Chapter 6

Chapter 6Medical Education and the Changing Practice of MedicineCHAPTER OBJECTIVESUnderstand influences that have shaped U.S. medical education and practice Understand how scientific and clinical advances contributed to the evolution of specialty medicine Acquire knowledge of current delivery system developments and how they have and will affect medical education and practiceReview Affordable Care Act and other reform impacts on physician education and practice

Medical Education: Colonial America to the 19th Century (1)No medical schoolsSick were treated with medicinal herbs and anecdotal information in their homesFew university-trained European physicians emigrated to America; trained colonial medical students in apprenticeshipsNo formal methods of testing new physicians; practiced without regulation of any kind

Medical Education: Colonial America to the 19th Century (2)Apprenticeship training with mentors continued until hospitals founded in mid- 1700sFirst medical school established in 1756 (College of Philadelphia), 2nd at Kings College, 1768 (later Columbia Univ.) 1800: only four U.S. medical schools added; each had a few faculty members teaching all courses

Medical Education: Colonial America to the 19th Century (3)1821: Georgia restricted practice to medical school graduates over apprentice-trained physicians protest; medical school graduates increased & MD degree became the standardState medical societies formed in mid-1800s to advocate for education improvements and affiliated with newly formed AMAs education agenda; educational reforms failed for decades due to members vested interests

Medical Education: Colonial America to the 19th Century (4)1876: American Assn. of Medical Colleges (AAMC- 22 medical schools) advocated a 4 yr. training program1892: Harvard 1st to require 4 years training, followed by Johns Hopkins in 1893

Flexner Report and Medical School Reforms (1)1904, AMA developed Council on Medical Education: address needed educational improvements and standardsJAMA: published medical school state licensing failure statistics and group schools by failure rates, demanding poor schools to improve or resign the association

Flexner Report and Medical School Reforms (2)1905: Support for AMA reforms by Carnegie Foundation for the Advancement of Teaching; examine all 155 US & Canadian schools entrance requirements, faculty, laboratories & hospital relationships Schools cooperated believing that review would lead to Carnegie Foundation support

Flexner Report and Medical School Reforms (3)Medical Education in the U.S. and CanadaLauded some schools: Harvard, Western Reserve, McGill, U of Toronto, Johns Hopkins (cited as a model for medical education)Stimulated support from foundations & wealthy; University affiliated schools w/favorable ratings were primary recipients establishing future influence over future directionsLicensing legislation pursued; new standards for training duration, labs & other facilities

Flexner Report and Medical School Reforms (4)1942: AMA & AAMC est. Liaison Committee on Medical education as official U.S. and Canadian medical school accrediting bodyTransition from Academic Medical Centers to Academic Health Centers (1)1950s & 1960s federal grants: support research-oriented medical schools & teaching hospitals in technology advances1965-1974: Regional medical program funded upgrading medical knowledge about heart disease, cancer & stroke with research, training, regional networkingAcademic medical centers broadened to Academic Health Centers (AHCs) with other professional schools: nursing, pharmacy, dentistry, allied health Transition from Academic Medical Centers to Academic Health Centers (2)AHCs with affiliated hospitals became primary sites of health professional training, basic medical and clinical research; affiliated hospitals:Major providers of most complex tertiary care, e.g. neonatal, trauma, burn, neurologic, heart disease; major providers of primary care for low-income patients in outpatient clinics6% of nations hospitals but provide 50%+ of care to underservedTransition from Academic Medical Centers to Academic Health Centers (3)AHCs technology, teaching requirements generate the highest costs of American system; pressures to reduce costsTeaching requires ordering more tests, procedures, consultationsMedical school revenues: faculty clinical practice plan contributions, research grants & contracts, state & local government, tuition & fees, other grants, contracts, endowments; Medicare & Medicaid subsidy reductionsGraduate Medical Education Consortia (1)Formal associations of medical schools, teaching hospitals, other organizations involved in residency training to improve organization, governance, MD supply and distribution through local coordination.MD: allopathic physicians (138 schools); DO (Doctor of osteopathy- 29 schools); degrees are equivalent No national licenses; state medical boards license with specific requirements; 3-7 yr. residency accredited by Accreditation Council for Graduate Medical Education (ACGME) required.Graduate Medical Education Consortia (2)ACGME: not-for-profit independent organization dedicated to quality of residents trainingAccredits ~ 9,000 U.S. residency programs; also addresses MD distribution and supply 2012 transition to outcomes-based evaluation system to measure competencies.ACA: redistribute specific resident training slots to needed specialties and areas with Medicare reimbursement flexibilityDelineation and Growth of Medical Specialties (1)AMA concerns began in mid 1800s:Fragmented care (not treating whole patient)AMA slow response prompted specialists to form their own societiesLate 1800s: specialty associations formed in ophthalmology, otology, obstetrics & gynecology, pediatrics

Delineation and Growth of Medical Specialties (2)Deficient training of medical specialistsAt 1910 Flexner Report, huge variations in specialty training duration & quality; virtually any physician could call themselves a specialist.1917 WWI army recruitment revealed shocking unfit to practice as specialist MDs and some overall unfit American College of Surgeons est. oversight & practice standards for certifying surgeons in 1917 Delineation and Growth of Medical Specialties (3)Deficient training of medical specialists, contd1924: AMA Council on Medical Education began approving hospitals for residency specialty training programs; for next 40+ years, poorly conducted programs persistedAMA: Citizens Committee on GME, chaired by John Mills; 1966 report eliminated independent internships, awarding residency accreditation to institutions, not hospital departments; report led to current residency requirements Delineation and Growth of Medical Specialties (4)Deficient training of medical specialists, contd1970: internship dropped; AMA endorsed first year graduate training in a program approved by a residency review committee (RRC); by 1980 AMA issued training recommendations for the first postdoctoral year.Current curriculum for specialization: well defined & standardized: medical school graduation-> approved residency program-> pass qualifying examination(s).

Specialty Boards & Resident Performance (1)American Board of Medical Specialties (ABMS) est. 1933 as independent not-for-profit entity; to maintain, improve medical care quality by assisting member boards in developing and using professional & educational standards for certifying specialists in U.S. & internationally.ABMS member boards ensure proper instruction & resident performance by exam & practice in 24 medical specialties & 130 subspecialties trained in fellowships for subspecialty practice and/or research (Table 6-1)Specialty Boards & Resident Performance (2)HospitalistsGrowing field outside of formal specialty training; sole responsibility caring for hospitalized patients; 30,000 in practice in 70% of U.S. hospitalsMost trained in internal medicine or pediatricsHospitalist benefits: expedite & improve coordination of hospital care, reduce costs, enable continuity, improve patient satisfactionCurrent initiatives to certify role in relevant specialtiesPhysician Workforce Supply and Distribution (1)Mid 1960s: Government predicted national MD shortage; policies to increase no. of MDsMedical schools increased by 50%: students by 100% 1980-2000: MDs increased from 467,679-> 813,770 (74%): 2012: 834,769 active U.S. physicians, median of 244/100,000 populationIssues: U.S. lacks national methodology to predict supply/demand

Physician Workforce Supply and Distribution (2)Wide variations in practice locations not actual supply, e.g. Massachusetts- 415/100,000; 176/100,000 in Mississippi; rural and inner-cities chronically plagued by undersupplyInternational Medical Graduates (IMGs) fill residency gaps in shortfall of U.S. graduates; about 6000 per year. Physician Workforce Supply and Distribution (3)Ratios of Generalist to Specialist Physicians and the Changing DemandPrimary care physicians (PMDs): family medicine, pediatrics, general internal medicine (sometimes obstetrics & gynecology included); historically, numbers considered deficient with concerns about specialists contributing to rising costs1990s managed care growth -> federal & state policies increasing primary care physician supplyPhysician Workforce Supply and Distribution (4)Ratios of Generalist to Specialist Physicians and the Changing Demand, contd2012 Annals of Family Medicine study- 52,000 more PMDs needed by 2025; 33,000 for sheer population growth, 10,000 for aging, 8,000 for newly insured.ACA & ARRA provisions include supports for increasing PMD supplySpecialist to generalist ratio: 67:33

Physician Workforce Supply and Distribution (5)Ratios of Generalist to Specialist Physicians and the Changing Demand, contdDemand for specialists is strong: growth in general population and aging populationMedical students career choices influenced by training role models values, skills; major income differentials between primary care & specialties; experience in clinical training sites; educational emphasis on specialty practice

Preventive Medicine (1)Historically, medical education has not made health promotion, disease preventive high priorities due to systems complaint-response approach; reimbursement favoring after-the-fact interventions; most $$ treat preventable diseasesCurrent public awareness, media attention, system leadership resulting in collaborations between clinical & preventive medicine on e.g. childhood obesity, diabetes, smoking cessation2012 IOM report highlights primary care/public health opportunities Preventive Medicine (2)2012 IOM report Primary Care and Public Health: opportunities of ACA to advance population/preventive mindset & community linkages between AHCs and community based providers to research, develop, implement system changes for improved population health status.

Changing Physician-Hospital Relationships (1)Historically, unique, interdependent relationship based on patient admissions; MDs paid fee-for-service, hospital for costs incurred; medical staff organization carried out responsibilities to ensure quality care; MDs sole decision-makers about admissions, lengths of stay, resource use & referrals.System changes: hospital fiscal penalties for lengths of stay; admissions require payer approval; readmissions carry penalties; health plans select hospitals based on cost-effectivenessChanging Physician-Hospital Relationships (2)Technology advancements allow MDs to compete with hospitals for outpatient services (diagnostic, surgical, etc.)Hospital MD employment increase of 32% since 2000. MDs leaving private practices due to: flat reimbursement, complex insurance, HIT requirements, desire for work-life balance

Changing Physician-Hospital Relationships (3)Hospitals desire MD employment to secure market share, use of diagnostic & outpatient services, referrals to high-revenue specialty services, ACO developmentAMA concerns in 2012: conflicts between MD loyalty to employer-hospital and patient best interests; MDs should inform patients about financial incentives related to treatment optionsEvidence-based Clinical Practice Guidelines (1)Clinical practice guidelines: protocols based on scientific evidence from rigorous review & synthesis of published medical literatureEvolved from data showing wide variations of medical procedures in different geographic regions and use of questionable services that added costsAHRQ created by Congress in 1989 to develop guidelines; taken up by many professional & scientific organizations and evaluated by AHRQEvidence-based Clinical Practice Guidelines (2)14,000+ guidelines in online AHRQ National Guideline ClearinghouseEvidence-based guidelines now considered most objective, least biased standards: help prevent use of unnecessary treatments, avoid errors with patient safety & consistent care prioritiesPhysician Report Cards and Physician Compare (1)1970s: AMA ethics prohibited exposing any information allowing comparisons among doctors; state laws supporting AMA deemed violations of 1st amendment; freedom of information acts removed more barriers1986: Health Care Financing Administration release Medicare patient hospital-specific mortality ratesPhysician Report Cards and Physician Compare (2)1991: Newsday published NY states hospital-specific, severity adjusted, heart surgery mortality rates; FIA court decision forced release of individual surgeon dataMany states release MD disciplinary actions, hospital privilege status; medical societies supportPhysician Compare: ACA requires Medicare by 2014 to list quality data on MDs in Physician Quality Reporting System and E-prescribing Incentive Program; concerns will continue about quality, accuracy, of information.

Health Information Technology and Physician Practice (1)HIT supported by ARRA, HITECH Act, ACA to incentivize EHR use, educate MDs in e-information collection, transfer & useMedical schools, hospitals provide medical informatics training on spectrum of subjects, e.g. patient management, EHRs, e-Rx, research.ABMS now certifies a MD subspecialty in clinical informatics within existing medical specialties.Health Information Technology and Physician Practice (2)HITECH: focus on EHR adoption among MDs, other professionals, hospitals through financial incentives for meaningful use paid through Medicare & Medicaid. Eligible providers categories specified under Medicare & Medicaid; incentives paid on demonstrating highly specific meaningful use criteria by 1st stage deadline dates.

Health Information Technology and Physician Practice (3)2nd stage meaningful use criteria require demonstrating active consumer engagement in communication with providersParticipation rates to date have met expectationsHIT applications expected to transition medical care to new norms of computerized decision support systems, evidence-based practice, EHR use, computerized physician order entry and e-prescribingEscalating Costs of Malpractice InsuranceSteeply rising insurance costs affect physicians, medical schools, hospitals.In 10 years, premium increases 6-10-fold, thousands to millionsRising malpractice jury awards; during economic downturn, insurance companies dependent on investment income increased premiums Physicians in high-premium states retire early, relocate or limit practicesEthical Issues (1)Two areas of major physician concerns in the changing health care systemMedical care use: insurers efforts to manage costs, quality, access, subject physicians to numerous cost-avoidance parameters prompting issues of patient risk; traditional fee-for service practice yielding unnecessary procedures, ineffective treatments, fragmented care

Ethical Issues (2)Technology advancements: life prolonging capabilities lack accompanying standard procedures for making terminal care decisions that must be dealt with by physicians, families, hospital ethics committees; gene manipulation and therapies present formidable use/abuse potential, e.g. genetic blueprints predicting future disease/treatmentPhysicians and the Internet86% of physicians use Internet in practicesUse personal websites to market services Email with patients increasingly commonObtain current data on 132,000+ clinical trials in 179 countries from NIH for their and patient informationFuture Perspectives (1)Although astounding medical progress, U.S. ranks poorly among 6 other developed nations in key areas: quality of care, access to care, equity of care, healthy lifestyle; ranks 50th worldwide in life expectancy at birth.HIT advances & added primary care workforce hold future promise for system improvementsPhysician resiliency among many prior changes is expected to continue with practice adaptations required by the reformed systemFuture Perspectives (2)Physicians will transition from piece-meal fee-for-service (volume-driven) to population health (value-driven) focus by participating in PCMHs & ACOs that align financial incentives with desired population health, i.e. public health outcomesPublic reporting on physician quality will increase overall quality and empower consumers

Future Perspectives (3)Medical schools will enhance public & population health curriculum content and include content in national licensing examinations.In the reformed system, medicine will seize opportunities to improve population health status through collaborations with other health & community-serving professionals, citizens & elected officials to ensure a coherent, effective and efficient delivery system for all Americans