Climate Change: It’s Not About the Weather—Continuing Medical Education and Maintenance of Certification and Licensure

Climate Change: It’s Not About the Weather—Continuing Medical Education and Maintenance of Certification and LicensureCarol Havens, MD; Jeffrey Mallin, MD

Summer 2011 - Volume 15 Number 3

State of Health Care in the US

Many feel that the impending acceleration of global warming is the greatest threat that our species has ever faced. Less arguable but already having an impact is a drastic climate change in health care. Not only is it shaking up health care delivery and insurance, but its effects are visible on the education, training, certification, and accreditation systems of physicians and other health care professionals and organizations throughout the US.

The US public is increasingly questioning medical care. Well-publicized cases of poor quality of care, wide variations in practice, embarrassing failures to achieve good patient outcomes (such as routine preventive care, hypertension control, management of chronic disease, and prevention of postsurgical infections),1 escalating health care costs,2 and interactions between physicians and commercial entities3 have led to increasing public outcry and legislative scrutiny.

It seems as if Mother Nature’s vengeance is palpable already.

In 2001, the Institute of Medicine described US health care in crisis, with 30-40% of patients not getting evidence-based care and with 25% of the care delivered not needed or actually harmful to patients.4 Evidence demonstrates overuse, underuse, and misuse, even in situations with appropriate access to care.5-7

A whole alphabet soup of health care-related organizations and groups has been trying to develop better methods of oversight in their areas of control.
Fortunately, all those groups are also now aligning around the common goal of improving patient care and protecting the public through a focus on performance assessment and improvement. They are creating systems that actually support each other rather than generate differing and sometimes bewildering requirements.

Realistically, physicians are only one part of the problem, and that means that we’re only one part of the solution. The systems and environments in which we practice, access to care, other health care professionals, and patients themselves play significant roles, too. But the challenge for us as physicians is to see how our role is changing and how the “be all and end all” is “Quality” of care (with a capital Q).

There are many factors driving up the Quality of care, and these include respected quality constructs (such as, Plan-Do-Study-Act and Six Sigma),8 electronic health records (such as, Kaiser Permanente HealthConnect), clinical decision support systems, public reporting, and pay for performance. There is also a relatively new construct called Continuous Professional Development. Think of it as Continuing Medical Education (CME) Version 2.0.

New Face of Continuing Medical Education

Similar to how The Joint Commission sets hospital standards for accreditation, requirements in the US regarding CME are directed by the Accreditation Council for Continuing Medical Education (ACCME). The ACCME is a national organization formed through and accountable to the joint membership of seven other key national organizations 9 (Table 1). Directly or indirectly, the ACCME accredits organizations that offer CME activities for AMA PRA Category 1 Credit. Whereas the credit system was developed and is maintained by the American Medical Association (AMA),10 the ACCME identifies, develops, and promotes standards for accredited CME providers nationwide who in turn offer CME activities to physicians.11 Just as medicine evolves over time, so have these standards.

The most recent CME standards, released in September 2006, explicitly require that CME activities support improvements in the Quality of care. Key components of the 2006 Accreditation Criteria require that CME activities relate to the actual scope of practice of physicians, narrow the differences between current practice and best practice, use formats that will meet the desired results, use evidence-based content, and are independent from commercial influence.12 Acceptable outcome measurements for CME activities focus on changes in physicians’ skills or abilities, actual performance on the job, or patient outcomes (Table 2).

The necessary skill set of physicians includes more than just clinical knowledge. Therefore, the content of CME must also address more than merely knowledge and include communication, working in teams and systems, use of information technology, patient-centered care, professionalism, commitment to lifelong learning and quality improvement, among other key attributes identified from health care organizations and professional societies. These competencies largely derive from those defined by the Institute of Medicine, the Accreditation Council for Graduate Medical Education, and the American Board of Medical Specialties.13 Essentially all these organizations are coming to closer agreement on what defines a quality and qualified practicing physician (Table 3).

Conventional CME has often been stand-alone lectures to large, diverse audiences featuring experts of national reputation flown in from far away delivering essentially canned presentations. New and improved models of CME are emerging to meet the different needs and learning styles of today’s physicians and health care system. CME is increasingly taking on new forms. Some examples of this include “just-in-time learning” in the work setting or online (eg, Internet Point of Care CME activities, Committee Learning CME Activities); problem-based, team and systems learning and change (eg, Performance Improvement CME Activities); and multi-interventional, experiential, and/or self-assessed curricula around particularly complex areas of practice.

How effective CME is at improving patient care is a longstanding question that still cannot be accurately answered. The limited evidence to date (almost exclusively based on conventional lecture formats) does show that CME can be effective in changing physician knowledge and performance.14,15 But not all CME is created equal.

Compared to older standards, the 2006 CME criteria help ensure that CME activities are not only more effective, but also more strategically important to physicians, health-related organizations and the public (ie, our patients).16 CME is no longer only about “getting credit.” Today’s CME is a means to an end—not the end in itself.

At its best, CME is a change agent. And a powerful one at that—partly because its credits are still of value to physicians and other health care professionals.

You’re probably now wondering what happened to the idea that CME is something that I need to do to maintain my medical license and prepare for my Board recertification. Why is CME so “difficult” now when that’s really all I want from it?

Climate Change: It’s Not About the Weather—Continuing Medical Education and Maintenance of Certification and Licensure

Climate Change: It’s Not About the Weather—Continuing Medical Education and Maintenance of Certification and Licensure

Climate Change: It’s Not About the Weather—Continuing Medical Education and Maintenance of Certification and Licensure

New Face of Board Recertification and License Renewal

The answer lies in the fact that maintaining Board certification and a medical license is no longer an episodic event every so many years. Like CME, the American Board of Medical Specialties (ABMS) and the Federation of State Medical Boards (FSMB) (who set the direction for Board certification and medical licensure, respectively) are putting a new face on these processes, and in doing so they are taking a different view of CME and CME credits. They aren’t far along in making the changes, but the winds have definitely shifted.

Maintenance of Certification (MOC) is a relatively new approach to Board certification. The ABMS, which is the umbrella organization governing all 24 recognized specialty Boards, has implemented a universal policy of time-limited certificates (no more lifetime certification!) and a process for maintenance of certification (ie, continuous process), rather than recertification (ie, one-time process). The biggest change is that instead of just having to get a certain number of CME credits and pass a test every 7-10 years, now there are additional requirements.17 The ABMS and all their Member Boards have agreed to an expanded 4-part MOC process (Table 4).

Yes, there is still an exam to take and CME activities to do, but there is more. Each of these four components is required for all Boards, though each Board gets to set its own process for how MOC will be implemented, and some are further along in this process than others. ABMS and the individual Boards might be prescriptive in terms of which CME activities will count, requiring that they be relevant to your specialty and perhaps even considering the role of commercial support and the relationships that the individuals involved have with commercial interests.

The Permanente Federation and the various Permanente Medical Groups are working together and with the ABMS and its Member Boards to support Permanente physicians in this process.18,19 Most notably, the National (Permanente Federation) and Regional CME offices are in various stages of gaining approval for physicians to use organizational quality-improvement projects in which they are already participating as their Part IV MOC. Board-approved Part II MOC activities are also being developed and offered within the organization. These efforts should drastically reduce the cost, time, and hassle otherwise typically encountered by individual physicians and outside practices struggling to meet MOC.

Maintenance of Licensure (MOL) is governed by the FSMB. The goal is to protect the public by licensing physicians who can demonstrate that they provide good care. Unfortunately, this has been difficult to assess in the absence of litigation or criminal proceedings. CME has been used as a “surrogate” marker for “competence” by many states that require it for licensure. However, as long ago as 2002, the FSMB realized that CME credit alone may be unrelated to a physicians’ competence or actual practice. Even so, they have struggled to find other ways to assess physicians.

In late 2010, the FSMB released a recommendation for all state licensing boards to adopt requirements similar to those required for MOC,20 including participating in CME, a proctored exam, and performance improvement (Table 5). They also recommended that this be a 5-year cycle, and that all 70 state licensing medical and osteopathic boards adopt this within 10 years. Although this is voluntary, some states have already started implementing the requirements, and as more states adopt this policy, it will create momentum for all states to adopt. The California Board of Osteopathic Medicine has already started implementing these requirements; however, the Medical Board of California has not. Presumably, if your state has adopted these standards, they have or will notify you, but you can also check with them directly as this is a moving target.

For those physicians who are either “grandfathered in” to specialty Board certification or do not wish or need to maintain their Board certification, the MOL requirements will likely catch up with them because they still need to maintain their medical license.

So either way you cut it, practicing physicians will need to participate in an ongoing process of continuous professional development and assessment, exemplified by MOC and/or MOL. And—if all goes according to plan—the similarities between the two systems are going to be many, and the role of CME is going to be critical.

Climate Change: It’s Not About the Weather—Continuing Medical Education and Maintenance of Certification and Licensure

Climate Change: It’s Not About the Weather—Continuing Medical Education and Maintenance of Certification and Licensure

Alignment between Continuing Medical Education, Maintenance of Certification, and Maintenance of Licensure

Recognizing that CME activities that are unrelated to a physician’s actual practice does not support the vision for MOC, the ABMS has implemented a policy that only CME related to the physician’s own practice can be used to meet the CME requirements for MOC. The FSMB has endorsed a similar principle for MOL. Luckily, because CME standards now require that activities be directed at the actual or desired scope of practice, it is much easier to demonstrate this if CME activities are chosen deliberately.

It is a fundamental truth that all physicians strive to provide great care.

A goal to be mediocre does not lead to success in medical school or residency. CME is changing to provide information and tools to help physicians provide that great care. With medical information changing so rapidly and the delivery of care changing (use of technology, informatics, team based care, etc), it is difficult for physicians to keep up with advances in their own fields.

Learning about other specialties might support a more “well-rounded” physician and be of interest to some physicians; however, given the limitation of time and monetary resources for CME, the questions are: Is it better spent on topics that are of interest but limited practical use, or instead spent on CME that will help support that great care we all want to provide? If Board certification denotes competence in that specialty and medical licensure denotes being a qualified physician, then shouldn’t CME that is used to support certification and licensure be related to what we actually do within the specific scope of our practice or job?

As primary care physicians, for example, the authors may be interested in the technique of hip replacement surgery, but for our practice—and our patients—what we really need to know is how to evaluate hip pain, how to manage it and prevent it getting worse, and how to know when to refer to an orthopedist about potential replacement or other interventions. Even physicians eventually become patients. So, as patients, if we ever end up on an operating table for that hip replacement (and we hope we don’t), we would want our surgeons to use their CME resources to learn about how to improve surgical and postsurgical outcomes, rather than about the latest controversy on breast cancer screening or the history of medicine in the 20th century.

Continuous Professional Development

Continuous Professional Development is the latest buzz.21 As we mentioned, some say it is CME Version 2.0 (Table 6). Whether or not you subscribe to that, continuous professional development and assessment are the basis of new faces of CME, MOC, and MOL.

In today’s world and going forward, physicians have more and more choices for CME opportunities, and accredited organizations that provide CME are responsible, under current CME standards, for creating activities that actually make a difference in practice.

When physicians expect and select CME activities to specifically help their practices (with content related to scope of practice, addressing actual care gaps, with tools and strategies to be able to apply the information based on the best and unbiased evidence), the entire health care system in the US will reap the benefits. Physicians will be poised for success in MOC and MOL, and patients will experience improved Quality of care (remember, with a capital “Q”).

We should demand nothing less!

And who knows? We might just come out of this climate change and realize that we have actually supported our fundamental desire as physicians to provide great care.

Climate Change: It’s Not About the Weather—Continuing Medical Education and Maintenance of Certification and Licensure


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2.    Kimbuende E, Ranji U, Lundy J, Salganicoff A. US Health Care Costs [monograph on the Internet]. Menlo Park, CA: The Henry J Kaiser Family Foundation; 2010 Mar [cited 2011 Jul 24]. Available from:
3.    Hager M, Russell S, Fletcher SW, editors. Continuing education in the health professions: improving healthcare through lifelong learning. Proceedings of a conference sponsored by the Josiah Macy, Jr Foundation; 2007 Nov 28-Dec 1; Bermuda [monograph on the Internet]. New York: Josiah Macy, Jr Foundation; 2008 [cited 2011 Jul 24]. Available from:
4.    Institute of Medicine Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press; 2001.
5.    McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003 Jun 26;348(26):2635-45.
6.    Mangione-Smith R, DeCristofaro AH, Setodji CM, et al. The quality of ambulatory care delivered to children in the United States. N Engl J Med 2007 Oct 11;357(15):1515-23.
7.    Hospital compare [Web page on the Internet]. Washington, DC: US Department of Health and Human Services; updated 2011 Apr 11 [cited 2011 Jul 24]. Available from:
8.    Varkey P, Reller MK, Resar RK. Basics of quality improvement in health care. Mayo Clin Proc 2007 Jun;82(6):735-9.
9.    About us: Board of Directors [Web page on the Internet]. Chicago, IL: Accreditation Council for Continuing Medical Education; 2011 [cited 2011 Jul 24]. Available from:
10.    The Physician’s Recognition Award and credit system: Information for accredited providers and physicians [monograph on the Internet]. Chicago, IL: American Medical Association; 2010 [cited 2011 Jul 24]. Available from:
11.    About us [Web page on the Internet]. Chicago, IL: Accreditation Council for Continuing Medical Education; 2011 [cited 2011 Jul 24]. Available from:
12.    The ACCME’s essential areas and their elements [monograph on the Internet]. Chicago, IL: Accreditation Council for Continuing Medical Education; 2006 [cited 2011 Jul 24]. Available from:
13.    ACCME Standards for Commercial Support: Standards to ensure the independence of CME activities [monograph on the Internet]. Chicago, IL: Accreditation Council for Continuing Medical Education; 2006 Mar [cited 2011 Jul 24]. p 123. Available from:
14.    Marinopoulos SS, Dorman T, Ratanawongsa N, et al. Effectiveness of Continuing Medical Education. Evidence report/technology assessment No. 149 (Prepared by the Johns Hopkins Evidence-based Practice Center, under Contract No. 290-02-0018. AHRQ Publication No. 07-E006.) Rockville, MD: Agency for Healthcare Research and Quality; 2007 Jan.
15.    Moores LK, Dellert E, Baumann MH, Rosen MJ; American College of Chest Physician Health and Science Policy Committee. Executive summary: effectiveness of continuing medical education: American College of Chest Physicians Evidence-Based Educational Guidelines. Chest 2009 Mar;135(3 Suppl):1S-4S.
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We will do whatever we have to do to improve health outcomes and the quality of life for our patients. The other area about this that I’m pleased with is that we made a decision to work on this for two to three years to determine what difference it makes. We have our matrix in place and we’re not going to be grounded by the limitations of a grant or external funding. CH: I wanted to mention a community-hospital linkage in San Francisco. There is a lot of attention now on transitions of care and how patient safety and quality of care suffer during transition periods. SFGH has a nurse practitioner (NP)-staffed “bridge clinic” for patients without a primary care physician after hospital discharge. This NP sees the patients after discharge, follows-up on important post-hospital treatment and workup plans, and arranges ongoing community-based primary care for the patient in the setting that’s most appropriate for him or her. SC: As part of that transition-care program, we’re piloting an after-care plan which is an intensive discharge teaching process—within 48 hours the patients receive a phone call from the nurse to review their plan, their medications, the action they need to take if certain symptoms appear. This teaches people how to access the system. If they need to be seen, they go to this bridge clinic that Dr Horton described, and they have a follow-up call at ten days. We are observing now what impact that will have on readmission rates. Leadership is critically important for us, so several staff of the San Francisco Department of Public Health are part of the current NAPH fellowship program: myself; Mivic Hirose, the CEO from Laguna Honda Hospital, (a 780-bed skilled-nursing facility); Tangerine Brigham, the Deputy Director of Health over our Healthy San Francisco program for uninsured patients; and Barbara Garcia, the Deputy Director of Health over community programs and community-based primary care. (She has just been named Director of Public Health, with the departure of Mitch Katz to Los Angeles). We have all the components for an integrated delivery system, but they’re not linked yet. We’re here to learn the current best practices so that we can prepare for health care reform, provide better care for our patients, and make sure that their care is provided at the right place, at the right time, and by the right staff. CH: On my way to this interview, I was reflecting on working in the San Francisco County system compared to working in another county where the Department of Public Health, the public hospital and the community clinics were much less linked. I’ve really appreciated how linked those three San Francisco entities are. If there’s a major initiative going on, all three of those bodies are present at the table and the Department of Public Health actually directs a lot of those community-based programs. That creates cohesion and communication in San Francisco, which moves us towards a more integrated system. In addition, the Healthy San Francisco program of universal health care has been tremendous in teaching us to work together. Patient data is much more readily available and easily shared, and our approach to quality improvement initiatives in the San Francisco safety net has become more coordinated and cohesive as well. JB: Some of the most exciting activities are the external partner relationships we are nurturing. The future will create different and meaningful partnerships that may have been unthinkable in the past. Just over the past year we have forged strong business relationships with the local Hyatt Hotel to support sleep studies; the local Blue Cross and Blue Shield franchise to support our fresh produce market; the Kansas City Chiefs to support community health initiatives; and meaningful connections with Federally Qualified Health Centers. This follows longer-standing relationships with Walgreens, JE Dunn Construction, US Bank, Cerner, Morrison Food Services, and Cardinal Health, all in extraordinary support of both our patients and employees through creative relationships and programs. Integration of People in the System TJ: Let’s complete our talk on system integration by also discussing the integration of people, like multidisciplinary teams, or integrating physicians and practitioners across primary care-specialty care departments and services. SH: We do a lot of work in a multidisciplinary way in Birmingham. We train that way; in fact, I’ve done it that way all of my professional life. We have an inpatient-outpatient community base. We’ve got 600,000 people in Birmingham, and our one public hospital sees over 185,000 patients in the Outpatient Department alone. We work very hard to keep people healthy enough to stay out of the hospital. To make this work, for the people, we have 18 to 20 subspecialty services in our clinics because most of the people come for subspecialty care. Our community-based clinics are more primary care based. We have a staff integrated with NPs, physician assistants, and physicians; and have integrated primary care with subspecialty care. In many areas our people are cross-trained, so they can move where we need them. So we have multidisciplinary and interdisciplinary integration. It is cost effective to do it that way too. In addition, in public facilities you find more social support services. Education is also very important. You want people to understand why they are there, and how to take care of themselves when they go home to prevent them from coming back. And you don’t get paid very much for these services, if at all. SC: Part of our system includes a large number of community clinics that are not part of the Department of Public Health but are part of our safety-net system. We do not have enough primary care capacity just within the Department of Public Health to meet the needs of the residents of San Francisco, so we’ve expanded our network in the community to include these other clinics. One of the major changes over the years is that SFGH is not the hub of the system anymore. The hub is really primary care in the medical home. That’s been a major shift in the last three years, before people even thought health care reform could become a reality. There’s been major work in specialty care and primary care integration that is so important to well-coordinated medical care. All of our community clinics and hospital-based clinics are now linked with most of our specialists at hospital-based clinics through an electronic referral system that brings tremendous improvement in communication and access to specialty care. Other primary care-specialty care linkage projects represented at this conference further increase communication and integration between specialty and primary care. We’re moving beyond just linking the hospital-based primary care clinics and the specialists by linking to the community-based clinics as well. CH: This electronic referral system that Susan Currin referred to did increase the communication between the primary care physician and the specialist, but also it increased specialist capacity for patients. As each of the specialty clinics agreed to participate and established guidelines for a referral, this increased communication back to the primary care physician. About 30% of all the referrals were able to be handled with specialist-primary care communication, rather than an actual patient appointment. That opened up appointments for other patients without hiring additional specialists. It was a good learning experience for everybody. It served the patients a lot better too. Part of the grant to develop the electronic referral system also allowed us to create, at the hospital, a Center for Innovation and Quality to support research in primary care-specialty care linkage projects. JB: On graduate medical education, most of the hospitals affiliated with the NAPH are teaching institutions so the partnership, collaboration, integration, and alignment with the medical school is critical. I don’t have an answer for that yet. I do know that everybody’s talking about doing something. I think it needs to be a major paradigm shift in the delivery of medical education and how it compliments and better fits the needs of our patients, which should be priority number one. Another thing is critical: many of us have independent 501(c)(3) Medical Group practices that are not employee positions by the institutions per se but are connected at the hip. Nonetheless, a lot can be done relative to alignment with the physician group, for example, with the medical home a single bill can be submitted. First and foremost, however, there needs to be a fundamental understanding between management and physician leadership that we are one. This is the same for the medical school. And once we get to that point, with a stronger trust factor, I think we can start the hard work of integration, which is the details on how do we work within the confines of the legal construct to make things happen. This is the conversation of the times. TJ: Those are extremely important innovations in all of your public hospitals and systems, and very informative for those seeking ideas and outcomes from implementing them. In the next section of the interview to be published as Part 2 in the Spring 2011 issue, we would like to hear from you about quality improvement efforts, improving patients’ experience, and finally about your approaches to health care reform.
Biostatistics 101: Understanding Data
Friday, 02 July 2010
David Etzioni, MD, MSHS; Maher A Abbas, MD, FACS, FASCRS Summer 2009 - Volume 13 Number 3 Introduction Kaiser Permanente (KP) is a leader in health care delivery and provides care for millions of Americans in several regions and states, including Northern and Southern California, Colorado, Georgia, Hawaii, Ohio, the Northwest, and the Mid-Atlantic States. The volume of clinical care rendered every year throughout the organization presents a great opportunity for research and innovations. In recognition of the importance of research, the Kaiser Foundation Research Institute was created in 1958 to administer and support research within KP at a national and regional level. High-quality innovative translational research is performed every year, in the form of randomized clinical studies, epidemiologic research, retrospective databases review, and health care policy research. Supported by an electronic medical record and computerized databases, KP is well-suited to provide the scientific community with a wealth of data on outcome of interventions. In 2007, there were approximately 2800 active studies, all approved by institutional review boards, being conducted nationally. That same year, reports on 571 studies were published by KP physicians and scientists in prestigious medical, surgical, and scientific journals, including The Permanente Journal. Because of the size of the KP population, KP research studies often contain a large number of study subjects. Such projects and endeavors can generate complex data and results that require analysis to demonstrate the effect of therapies and interventions, to establish the efficacy or limitation of treatments, and to prove or to refute a scientific hypothesis. An understanding of biostatistics is critical to the researcher investigating clinical questions. Equally important is an appreciation of statistics by the reader and interpreter of published studies. As with all fields of scientific endeavor, statistics encompasses a rich jargon that is necessary to abbreviate and refer to underlying concepts. In this article, the first of a three-part series on statistics for clinicians, we begin with an overview of how statistics can and should be used to describe data.
Interview with Lawrence Weed, MD-- The Father of the Problem-Oriented Medical Record Looks Ahead
Friday, 02 July 2010
Lee Jacobs, MD Summer 2009 - Volume 13 Number 3 I first met Lawrence Weed, MD, in 1972 when I was a third-year medical student at the University of Vermont. To this day I remember his passion for a disciplined approach to medical record documentation to optimize the care provided to each individual patient. Now, 35 years later, I was privileged to meet with Dr Weed at his home in Vermont. We discussed when he first was alerted to the nonscientific approach clinicians use to make decisions on patients. The rest of the interview time was spent with Dr Weed teaching me about the solution that he has spent the last 30 years designing and implementing. This interview is published to complement the editorial in the most recent issue of The Permanente Journal (Spring 2009;13[2]:85-7). We believe that in the era of health care reform and quality improvement initiatives, it is important that the medical community take a close look at Dr Weed’s total approach decision-making information support defined in this interview. -- Lee Jacobs, MD
Innovation in Our Nation’s Public Hospitals: Three-Year Follow-Up Interview with Five CEOs and Medical Directors—Part 2
Tuesday, 28 June 2011
Tom Janisse, MD Summer 2011 - Volume 15 Number 3 This is Part 2 of a two-part conversation with leaders (Table 1) from four hospitals and systems who participated and attended the 2010 annual meeting of the National Association of Public Hospitals in Boston, MA. Part 1 appeared in the Winter 2011 issue of The Permanente Journal. Tom Janisse (TJ): Welcome. It’s good we can talk together again. In Part 1 you discussed: community interventions, community clinics and the hospital, system integration, and integration of people in the system. In this second part we will talk about innovations in quality improvement (QI), resident training and QI, how you improve a patient’s experience, and your approach to health care reform. To begin, let’s discuss about innovations in QI. This is a growing area and becoming more credible as it is recognized that the delivery system offers a critically important way to advance medicine. LaRay Brown (LB): Just getting everybody involved is a major advance. Traditionally, it’s been primarily the quality control people and the nurses, but the physicians weren’t involved much. Now our physicians are involved as part of a quality objective and they are actually doing peer reviews. We’re seeing a tremendous difference in how they perform. Sandral Hullett (SH): They didn’t like being involved at first, but now they see the results. They’re doing things correctly and they make no mistakes, and when they see the results of the hard-core data it just makes them more involved. LB: I agree. You talked about the multidisciplinary team, which is essential to QI and successful outcomes: everyone involved in achieving their identified area of improvement. Another example, at Kings County Hospital, was achieving an award for zero ventilator-associated infections in the Emergency Department, and the surgeon who stood up there and accepted the award was very clear that it wasn’t just the surgeon. It was, of course, the quality person, the data analyst—the entire team must work together to achieve this. There’s a myriad of examples of work throughout the New York City Health and Hospitals Corporation (HHC) that demonstrates that QI has become embedded in the organization. The quality assurance committee of our governing body meets weekly for two to three hours to hear from each facility, which on a quarterly basis reports on what has happened—what’s great that has happened, and what’s bad that happened. Most important, they report on their QI efforts with outcomes data. These are good improvement stories with good data. TJ: Dr Horton, you wanted to talk about training residents and QI, specifically in the safety net. Claire Horton (CH): We recently had the first of what hopefully will be a recurring set of conferences focused on residents and QI, funded and coordinated by the Safety Net Institute, which is part of the California Association of Public Hospitals (CAPH). It grew out of a work group, launched by the Safety Net Institute, of faculty at public hospitals in California that are training residents. One of the outcomes of the conference was more networking for residents learning about QI. Ten years ago that training was rudimentary, now many more people are interested and many more residents look toward QI as a career path. We would like them to consider a career not only in QI, but QI in the safety net. That’s why this collaboration between the Safety Net Institute and our training sites was so important. There were QI seminars and conferences where we could send residents, but there wasn’t a forum for them to showcase their own great work in QI, nor for the faculty who teach QI in the safety-net network to compare teaching methodology and curricula. Last June, we had the first conference for academic CAPH hospitals. Seven institutions participated and many residents gave oral presentations. The Safety Net Institute selected one resident for a scholarship to the Institute for Healthcare Improvement National Forum on Quality Improvement in Health Care. The whole endeavor represents a great new collaboration. TJ: Could you mention a couple of specific QI activities that residents do now that they never did before? CH: When you look at published papers about how to teach QI to medical residents, it is apparent that it’s critical to have experiential components. This allows them to be integrated into and to work closely with the staff of the clinic or hospital. What wasn’t obvious to everyone was that the residents really know the system better than anybody else. They’re absolutely on the front line. There are several examples of what residents presented at this conference. One focused on improving cervical cancer rates. Two clinics had different systems to reduce the Papanicolaou smear rates; two residents formed teams at both of those sites, learned what sources of data were used at the hospital, and taught staff the guidelines for who should get a pap smear, which resulted in significant rate improvements at both clinics. Another project was conducted by a resident who coordinated with clinic schedulers to ensure that patients were scheduled with a follow-up appointment when they left the clinic. The resident learned a lot, but the project was also critical for us because so many of our patients get lost to follow-up, in part because the residents’ clinic schedules are notoriously difficult to predict because of the demands of the inpatient service. The percentage of patients who never received a follow-up visit declined from 18% to 11%. Another great project integrated postpartum depression screening into a pediatric residency clinic. There were many well-done projects presented. TJ: Let’s continue with your thoughts and activities to improve the patient’s experience. Is there something particular you want to mention? John Bluford (JB): The industry and particularly safety-net hospitals are really getting engaged and involved in improving patients’ experiences. We have a concierge service at our hospital that is not any different from what you would see at a hotel in terms of meeting patient needs. We have a very strong initiative right now to balance our workforce to better match the patient base that we serve. As a particular challenge in our community, the birthrate of Hispanics is exploding: 20% to 25% of all of our babies delivered. Our Hispanic patient growth is new for us (as in the West Coast, Florida, Texas, and Kansas City), and we have nowhere near that percentage of Hispanic employees. So we’re working to improve that inequity. TJ: Remember the last time we talked, John, you mentioned that you didn’t want your hospital or health system to be for one purpose—for poor people. You wanted it to be for everyone in the community. JB: That’s right, and the concierge service is a model for this. It starts at the front door with the baby grand piano, and the ambiance of a hotel lobby, and follows through to the art gallery that we’re producing—changes that are good for everyone. Susan Currin (SC): As far as improving the patient care experience, our initial approach has been to focus on patient safety. For example, to examine and improve our culture, we’re participating in an Agency for Healthcare Research and Quality culture-of-safety survey. It dovetails with what Dr Horton is doing with the residents in QI. Another example is a new system of “rounding with a purpose” where staff make frequent rounds on the medical-surgical units. Through this program, we’ve decreased the number of falls as well as the number of hospital-acquired pressure ulcers.  Also, we are looking at the patient satisfaction data related to noise on inpatient units and are developing several initiatives to decrease noise during certain hours of the day. Patient safety and satisfaction really come together in our care for the elderly. We have two acute care for the elders (ACE) units—one that’s a general medical unit; the other focuses on cardiac patients. We have attendings specializing in the geriatric patient population, who lead a multidisciplinary team of nurses, many with national certifications in geriatric care, nutritionists, rehabilitation staff, and social workers. This group starts discharge planning early in the hospitalization and develops treatment plans focused on improving the functional status of patients. We’re excited about this program’s success in returning patients home after discharge, as well as reducing their readmission rates. It is a great experience for the patient and delivers quality, team care. CH: I’d like to talk about the ACE unit that Sue Currin just mentioned because it’s so fantastic. When I first saw the San Francisco General ACE unit, when anyone sees the ACE unit, you think why on earth haven’t we been doing this all along. The geriatric patients on that unit have meals together in a communal room at the end of the hall. And people actually get to sleep through the night at the hospital, if you can imagine that—because the staff minimizes nighttime wake-ups for vital signs, etc. There is a huge emphasis on function as opposed to the normal parameters of getting better from a medical standpoint. Physical therapists and nurses work intimately together for patients. Our patients are always very happy when they are transferred to the ACE unit. Besides the ACE unit, another new service we have is palliative care, which is incredibly important for patients facing the end of life; and in the hospital, it has made a tremendous difference in many, many patient’s lives to have a specially trained multidisciplinary palliative care team available to consult with any patient who is at the end of their life. SC: We’re hoping to expand this program to the ambulatory care area. That’s really where we need palliative care: in the outpatient setting. Although there are some who believed they provided really good care and did not need a palliative care service, the number of projected consult requests doubled after six months. CH: We didn’t know how much better we could be. SH: We had a great problem with patient satisfaction because in our community the public hospital has the image of being not the best place in the world, even though we have the same quality physicians as most of the hospitals—most of our physicians are from the university. But still, people don’t really want to go there. We did a lot of facility renovation—cleaning it up—and addressed staff behavior, teaching them customer service. That has been difficult because people worry about potentially losing their jobs. I work for the county, and people just get callous after a while when you put them in the same spot; you don’t move them around, you don’t do anything special for them to make them feel good about who they are and what they do. And we just started doing that. There’s a new program within the hospital where staff contribute their ideas of the best ways to improve both staff relationship and patient satisfaction. They suggest very simple things but they make a world of difference for both the patients and the staff. We acknowledge the staff by listening to what they have to say. And then for our patients, they now feel much more comfortable. Instead of complaints every day—we never get them now—we get many compliments because people feel wanted. And that’s what we want them to feel. For three years in a row, we have had one of the highest Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores in the nation. But it dropped last year. It’s still high, highest in the state, even though we dropped from a score of 95 to 90—I think we got a score of 89 in 2009. The lower scores were related to multiple issues during the time of the survey; such as the changing economy and the financial shortfalls of the county. Cooper Green suffered loss of staffing and reduced staff working hours, and other significant changes, which caused decreased staff morale. The staff wasn’t happy and that unhappiness was observed by the patients and I think this was the reason for the lower scores. LB: From our perspective, the patients’ experiences are important because we are in a very competitive environment. We have some of what are called the boutique, internationally renowned hospitals. We do not aspire to be the hospital only for individuals who have no alternative. We aspire to be the hospital and health care system for all New Yorkers. And New Yorkers are persnickety. It’s also an issue of when people feel wanted, they will come to you, and moreover, they will engage in a partnership for their health care. Therefore we invest in language-assist services not only because it’s important to communicate with patients and make sure that you’re getting as much information as possible to be effective in your service delivery, but it also indicates respect for patients. For many communities the availability of language services isn’t as expansive as in HHC. People see that, and so they choose an HHC facility. We have people who look like them, and people who speak their language—both improve patient experience. We don’t have Health Communities Access Program (HCAP) scores of 95—I wish. But our HCAP scores exceed other New York City hospitals on questions, such as “Would you refer this hospital to family and friends?” or “Would you come back?” Across the board, the HHC hospitals’ scores exceed New York City scores and in some cases New York State scores, something that we’re quite proud of, although we’d like to get to the national percentile level. New Yorkers are more critical than most folks. And, there remain many things that we can do better. We have invested a great deal in our capital program so we have new facilities, ambulatory care, including inpatient and ambulatory care centers. But it’s not just the bricks and mortar, it’s what you put in place in terms of patient flow. People won’t be happy in a beautiful place when they wait in a room or a waiting area for two hours before they see a physician. They’re not happy if in the business office or the financial counseling office they’re asked the same questions as before. We’re also engaged with our workforce in performance improvement and we see increases in patient satisfaction and staff satisfaction. TJ: With a new health care reform law, what particular adaptations or programs do you have in the works, in the context of your vision for the future of health care, to allow you to compete, or even excel? LB: Creating an integrated delivery system will be more critical than ever in health care reform, particularly if the payment mechanism changes to bundle payments. With the emphasis on accountable care organizations—responsibility for the whole episode of care—then tightening up our current attributes will allow us to perform in that context. Our investments in care management will also provide us with foundational work required post health care reform. The year 2014, which is right around the corner, is also not a long way off when you’re trying to balance your current budget confronted with hundreds of million dollars of cuts because of state budget problems. SH: In a smaller area we still have the challenge of being competitive with other hospitals. However, we have 24,000 people we are already seeing, who fall in the uninsured group that would be eligible for this extended health care reform program. Our goal is to keep them. Once people get the insurance card, they’re not obligated to choose us. They may have seen us as their last resort. Now they can go anywhere in town, or so they think. Some people actually do leave us; and when they come back, they say: “They don’t treat me the same way you do,” “I don’t feel as comfortable there,” ”They treat me like a number,” and “Everybody knew me here, so I wanted to come back.” We want to keep them, so we maintain emphasis on personal customer service. On finances, we work to be sound. The county doesn’t want to be responsible for us any longer, even though we get no funds from them. We have to get services like Medicaid, Medicare, and third-party to diversify the ways we generate revenue. For people that pay, we have the Geriatric Psychiatric (GeriPsych) unit now. We also have a contract with the state prison system for their less difficult patients and surgeries. The other hospitals don’t want to see prisoners in their facility, but in Alabama, prisoners have Blue Cross/Blue Shield, which is the best insurance you can have. We work with a medical detoxification program, which requires seven days in-house. We’re diverse in some other areas in the community. Our rehab facility is very large, and we have a contract with both the county and the city for disability. In fact, we are ready to lease a larger building to expand some of our services. SC: With the advent of the Healthy San Francisco program, the Department of Public Health positioned ourselves to prepare for health care reform by reaching out to the community clinics to form a network of primary care medical homes that would provide access to health care and care coordination. It’s been very successful. We have preliminary data that shows Emergency Department use by Healthy San Francisco members is down, as are hospitalization rates. Chronic care programs we have designed have been successful in this patient population. We enrolled 53,000 patients so far, going all the way up to 400% of the Federal poverty level. When health care reform funds the uninsured, we expect many of the patients currently in our system will want to stay. TJ: Could you give us some specifics about both Healthy Choices and one of your Chronic Disease Programs? CH: Healthy San Francisco, which is not a health insurance program, provides clinical care to uninsured patients, without distinguishing between documented or undocumented status. They get all of their inpatient health care at San Francisco General and they have to be assigned to a medical home within our safety net system. The San Francisco Health Plan (San Francisco’s managed Medi-Cal plan) administers various aspects of Healthy San Francisco so that there is greater synergy among all leaders of the San Francisco safety net. It’s just been fantastic so far. SC: I think we had 80,000 uninsured patients and we got 50,000 of them into our system. CH: The Healthy San Francisco program accomplishes many things that health care reform proposes. And under health care reform, many of these uninsured patients that San Francisco is now providing active care for will have Medicaid, so those dollars will flow into our system. The question is how to attract more medical students and residents into primary care, because health care reform supports primary care practice, and our Healthy San Francisco program needs primary care capacity. So what can we do to make them see the importance of primary care and make that an interesting career choice? In addition to being a universal-access program, Healthy San Francisco is funding six chronic disease management programs. These programs have been in existence for three years and are meant to address flaws in the system, such as poor specialty care access and inadequate attention to chronic disease management in primary care. Three of the six programs are nurse-practitioner (NP) based and are a bridge between the primary care physician and the specialist. The idea is to expand capacity for chronic care management. For example, for a patient with congestive heart failure, the NP works closely with the cardiology clinic, not to assess people for pacemakers or to work on complicated congenital heart conditions, but to provide self-management support, patient education, and some elements of care management. This approach helps patients with their self-management, as well as provides a strong communication link between primary care and specialty care. Our Healthy Spine program addresses patients with low back pain (the cost and impact of low-back pain places a huge burden on the overall health care system). NPs with specialty training work closely with physical therapists and podiatrists in conjunction with primary care physicians to improve patients’ back pain. Another one of the six programs is an integrated behavioral health and primary care program in which we have behavioral health specialists integrated into our hospital-based primary care clinics. They see patients who have chronic illness and a psychosocial or mental health problem that interferes with that patient’s ability to self-manage their chronic medical condition. The behavioral health specialists conduct a series of focused brief therapy sessions. Finally, we have a program with NPs in a residency-based clinic who are working in teams with the residents to provide continuity for the patients when their residents are not there, which also improved access for patients to the clinic. JB: As I’m sitting here thinking and listening to all these great programs, I realize that when you get down to it the health care reform act basically, once you get past the money, talks about access and then it talks about care coordination. Therefore our efforts need to quickly get to quality. One of the things that has been an eye opener for me over the last two quarters is that we’ve partnered with our IT vendor as we pursue implementation of electronic health records. We have constructed a fairly unique gain-sharing relationship with this vendor relative to certain products that will increase our health quality quotient. For example, we’ve got baseline data on patient falls, on pressure ulcers, and on hospital-acquired infections, etc. We put in place some of these technologies, techniques, and policies, and over the last two quarters all of those negative incidents have reduced significantly. We’re splitting those savings with our vendors. It’s amazing what can happen when everybody is on the same page. And these are proper and appropriate incentives. So that’s exciting. TJ: Thank you for your thoughts and this conversation. That concludes our time together, and with this article now represents a three-article conversation about innovation in our nation’s public hospitals from the current practices of multiple hospitals, health systems, locations, size, complexity, and patient populations.
Medical Education—the Challenge of Distinguishing Actual Costs versus Charges (Tuition)
Sunday, 01 April 2012
William L Toffler, MD Spring 2012 - Volume 16 Number 2 How much does it cost to educate a medical student? At face value such a straightforward question seems trivial. Yet the complexity of income sources and lack of transparency of medical university budgeting makes the answer elusive. In the article “Financial Implications of Increasing Medical School Class Size: Does Tuition Cover Cost?” (see page 10), Scheiffler et al take on the challenge. Having an accurate answer is of increasing importance as most medical schools are expanding or making plans to expand in the near future. Their methodology involves the use of published (albeit self-reported) data of available funding for medical education for American medical schools1 and an estimate from the University of Wisconsin, as to what percentage of this funding is dedicated to actually paying for medical student education.2 This creative “back door” approach might indeed provide insight into the true cost, if, and only if, two basic underlying assumptions are correct—that: 1) the funding coming from these sources does correlate with true costs, and 2) the estimated percentage actually allocated to education is correct. In reality, there is no way to know with certainty that either assumption is correct. As such, this approach may be inherently flawed. Consider the following: The first assumption that income stream directly correlates with cost may indeed be true as it is with some common commercial products—for example, food items like eggs and milk. On the other hand, the income stream with other less competitive and more exclusive products may have little connection with cost—for example, high-end perfumes or designer dresses. With these, the cost of making the product may have little bearing on the charge set by the seller. The accuracy of the second assumption—the estimated percentage of a given income stream directly relates to the actual cost—is also uncertain. Decisions by medical university Presidents and Deans aren’t made public. Income streams may well be partially, or even fully, fungible (excepting dedicated scholarships, endowments, and fees). Tuition dollars, then, could be shifted to support a building program, a dowry for a new department chair, research programs, or, even a different program entirely disconnected from any medical student educational costs. In short, the percentage estimate could be entirely wrong. Furthermore, despite perennial complaints from medical school leaders as to the lack of state and federal funding,3 Scheiffler et al are correct in pointing out that no medical school is currently filing for bankruptcy. How then have schools achieved so much with so little? Many medical schools not only survive, they appear to thrive—expanding despite seemingly “inadequate” tuition? Have the Deans discovered how to replicate the miracle of the “loaves and fishes”?4-7 It is unlikely. On the other hand, I believe the following factors, among others (not meant to be an exhaustive list) favorably affect the fiscal health of medical schools: Although increasing class size can increase some costs (eg, the need for more microscopes and number of small-group facilitators), other costs per student actually remain the same—for example, there is no additional cost to provide a lecture to 200 students than to 100. Further, at some schools, real cadavers and microscopes have been replaced with their virtual equivalents.8,9 Teaching materials increasingly are in digital format—eg, syllabi and handouts now incur little or no printing and collating costs. Often, unpaid, volunteer faculty from the community (or even senior students or graduate students) facilitate small-group learning. Almost half of medical school learning occurs in hospital settings where students are taught and evaluated by physicians and residents who receive most or all of their compensation from other sources apart from tuition dollars. In addition, students now spend time in outpatient settings with urban, suburban, and rural practices. Often, the physicians in these practices volunteer to teach—with little or no pay from the university. Although teaching students in the office has been shown to take additional time, there may be minimal impact to the physician’s income.10 Increasingly with distance learning and related online technology, lectures and class time all have been reduced as students become active learners online. In fact, at some medical schools, attendance in class is now optional.11 Testing and grading is increasingly automated; even objective structured clinical exams can be done without the need for on-site, physician reviewers. Furthermore, if medical school education is as expensive as the authors conclude, it becomes difficult to explain the rapid expansion of osteopathic schools where student enrollment increased by 30% between 2000 and 2008.12 Admittedly, such schools depend on a higher percentage of volunteerism by faculty.13 At the same time, they generally do not enjoy the same degree of state, research, or endowments available to most allopathic institutions. On the other hand, if medical schools (whether allopathic or osteopathic) currently receive adequate (or even excess tuition dollars), the question then shifts. Instead of asking “Where will additional tuition dollars be found?,” the question instead should become, “Where are current tuition dollars going?” Is there justification that the average cost of medical education has risen far faster than the cost of living?14 Are students really getting what they pay for? Such questions certainly challenge the status quo. Answers aren’t likely to be easily forthcoming. Yet, at least some medical schools, like the Mayo Medical School, have been able to eliminate tuition as a barrier to admission?15 All students are on scholarships and any qualified student, regardless of financial institution, can gain entrance. Clearly, the development of a more affordable and equitable tuition can positively affect the quality and diversity of the applicant pool. This, in turn, directly relates to the quality and ultimately impacts the overall health of everyone. In conclusion, like all good research, the authors’ published work raises more questions than have been answered. At the same time, their work should call all of us to persistently and patiently press the leadership of our medical schools to provide clearer answers. References 1.    Tables and Graphs for Fiscal Year 2009 [monograph on the Internet]. Washington, DC: Association of American Medical Colleges; 1995-2012 [cited 2012 Apr 9]. Available from: 2.    Ridley GT, Skochelak SE, Farrell PM. Mission aligned management and allocation: a successfully implemented model of mission-based budgeting. Acad Med 2002 Feb;77(2):124-9. 3.    Mann S. Concern remains over federal funding at medical schools, teaching hospitals [monograph on the Internet]. Washington, DC: Association of American Medical Colleges; 2012 Jan [cited 2012 Apr 9]. Available from: 4.    Matthew 14:13-21. NIV 5.    Mark 6:31-44. NIV 6.    Luke 9:10-17. NIV 7.    John 6:5-15. NIV 8.    Virtual Microscope [monograph on the Internet]. New York City, NY: NYU School of Medicine: Division of Educational Informatics: [cited 2012 Apr 9]. Available from: 9.    Singer N. The virtual anatomy, ready for dissection. The New York Times. 2012 Jan 7; Sect BU:3. 10.    Fields SA, Toffler WL, Bledsoe NM. Impact of the presence of a third-year medical student on gross charges and patient volumes in 22 rural community practices. Acad Med 1994 Oct;69(10 Suppl):S87-9. 11.    The Yale System [monograph on the Internet]. New Haven, CT: Yale School of Medicine; updated 2010 Feb 16 [cited 2012 Apr 9]. Available from: 12.    Shannon SC, Teitelbaum HS. The status and future of osteopathic medical education in the United States. Acad Med 2009 Jun;84(6):707-11. 13.    Krueger PM, Dane P, Slocum P, Kimmelman M. Osteopathic clinical training in three universities. Acad Med 2009 Jun;84(6):712-7. 14.    Medical educational costs and student debt: A Working Group report to the AAMC Governance [monograph on the Internet]. Washington DC: Association of American Medical Colleges; 2005 Mar [cited 2012 Apr 9]. Available from: 15.    Tuition and financial aid [Web page on the Internet]. Rochester, MN: Mayo Medical School; 2012 [cited 2012 Apr 9]. Available from:

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