a stimulus for educational innovation. We believe we could achieve this alignment by recognizing the similarities in the theories that help us understand how to improve education and clinical care. In education, several theories emphasize the critical role of experience, social environment, reflection on experience, and integration of knowledge with experience in a cycle that repeats itself and grows.31,32 A cycle is also the model commonly used for quality improvement in clinical care in which a problem is identified and planning occurs to identify an intervention that might address the problem. Quality improvement activities can use some of the same types of theories that education does.33 The improvement cycle is in line with social cognitive theories such as situated cognition, situated learning, and distributed cognition.31,32 The main difference is that in the quality improvement cycle, the goal is process improvement, while in social cognitive learning theories, the goal typically is individual or group learning. However, this separation is not inherent, since process improvement is a form of learning. If the goals of reforming medical education and clinical care delivery were the same, it would be easy to recognize the dual purpose—in quality improvement and in learning—being accomplished through process improvement activity.

Situated cognition31,32 is an educational theory that attempts to integrate knowledge with activity and practice. This theory provides the shared conceptual framework that could help address the misalignment of education and clinical care. Situated cognition sees outcomes (e.g., patient care, societal care) as the result of emergent interactions between participants and the environment (or system); this contrasts with the long-held view that the provision of health care is predominantly by an individual practitioner. Principles of both education and clinical health delivery can be explicitly incorporated into the theory’s design by (1) choosing system and interaction “factors” from the perspective of clinical delivery system expertise to help inform physicians, and (2) choosing interaction factors from the perspective of medical education expertise to help inform both physicians and medical educators. Figure 1 illustrates how the approach of situated cognition can be used to align education and care delivery and, ultimately, patient care outcomes. As an example of how one aspect of care delivery (payment priorities) can be aligned with educational approaches, see Chart 1.

Figure 1

Figure 1

Physician factors include acquisition of new knowledge (including exposure to new content that could occur in a variety of ways depending on learner preferences and institutional resources). The contribution of the health care team, the information system, and new technology can be easily incorporated into this model as system factors; the empowered patient who has access to information and shares in decision making can be accommodated in the model as a patient factor. The outcomes (shown in the center of the figure; e.g., patient care) emerge from the dynamic interactions among the physician, patient, and system factors that are considered relevant. Such a model allows for quantitative, qualitative, or mixed methodologic approaches to explore the outcome of interest with appropriate labeling and measurement of the variables of interest.

With shared goals and mental models, educational programs across the continuum would be able to better prioritize the numerous areas of new knowledge and new technology that endlessly seem to creep into already-overcrowded curricula. For example, medical students could learn about systems design, health economics, patient safety, philosophy, ethics, and anthropology as well as current basic sciences throughout medical school. Many medical schools have begun to explore health systems sciences, and the American Medical Association has funded 32 medical schools to address curricular change to integrate medical education and health care systems.14 Some examples of these efforts include creating more flexible, competency-based pathways during medical school, defining meaningful medical student contributions in the clinical environment from early in medical school, and using big data and analytics to help inform health professions education. While some medical schools have voluntarily undergone curricular changes to incorporate health systems perspectives,34 a full-scale transformation of medical student curricula would be facilitated by changes in the accreditation system for medical schools and the assessment system for students and residents.

By introducing health systems, quality improvement, and patient safety concepts early in training (perhaps even as a medical school admission prerequisite), students would then be better prepared to practice these skills as residents. The Association of American Medical Colleges in its Teaching for Quality program identified an approach to faculty development in the area of quality improvement and patient safety (QI/PS) that could serve as a model for a broader faculty development applied to these new content areas.35 Ultimately, through faculty development, we anticipate that there would be changes in behavior that would be reinforced by the new payment incentives that support the changes. Sklar and Lee33 described how a curriculum could be designed based on the six attributes of quality care: safe, timely, effective, efficient, equitable, and patient centered.36 Curriculum could also be designed around the Triple Aim, which incorporates the attributes of quality and would also lead to an increased emphasis on reduced health care spending, evidence-based care, health promotion, epidemiology, and social sciences. By redesigning the medical school curriculum so that it better aligned with the care delivery system, medical students would be able to more smoothly transition to GME, where competencies in systems-based practice have long been recognized as foundational.

QI/PS are natural vehicles for integration of education and care delivery because they involve core elements of education, such as experience and reflection, and can bring about integration in a way that leads to improvements in care. Medical education theory has been developed to help explain how individuals learn and improve. Quality improvement theory has been developed to describe how systems learn and improve. However, learning occurs when systems improve, and systems can only improve when individuals learn and improve their work both as individuals and as members of teams. Individual learning is integral to systems improvement.

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Building Bridges to Align Education and Health Care Delivery

In this section, we describe examples of bridges between education and health care delivery though engagement in quality improvement activity, innovation, diffusion of innovation, population management, and elimination of waste. These bridges are also linked to changes in payment incentives that can facilitate the collaboration. Chart 1 provides examples of how care delivery and payment priorities can be aligned with educational approaches and demonstrates that there are current payment incentives that could provide the financial support to integrate education and health care delivery. For quality improvement, the payment incentives include increasing percentages of the physician fee-for-service payment based on the achievement of quality measures as well as having value-based hospital payments that can be reduced for certain conditions depending on readmission rates and hospital-acquired conditions.5,6

The recent experience of improving central line insertion and management described by Pronovost et al37 is an excellent example of co-creation of learning and improvement as part of quality improvement. In this example, education of providers occurred to change behaviors associated with central line insertion and management procedures, then data were collected to see what the effects of the changes were, to ensure compliance with protocols and to adjust procedures. The effects of the intervention were reductions in central line infections and improved learning about the procedure and performance. Barsuk et al38 used a mastery learning approach with simulation to improve central line insertion by residents and found that through this educational intervention, complications associated with the insertion of central lines on patients were reduced. Value-based purchasing incentives that reward hospitals for low rates of hospital-acquired infections and other conditions are aligned with quality improvement educational programs such as these.39

On a more day-to-day level, the use of effective feedback can improve individual provider knowledge and clinical care as part of system-wide quality improvement initiatives. There are methods of delivering feedback in medical education that could be similarly applied in the clinical care environment to improve quality and provider knowledge40; these should result in learning and better care.41 For example, feedback that is accompanied by data (e.g., the number of tests ordered compared with goals and peer comparisons) has been used effectively to reduce unnecessary laboratory test ordering42 and improve antibiotic stewardship.43 Such feedback can take advantage of big data systems and be provided to teams to allow them to compare their performances against standards and/or performances of others and make appropriate changes to improve the patient experience and quality of care.

Another bridge between education and health care delivery involves the development and diffusion of innovations. A recent innovation is the replacement of general anesthesia with peripheral nerve blocks for orthopedic surgery.44 This approach could reduce the need for postoperative hospitalization and reduce postoperative pain and other complications, thus improving quality and reducing costs. Even after the technique had been known for some time, there was resistance to adoption. Leggott et al44 describe how, through the education of providers, communication between specialties, and supportive changes in the clinical environment, the innovation diffused through the health care system following a pattern described by Rogers.45 Understanding diffusion of innovation should be a part of the education of medical students and residents who will be faced with decisions about when and how to adopt innovations during their careers. Bundled payment programs that combine hospital and provider payments for a procedure encourage the development and diffusion of innovations, such as the use of peripheral nerve blocks, that improve efficiency (see Chart 1).

Population health management is another bridge between education and health care delivery systems through its emphasis on identification of various groups within a population and changing incentives so that hospitalization can be avoided through better case management. Project ECHO46 is an educational telemedicine program used to connect experts in the care of complex patients, such as those with hepatitis C, with primary care providers. The project allows patients to remain in their home communities and receive care equal in quality to what they would receive at a specialized center. In this way, transportation and hospitalization costs can be reduced without reducing the quality of care.

For patients with multiple chronic illnesses, Bodenheimer et al47 have described how a chronic care model using teams and data can help to reduce hospitalization, improve quality, and reduce health care spending. Educational programs that prepare students to work in teams with nurse case managers and social workers and the use of big data systems to identify patients who can benefit from management can provide a workforce that will be prepared to improve health systems. Payment incentives that align with population management include a chronic care management fee in the fee-for-service system or alternative payment incentives in the alternative payment model for population management (see Chart 1). Accountable care organizations that are included as part of the Affordable Care Act also provide incentives for population management.

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Time to Get Started

It is time for our clinical and education professional communities to work more closely together. We can start by adopting the Triple Aim as the goal and purpose for medical education and aligning our various health professions curricula with it. This would stimulate changes in curricula to include new content and new experiences in team-based care, shared decision making, health information systems, and care management to prepare a health workforce with the skills needed to redesign the care delivery system. Current payment incentives in the delivery system can facilitate this collaboration if the savings and rewards are shared with the education program. Funding for education research that improves health care quality and reduces costs could open new opportunities for scholarship that would have direct effects on meeting health systems goals and health policy goals and on making improvements in education.14 We also envision the expansion of opportunities for medical students (or residents) to pursue master’s degrees in public health or health professions education to provide needed expertise to achieve our stated purposes.48 Intentionally creating explicit interprofessional educational experiences and establishing funding streams and perhaps conferences for fostering synergies between these communities could also better align goals and purposes.

We believe that investment in medical education to improve its alignment with care delivery reform and payment changes offers the best chance for successful health reform that will be consistent with professional values and will be sustainable as care models evolve.

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