Initiative to Transform Medical Education

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1 American Medical Associaion Iniiaive o Transform Medical Educaion American Medical Associaion Recommendaions for change in he sysem of medical educaion Iniiaive o Transform Medical Educaion Recommendaions for change in he sysem of medical educaion June 2007 Table of conens Summary Table of conens Summary Table of conens Summary Background ITME he goal

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3 Table of conens Summary Background ITME he goal ITME he process Phase 1: Idenificaion of srenghs and gaps in physician preparaion Srenghs in physician preparaion Gaps/opporuniies for improvemen in physician preparaion Phase 2: Soluions o address gaps in he preparaion of physicians Prioriy changes in he medical educaion sysem o address specific gaps Recommendaions for change in he medical educaion sysem Barriers o change Sakeholder groups o involve in bringing abou change Phase 3: Nex seps for ITME program implemenaion Conclusion References Appendix

4 Summary A number of recen repors 1-7 have raised concerns abou he process and produc of he U.S. medical educaion sysem, especially he inadequacies in physicians preparaion for pracice in a healh care sysem ha is newly focused on paien-cenered care and on qualiy and safey. While he U.S. healh care sysem has changed dramaically in he pas cenury including how care is organized, delivered and financed changes in physician educaion and raining have been less far-reaching and innovaive. In response o hese concerns, he American Medical Associaion (AMA) launched he Iniiaive o Transform Medical Educaion (ITME) in ITME aims o: Promoe excellence in paien care by implemening reform in he medical educaion and raining sysem across he coninuum, from premedical preparaion and medical school admission hrough coninuing physician professional developmen. Throughou is planning, ITME has involved many sakeholder groups. Paricipans a he wo ITME working conferences have included represenaives from: (1) pracicing physicians; (2) medical educaors and medical educaion organizaions; (3) payers and purchasers; (4) accrediaion, cerificaion and licensure organizaions; (5) oher healh professions; (6) public healh; (7) consumer groups and he public; and (8) policymakers, including federal and sae governmen. ITME consiss of hree phases: Phase 1 ( ) idenified exising srenghs, gaps and opporuniies for improvemen in physician preparaion. Phase 2 ( ) developed recommendaions for change in he sysem of medical educaion o address he gaps. Phase 3 ( ) is now focused on prioriizing needed changes in medical educaion. Wih he involvemen of appropriae collaboraors, specific changes are being seleced for implemenaion. Based on is work o dae, ITME proposes he following overarching recommendaions for change in he sysem of medical educaion. Recommendaion 1: Apporion more weigh in admissions decisions o characerisics of applicans ha predic success in he inerpersonal domains of medicine. Use valid and reliable measures o assess hese rais. Consider expanding premedical course requiremens beyond he biological and physical sciences, for example, by adding requiremens in he humaniies or social sciences. Develop, validae and uilize new ools in he admissions process o assess relevan personal qualiies of applicans ( for example, analyic and sysems hinking, service orienaion, eam orienaion, commimen o lifelong learning, likelihood of mainaining alruism). Use he inerview in a more sandardized way o beer idenify applicans wih desirable characerisics, bu also consider alernaives o he sandard inerview, such as group inerviews, ha would beer allow he applican o demonsrae desirable characerisics. Admission o residency raining also should ake ino acoun hese desirable characerisics. Recommendaion 2: Consider creaing alernaives o he curren sequence of he medical educaion coninuum, including inroducing opions so ha physicians can re-ener or modify heir pracice. Develop flexible and cos-efficien mechanisms o allow physicians who have lef pracice, or who have had heir pracice inerruped, o have heir coninued compeency assessed. Develop mechanisms for physicians idenified as needing addiional raining for re-enry or remediaion o obain his educaion in a ime- and cos-efficien manner, such as hrough focused mini-residencies. Develop educaionally sound programs for physicians who wish o change he focus of heir pracice midcareer. Ensure ha licensure and cerificaion requiremens do no impose unreasonable ime and

5 cos barriers o physician re-enry and pracice change. Consider how he educaional coninuum could be srucured o reduce he overall lengh of iniial raining. Recommendaion 3: Inroduce core compeencies across he medical educaion coninuum in new and expanded conen areas ha are necessary for pracice in he evolving healh care sysem. Develop and implemen longiudinal educaion in core compeencies across he coninuum, including informaion acquisiion and applicaion, self-assessmen, professionalism, and specialized communicaion skills. Inegrae hese core compeencies ino he eaching program a all levels, in a way ha illusraes heir relevance. Consider wha should be removed from he curriculum, as well as wha should be added, o ensure ha curriculum overload is minimized. Creae learning maerials o suppor educaion in hese compeency areas and develop/implemen new or enhanced approaches o eaching, such as he use of simulaion. Ensure ha pracicing physicians have or are graned ime o paricipae in educaion, including formal educaional sessions and self-learning, and ha such educaion does no impose a serious financial burden on physicians. Recommendaion 4: Inroduce new mehods of evaluaion (such as muli-source evaluaions, self- and peer assessmen, and compeency-based assessmen) ha are appropriae o assess he core compeencies. Ensure ha he new mehods of evaluaion reliably assess desired characerisics boh of physicians-in-raining and of physicians. Provide opporuniies for formaive evaluaion (self-assessmen for he purpose of improvemen). Inroduce summaive evaluaions a milesone poins in he educaional coninuum. Ensure ha evaluaion suppors, and does no sifle, needed educaional innovaion and change. Recommendaion 5: Ensure ha faculy a all sages of he educaional coninuum are prepared o each new conen, employ new mehods of eaching and evaluaion, and ac as role models for learners. Make he provision of faculy developmen an insiuional expecaion. Ensure ha faculy developmen is available for boh new and experienced faculy. Consider expanding he pool of eachers o include individuals wih imporan new conen experise (for example, public healh, economics, social sciences). Recommendaion 6: Ensure ha he organizaional environmen in medical schools and eaching hospials angibly values and rewards paricipaion in educaion. Provide appropriae financial and oher incenives for faculy o paricipae in educaional planning and delivery, as well as in faculy developmen. This includes release ime and salary suppor for paricipaion in educaion and explici consideraion of educaional planning, delivery and research in promoion and enure guidelines. Recommendaion 7: Ensure ha he learning environmen hroughou he medical educaion coninuum is conducive o he developmen of appropriae aiudes, behaviors and values, as well as knowledge and skills. The formal curriculum is designed o each rainees he knowledge and skills o funcion as compeen physicians. However, rainees also learn from faculy role models and hrough informal ineracions wih members of he healh care eam. Aenion mus be paid o hese characerisics of he learning environmen o ensure ha he environmen suppors physicians developmen of appropriae core aiudes, behaviors and values. Recommendaion 8: Enhance coordinaion among accrediaion, cerificaion and licensing bodies. During he 20h cenury, medical educaion grew by accreion. Specialy raining afer medical school (graduae medical educaion) was added o recognize he need for advanced raining in a paricular specialy field. Coninuing professional developmen (coninuing medical educaion) emerged in response o he rapid growh in knowledge and he resuling need for lifelong learning. Each phase of educaion has, in general, funcioned in relaive isolaion from he ohers, and he educaional regulaory sysems of accrediaion, cerificaion and licensure have mirrored his pachwork design. There needs o be enhanced communicaion and coordinaion among hese bodies o suppor he creaion of a rue educaional coninuum.

6 Recommendaion 9: Suppor enhanced funding for medical educaion research, planning and delivery across he coninuum. Advocae for funding o suppor needed changes in medical educaion across he coninuum. Idenify new funding sources o suppor medical educaion research and developmen and he implemenaion of innovaive programs. Enhance exising and develop new mechanisms o reduce he significan deb burden ha medical sudens accumulae so ha he high coss of medical educaion do no exclude qualified applicans from pursuing a medical career or selecing a desired specialy. A he level of he physician in pracice, here should be consideraion of how bes o fund coninuing professional developmen (coninuing medical educaion), so as o eliminae he poenial for commercial bias. Recommendaion 10: Evaluae he effeciveness of changes in he medical educaion sysem based on heir oucomes. The resuls of changes in he sysem of medical educaion should be evaluaed for heir feasibiliy and uiliy, as well as for learning oucomes. This assessmen should also include he effecs of he changes on evenual pracice and paien oucomes. ITME sresses ha implemening a change in any one of hese areas alone likely will no resul in he desired oucome. True reform of medical educaion requires a comprehensive rehinking of he educaion sysem, which includes all of hese elemens.

7 Background According o many quaniaive indicaors, U.S. medical educaion is doing well. For example, mos individuals who ener U.S. medical schools will evenually graduae. U.S. graduae medical educaion aracs physicians from around he globe. Mos physicians who complee raining obain and reain a license o pracice medicine, and he grea majoriy currenly obain cerificaion by a medical specialy board. However, serious concerns have been expressed abou he process and produc of he U.S. medical educaion sysem. 1-7 Many of hese concerns have focused on inadequacies in physicians preparaion for pracice in he evolving heah care sysem, including he need for more of a paien and qualiy/safey focus. While he U.S. healh care sysem has changed dramaically in he pas cenury, including how care is organized, delivered and financed, changes in physician educaion and raining have been less far-reaching and innovaive. This repor describes he resuls, o dae, of a comprehensive iniiaive aimed a addressing he significan gap beween he oucomes of medical educaion and he needs of he pracice environmen. The core principle underlying his American Medical Associaion (AMA) sponsored iniiaive is ha safe, qualiy medical care is ulimaely dependen on a welleducaed physician work force. The Iniiaive o Transform Medical Educaion (ITME) is grounded in work by he AMA Council on Medical Educaion. A is 2002 Annual Meeing, he AMA House of Delegaes adoped a Council on Medical Educaion repor iled Comprehensive Reform a he Inerface of Medical Educaion and Healh Care. This repor recommended a comprehensive iniiaive wih he following desired oucomes: The creaion of a sysem of medical educaion ha beer equips young physicians wih he knowledge, skills, aiudes and values necessary o provide qualiy medical care and he abiliy o coninually updae heir learning The availabiliy of appropriae resources, including funding, faculy, clinical sies and echnology, o suppor needed changes in medical educaion across he coninuum The repor recommended an ieraive process o bring abou medical educaion change, involving paricipaion by a widening circle of sakeholder groups. To prepare for a comprehensive iniiaive, he AMA Council on Medical Educaion reviewed a number of repors and commenaries describing problems wih he curren educaion of physicians. Alhough criiques of medical educaion come from a variey of perspecives, here are a number of similariies in he gaps ha have been idenified. The following illusraes some of hese problems and he general remedies ha have been proposed. Need o enhance healh sysem safey and qualiy. Landmark repors by he Insiue of Medicine idenified problems wih healh care qualiy and safey. 1-3 Among he deficis were he inabiliy of healh professionals o work smoohly in eams and o efficienly share informaion relaed o paien care. The soluions proposed for hese gaps included change in he educaion of physicians and oher healh professionals, such as enhanced opporuniies for eam-based learning and increased availabiliy of informaion echnology, such as elecronic medical record sysems. 2-3 Need for enhanced emphasis on educaion in raining insiuions. Insiuions ha rain physicians, such as academic healh ceners, are under increasing srain based on changes in he environmen in which healh care is delivered. 4 These financial and oher sresses have resuled in a decreased emphasis on he educaional mission. For example, faculy have become less available o plan and implemen needed educaional changes ha would, in urn, prepare physicians o deliver he ars and sciences of healh care essenial o he changing needs of sociey. 5 Reform of medical educaion requires

8 ha prioriies wihin eaching insiuions and sociey in general shif o provide more resources for educaional innovaion. 5,6 Inadequacy of physician preparaion in new conen areas. Concerns exis ha physicians-in-raining are no being equipped wih all he knowledge and skills needed o prepare hem for curren pracice. 7 This includes adequae raining in specific conen areas, such as physician-paien communicaion, 8 as well as in cerain skills, such as he abiliy o obain and apply evidencebased informaion in he conex of paien care. 9 This background helped o frame he plans for ITME. A leadership group was formed from groups wihin he AMA, including he Board of Trusees, Council on Medical Educaion, Secion on Medical Schools, Residen and Fellow Secion, and Medical Suden Secion. The leadership group firs ariculaed he overall goal for ITME and hen designed he process by which ITME would funcion. ITME he goal The ITME goal is o: and he financing of medical educaion and healh care. All hese areas in he eaching insiuion and he exernal environmen conribue o he success of he medical educaion sysem. The educaional coninuum Reform mus occur hroughou he medical educaion coninuum (medical school, residency raining and coninuing professional developmen). This will require coordinaion among all phases of he coninuum so ha he learner will sysemaically acquire, mainain and improve he requisie knowledge, skills, aiudes and values characerisic of a compeen physician. Change occurring only in one phase of he coninuum likely will no resul in he desired oucome. The focus of ITME is on he preparaion of physicians o deliver safe, qualiy medical care. While physicians have oher professional responsibiliies for example, as researchers, adminisraors and eachers mos spend a leas some porion of heir ime providing care o paiens. I is his specific role ha has raised he mos concern among advocaes for medical educaion reform. Specifically, ITME is concenraing on he adequacy of physician preparedness o: Promoe excellence in paien care by implemening reform in he medical educaion and raining sysem across he coninuum, from premedical preparaion and medical school admission hrough coninuing physician professional developmen. Inerac wih paiens. Funcion effecively and efficienly wihin heir own healh care organizaions and he enire healh care sysem. Ac as a caring professional in sociey. Promoe excellence in paien care In he curren healh care sysem, excellence in paien care includes expecaions ha he physician has he abiliy o efficienly deliver safe care, o measure and improve paien oucomes, and o communicae appropriaely wih diverse paien populaions. The educaion and raining sysem mus ensure ha physicians-in-raining and physicians in pracice acquire and demonsrae hese skills. The medical educaion and raining sysem Transformaion of medical educaion mus include, bu no be limied o, changes in wha is augh, and where and how eaching occurs. Successful reform also requires aenion o facors ha influence he educaional process, including faculy reward sysems, he aiudes and values displayed by supervisors and peers as par of he learning environmen, As ITME is direced a educaional reform, i will no work direcly o bring abou saluary healh sysem change. However, posiive healh sysem changes may resul as a consequence of addressing any curren gaps in he preparaion of physicians. ITME he process From is incepion, ITME has involved a broad array of sakeholder groups, including: Pracicing physicians Medical educaors and medical educaion organizaions Payers and purchasers Accrediaion, cerificaion and licensure organizaions Oher healh professions Public healh

9 Consumer groups and he public Policymakers, including he federal governmen and he saes The ITME process, which began in mid-2005, consiss of hree phases. Phases 1 and 2 have been compleed, and Phase 3 is under way. Phase 1 ( ) idenified srenghs in he preparaion of physicians, as well as gaps and opporuniies for improvemen. Addiionally, here was aenion devoed o idenifying posiive and negaive characerisics of he raining sysem. Phase 2 ( ) seleced gaps ha were amenable o change and creaed sraegies for addressing hem. This included developing specific plans for change, idenifying barriers ha mus be overcome in order for change o occur, and idenifying sakeholder groups ha could suppor or poenially oppose he changes. Phase 3 ( ) involves working wih appropriae collaboraors o prioriize needed changes in medical educaion. Specific recommendaions for change are being seleced wih he goal of rapid, effecive implemenaion, including he developmen of model programs, where relevan and feasible. As appropriae, he resuls will be evaluaed o deermine heir feasibiliy and broad applicabiliy.

10 Phase 1: Idenificaion of srenghs and gaps in physician preparaion In addiion o a review of relevan repors and published lieraure on medical educaion reform, Phase 1 included he firs ITME working conference (December 2005). Abou 40 represenaives from he sakeholder groups lised previously worked in small groups o idenify srenghs, gaps and opporuniies for improvemen in physician preparaion. Despie he wide differences in paricipan background, here was considerable similariy in he issues ha were idenified. A summary lis of srenghs and gaps/opporuniies for improvemen was generaed from he conference. This lis was reviewed by he conference paricipans and shared wih oher groups in he medical educaion communiy. Feedback from his review process resuled in a final lis, which is presened below. Srenghs in physician preparaion The following were idenified as srenghs in he curren preparaion of physicians: Physicians are knowledgeable and echnically proficien. Physicians are knowledgeable abou and echnically proficien in providing care for acue disease, bu less so for chronic condiions. Physicians wish o do wha is bes for heir paiens. There is a srong commimen by he physician o he care of his/her individual paiens. Paiens respec physicians as credible sources of informaion. Gaps/opporuniies for improvemen in physician preparaion The following general areas for improvemen were idenified in he curren preparaion of physicians. Treaing he heah care sysem There are gaps in physicians preparaion o diagnose and rea problems in heir own healh care organizaions and in he healh care sysem. This includes he abiliy o engage in a coninuous qualiy improvemen approach o sysem evaluaion and improvemen a a macro level (he healh care sysem) and micro level (wihin heir own healh care organizaion). Specifically, physicians are no prepared o evaluae he care hey provide in heir own pracices and o use he resuls o improve paien safey and he qualiy of care provided. Serving as advocaes for paiens Physicians are generally no prepared o be advocaes for paiens on issues relaed o social jusice ( for example, eliminaion of healh care dispariies, access o care) and o be ciizen leaders inside and ouside of he medical profession. This also includes engaging in advocacy on public healh issues. Losing alruism and he caring aspecs of medicine Physicians ofen lose alruism and qualiies of caring as hey proceed hrough raining and ener he pracice environmen. Applicans o medical school and residency raining are seleced for heir abiliies o acquire knowledge and o problem-solve, and our curren sysem of medical educaion reinforces hese rais. This may lead physicians o perceive paiens simply as sources of daa and problems o be solved, insead of as individuals in need. Dealing wih uncerainy Physicians are rained o believe i is imporan o have he answer. They are expeced o convey his impression o supervisors while in raining and subsequenly behave his way wih paiens and colleagues when hey are in pracice. This makes i difficul for physicians o deal wih he ineviable uncerainy arising from incomplee or conflicing informaion. Addiionally, hey are no ypically prepared o convey heir uncerainy when ineracing wih paiens and colleagues.

11 Managing informaion In he conex of he rapidly expanding knowledge base, many physicians are no prepared o rapidly acquire, evaluae and synhesize informaion in he conex of care for an individual paien. While here are generaional differences, many physicians are no prepared o uilize informaion echnology o assis in informaion acquisiion and managemen. Furher, hey are no prepared o develop and carry ou heir own lifelong learning curriculum, including idenifying heir own learning needs and esablishing learning goals o mee hese needs. Expecing o be auonomous Physicians are socialized o be in charge and ac as auonomous decision-makers in he care of paiens. This philosophy can be a barrier o providing paiencenered care, where paien values and desires are an inegral par of shared decision-making. Physicians need addiional preparaion in balancing heir own values and expecaions wih hose of heir paiens, while aking ino accoun changing socieal needs and expecaions. This expecaion of auonomy sarkly conrass wih increasing requiremens for physicians o be more accounable o various consiuencies, including he public, payers and governmen. Physicians mus coninue o ake a leadership role in professional self-regulaion or ha privilege will be hreaened and diminished. Lasly, he expecaion of auonomy diminishes he abiliy of physicians o ac as eam players wih oher physicians and oher healh professionals. They may be relucan o learn from oher professions and disciplines and o work wih ohers as parners in he care process, which may hamper he care ha is provided o paiens. Balancing he paien and populaion perspecives Physicians are prepared o do wha hey believe is bes for individual paiens. They are no, however, prepared o paricipae in ehical and poliical discussions abou he allocaion of healh care resources, which are no limiless. Exercising skills in communicaion wih paiens Physicians need addiional preparaion in communicaing wih paiens abou difficul issues, such as hose relaed o deah and dying. There is a need o expand skills in culural compeence/awareness and o recognize ha some paiens may have healh lieracy issues. Addiional gaps and opporuniies for improvemen in he medical educaion sysem were idenified: Absence of a rue educaional coninuum The sysem of medical educaion in he Unied Saes ofen is referred o as a coninuum encompassing medical school (undergraduae medical educaion), residency and fellowship raining (graduae medical educaion), and coninuing professional developmen (coninuing medical educaion). While he physician does progress hrough each of hese sages of professional developmen, he sages have developed and are regulaed in isolaion. There are separae accrediing bodies for each phase of he coninuum, so here is lile incenive for join planning and curriculum coordinaion across phases. The evaluaion of learners also occurs wih less coordinaion han is desirable, so i is difficul o ensure ha learners are moving oward masery in a sysemaic way. This is especially he case for pracicing physicians. Limiaions in educaional and career pahways The oal lengh of raining from medical school hrough fellowship coninues o increase, based primarily on he addiion of muliple new subspecialy areas. The curren srucure of he medical educaion sysem consrains physicians o paricipae in such advanced raining a he beginning of heir career. Curren regulaory guidelines (licensure, cerificaion and credenialing) affec he abiliy of physicians o make midcareer adjusmens (such as re-enry afer a period ou of pracice and specialy or pracice changes) based on personal circumsances or changes in how healh care is delivered. In general, here are limied pahways for pracicing physicians who leave pracice for a period o re-ener.

12 Phase 2: Soluions o address gaps in he preparaion of physicians Phase 2 of ITME aimed o address 11 specific gaps in physician preparaion or in he characerisics of he medical educaion sysem ha were based on he resuls of Phase 1. Plans for changes in he sysem of medical educaion o address each gap were developed a he second ITME working conference* (Sepember 2006). The approximaely 100 paricipans came from he same sakeholder groups as paricipaed in Phase 1. See he Appendix for a paricipan lis. For he second ITME working conference, paricipans were divided ino 11 small groups, each of which was assigned a specific gap/problem area from Phase 1. Each group included represenaion from muliple sakeholder groups, bu also experise in is specific assigned gap/problem area. During he wo-day conference, paricipans: (1) idenified changes in one or more phases of he medical educaion coninuum o address he gap; (2) prioriized he recommended changes, based on perceived impac and feasibiliy; (3) idenified barriers o implemenaion of heir recommended changes; and (4) deermined which sakeholder groups would have impac on he change process, including hose ha would suppor he change, be neural o he change and oppose he change. In order o address each specific gap, paricipans were asked o consider wheher he gap/problem area could bes be addressed hrough change in one or more of he following areas: Premedical preparaion (such as required courses) and he process for he selecion of medical sudens and residen physicians The educaional program for medical sudens and residens, including boh he formal curriculum and he learning environmen (such as he aiudes/values displayed by eachers and oher role models) The process and conen of coninuing physician educaion/professional developmen The regulaory environmen of medical educaion, including accrediaion, cerificaion and licensure The sysem of financing undergraduae, graduae and coninuing medical educaion The suppor sysems creaed wihin healh care organizaions (for example, informaion sysems, error reporing sysems) Prioriy changes in he medical educaion sysem o address specific gaps Following are he changes recommended by each group o address he 11 lised gaps/problem areas considered during he second ITME working conference. 1. Physicians are no prepared o evaluae heir own pracice and o use he resuls of he evaluaion o improve he qualiy of care and paien safey. Creae financial incenives in he educaional and reimbursemen sysems ha suppor aenion o qualiy and safey. Inroduce changes in cerificaion, licensure and credenialing/privileging o simulae educaion in and assessmen of safey and qualiy. Develop and inroduce opporuniies for self-direced learning (coninuing educaion) for pracicing physicians ha promoe qualiy improvemen and safey. This could include expanded use of new educaional formas, such as performance improvemen coninuing medical educaion. 2. Physicians are no prepared o funcion in a healh care sysem ha requires pracice o be efficien and evidence-based. *The second ITME working conference was parially suppored by U.S. Deparmen of Healh and Human Services/Agency for Healhcare Research and Qualiy Small Conference Gran R13HS

13 Selec for, each and reinforce new skills ha are relaed o evidence-based, efficien pracice, including ime managemen, eamwork, delegaion and abiliy o work hrough problems. Provide ools o assis physicians, such as real-ime decision-suppor sysems ha have been developed o be evidence-based. Provide incenives/rewards, such as coninuing medical educaion credi, for jus in ime learning. Provide paymen incenives for evidence-based pracice. 3. Physicians are no prepared o paricipae in decisions abou he jus allocaion of finie healh care resources and o be advocaes for paiens relaed o issues of social jusice ( for example, eliminaion of healh care dispariies, access o care). Consider he addiion of premedical course requiremens in he social sciences (such as sociology, economics, public healh). Include issues relaed o social accounabiliy among admissions crieria. Refine admissions ools, such as he inerview, o include a focus on such issues. Ensure ha inerviewers are prepared o address his issue during he inerview. Revise he medical school and graduae medical educaion curriculum o include new/expanded conen areas, such as service learning, payer sysems, healh sysem design/oher healh care sysems. Involve faculy from oher schools (such as public healh, universiy deparmens) in eaching. 4. Physicians lose alruism and he caring aspecs of medicine as hey proceed hrough raining. Emphasize service in admissions crieria and hroughou raining. Consider providing opporuniies for volunary (or mandaory) service direced a meeing paien needs. Creae an inegraed, longiudinal curriculum from premedical educaion hrough coninuing professional developmen in humanism, ehics and professionalism. Suppor he developmen and implemenaion of his curriculum wih funding and appropriae ime allocaions for eachers and learners. Address he hidden curriculum. 5. Physicians are rained o convey he impression ha hey have he answer, so hey are no prepared o deal wih he ineviable uncerainy arising from incomplee or conflicing informaion or o convey heir uncerainy o paiens. Selec for and suppor/reinforce he abiliy o recognize and acknowledge uncerainy across he educaional coninuum. Develop eaching and assessmen, including selfassessmen, ools relaed o dealing wih uncerainy. Creae suppor sysems o help physicians find answers o assis hem in decision-making. Change evaluaion sysems for physicians-in-raining and pracicing physicians o permi acknowledgmen of uncerainy. 6. Physicians are no prepared o develop and carry ou heir own lifelong learning curriculum. Assess applicans o medical school on characerisics ha predic he capaciy and moivaion for lifelong learning. Develop ools ha can be used by learners across he coninuum o idenify heir own learning needs. Prepare learners a each sage of he coninuum o use hese ools. Develop collaboraions beween academic medical ceners/eaching sies and he coninuing medical educaion communiy o creae educaional opporuniies ha suppor re-enry, remediaion and pracice change for individual physicians. Eliminae he barriers o physicians a all career sages making such changes. 7. Physicians are no prepared o rapidly acquire, evaluae and synhesize informaion in he conex of he care of individual paiens. 11

14 Ensure ha faculy (no jus physicians) are able o each and model his skill. Develop informaion suppor sysems for physicians, care eams and paiens. Teach he use of hese sysems across he coninuum. Ensure ha physicians-in-raining have masered he use of informaion suppor sysems (such as elecronic medical records). Ensure ha informaion suppor sysems are used in all healh care seings and ha he sysems are designed so ha informaion can be shared. 8. Physicians are seleced and rained for he abiliy o acquire knowledge and o problem-solve, o he exclusion of he qualiies of caring and he abiliy o see paiens as individuals in need. Shif he emphasis in he admissions process away from quaniaive measures ha assess science-based knowledge. Develop valid and reliable ools o assess humanism, alruism and relaed qualiies during he admissions process. Teach oward core compeencies relaed o professionalism and qualiies of caring during medical school and residency raining. Creae valid and reliable measures o assess he aainmen and demonsraion of hese compeencies. Coninue o assess for hese qualiies during pracice. Provide faculy developmen and incenives o change he learning environmen o suppor he learner s developmen of he core professionalism compeencies. 9. Physicians are no prepared o be eam players wih oher physicians and healh professionals. Assess readiness for and skills of eam-based learning a admissions and coninue o assess hese skills hroughou raining and pracice. Incorporae new assessmen mehods, such as muli-source evaluaion and eambased grades. Change he organizaional culure of educaion and pracice sies o suppor eam learning and pracice. For example, creae an environmen in eaching insiuions ha suppors effecive eam funcioning, such as rewards for eam oucomes. 10. Physicians are no prepared o deal wih difficul communicaion issues, such as disclosing or apologizing for errors in paien care or demonsraing culural compeence/awareness. Change admissions crieria o give greaer weigh o emoional inelligence, reflecion, self-awareness and oher relevan rais. Creae/idenify and implemen valid and reliable measures of hese rais. Develop eaching ools specifically relaed o difficul and complex communicaion skills. Ensure ha sudens and residens have supervised experience (real and/or simulaed) in difficul communicaion siuaions. Inroduce/expand evaluaion insrumens and mehods ha specifically assess complex communicaion skills across he coninuum of medical educaion and pracice, such as objecive srucured clinical examinaions and oher simulaion mehods. 11. Physicians are no able o make midcareer adjusmens (such as re-enry o pracice and specialy or pracice change) as a resul of personal circumsances or changes in how healh care is delivered. Creae compeency-based mehods for self-assessmen. Ensure ha he assessmens use mehods ha are valid and reliable. Provide educaional opporuniies for physicians o remedy gaps and o updae heir knowledge and skills. Encourage collaboraion among organizaions responsible for licensure, credenialing and cerificaion o creae a common se of requiremens for re-enry and reraining. Creae financing mechanisms o suppor physician reraining/remediaion. 12

15 Recommendaions for change in he medical educaion sysem The changes proposed o address he 11 specific gaps/problem areas have a number of areas of similariy. The following 10 recommendaions represen a comprehensive synhesis of he changes and are aimed a addressing all he facors ha ITME believes mus be considered if change is o be successful. Noe ha no all he recommendaions apply o each gap/problem area. Recommendaion 1: Apporion more weigh in admissions decisions o characerisics of applicans ha predic success in he inerpersonal domains of medicine. Use valid and reliable measures o assess hese rais. Consider expanding premedical course requiremens beyond he biological and physical sciences, for example, by adding requiremens in he humaniies or social sciences. Develop, validae and uilize new ools in he admissions process o assess relevan personal qualiies of applicans (for example, analyic and sysems hinking, service orienaion, eam orienaion, commimen o lifelong learning, likelihood of mainaining alruism). Use he inerview in a more sandardized way o beer idenify applicans wih desirable characerisics, bu also consider alernaives o he sandard inerview, such as group inerviews, ha would beer allow he applican o demonsrae desirable characerisics. Admission o residency raining also should ake ino acoun hese desirable characerisics. Recommendaion 2: Consider creaing alernaives o he curren sequence of he medical educaion coninuum, including inroducing opions so ha physicians can re-ener or modify heir pracice. Develop flexible and cos-efficien mechanisms o allow physicians who have lef pracice, or who have had heir pracice inerruped, o have heir coninued compeency assessed. Develop mechanisms for physicians idenified as needing addiional raining for re-enry or remediaion o obain his educaion in a ime- and cos-efficien manner, such as hrough focused mini-residencies. Develop educaionally sound programs for physicians who wish o change he focus of heir pracice midcareer. Ensure ha licensure and cerificaion requiremens do no impose unreasonable ime and cos barriers o physician re-enry and pracice change. Consider wha should be removed from he curriculum, as well as wha should be added or modified, and how he educaional coninuum could be srucured o reduce he overall lengh of iniial raining. Recommendaion 3: Inroduce core compeencies across he medical educaion coninuum in new and expanded conen areas ha are necessary for pracice in he evolving healh care sysem. Develop and implemen longiudinal educaion in core compeencies across he coninuum, including informaion acquisiion and applicaion, self-assessmen, professionalism, and specialized communicaion skills. Inegrae hese core compeencies ino he eaching program a all levels, in a way ha illusraes heir relevance. Consider wha should be removed from he curriculum, as well as wha should be added, o ensure ha curriculum overload is minimized. Creae learning maerials o suppor educaion in hese compeency areas and develop/implemen new or enhanced aproaches o eaching, such as he use of simulaion. Ensure ha pracicing physicians have or are graned ime o paricipae in educaion, including formal educaional sessions and self-learning, and ha such educaion does no impose a serious financial burden on physicians. Recommendaion 4: Inroduce new mehods of evaluaion (such as muli-source evaluaions, self- and peer assessmen, and compeency-based assessmen) ha are appropriae o assess he core compeencies. Ensure ha he new mehods of evaluaion reliably assess desired characerisics boh of physicians-in-raining and of physicians. Provide opporuniies for formaive evaluaion (self-assessmen for he purpose of improvemen). Inroduce summaive evaluaions a milesone poins in he educaional coninuum. Ensure ha evaluaion suppors, and does no sifle, needed educaional innovaion and change. Recommendaion 5: Ensure ha faculy a all sages of he educaional coninuum are prepared o each new conen, employ new mehods of eaching and evaluaion, and ac as role models for learners. 13

16 Make he provision of faculy developmen an insiuional expecaion. Ensure ha faculy developmen is available for boh new and experienced faculy. Consider expanding he pool of eachers o include individuals wih imporan new conen experise (for example, public healh, economics, social sciences). Recommendaion 6: Ensure ha he organizaional environmen in medical schools and eaching hospials angibly values and rewards paricipaion in educaion. Provide appropriae financial and oher incenives for faculy o paricipae in educaional planning and delivery, as well as in faculy developmen. This includes release ime and salary suppor for paricipaion in educaion and explici consideraion of educaional planning, delivery and research in promoion and enure guidelines. Recommendaion 7: Ensure ha he learning environmen hroughou he medical educaion coninuum is conducive o he developmen of appropriae aiudes, behaviors and values, as well as knowledge and skills. The formal curriculum is designed o each rainees he knowledge and skills o funcion as compeen physicians. However, rainees also learn from faculy role models and hrough informal ineracions wih members of he healh care eam. Aenion mus be paid o hese characerisics of he learning environmen o ensure ha i suppors physicians developmen of appropriae core aiudes, behaviors and values. Recommendaion 8: Enhance coordinaion among accrediaion, cerificaion and licensing bodies. During he 20h cenury, medical educaion grew by accreion. Specialy raining afer medical school (graduae medical educaion) was added o recognize he need for advanced raining in a paricular specialy field. Coninuing professional developmen (coninuing medical educaion) emerged in response o he rapid growh in knowledge and he resuling need for lifelong learning. Each phase of educaion has, in general, funcioned in relaive isolaion from he ohers, and he educaional regulaory sysems of accrediaion, cerificaion and licensure have mirrored his pachwork design. There needs o be enhanced communicaion and coordinaion among hese bodies o suppor he creaion of a rue educaional coninuum. Recommendaion 9: Suppor enhanced funding for medical educaion research, planning and delivery across he coninuum. Advocae for funding o suppor needed changes in medical educaion across he coninuum. Idenify new funding sources o suppor medical educaion research and developmen and he implemenaion of innovaive programs. Enhance exising and develop new mechanisms o reduce he significan deb burden ha medical sudens accumulae so ha he high coss of medical educaion do no exclude qualified applicans from pursuing a medical career or selecing a desired specialy. A he level of he physician in pracice, here should be consideraion of how bes o fund coninuing professional developmen (coninuing medical educaion), so as o eliminae he poenial for commercial bias. Recommendaion 10: Evaluae he effeciveness of changes in he medical educaion sysem based on heir oucomes. The resuls of changes in he sysem of medical educaion should be evaluaed for heir feasibiliy and uiliy, as well as for learning oucomes. This assessmen also should include he effecs of he changes on evenual pracice and paien oucomes. ITME sresses ha implemening a change in any one of hese areas alone likely will no resul in he desired oucome. True reform of medical educaion requires a comprehensive rehinking of he educaion sysem, which includes all of hese elemens. Barriers o change During he second ITME working conference, small groups also idenified barriers ha mus be overcome in order o successfully inroduce and mainain recommended changes. The following summarizes he caegories of barriers ha were idenified by a leas some of he groups. These barriers should be considered in planning for change in any phase of he educaional coninuum. 14

17 Barriers a he level of individual sysem paricipans Resisance o change is a subsanial barrier. Resisance may arise from personal characerisics and/or may be a resul of facors a he organizaional or environmenal levels, for example, he individual s response o wha he organizaion values and rewards. Resisance can exis a he level of boh he eacher and he learner, so boh perspecives mus be addressed in planning for change. Limied experise among individuals in he medical educaion sysem is a barrier o carrying ou some of he recommended changes. Overcoming his requires increasing he availabiliy of experise in new conen areas and in new evaluaion mehods hrough faculy developmen or he recruimen of faculy wih addiional skills. There also may be limied knowledge abou he sraegies o successfully bring abou change and o suppor innovaion. Planning should include a consideraion of he lieraure from oher disciplines on how o bring abou change successfully. Many of he ools ha individuals would need o use o implemen desired changes do no exis. This includes such hings as a uniform elecronic medical record and oher informaion suppor sysems. Oher ypes of ools ha would suppor he eaching and assessmen of new compeencies also are no available. For example, while excellen esing mechanisms exis o assess cogniive knowledge, valid and reliable insrumens o evaluae personal characerisics in he admissions process and during raining are no generally available. Barriers a he organizaional level There may be an organizaional climae ha does no suppor change. If educaion is no a prioriy a he insiuional level, faculy wih needed experise o suppor educaional innovaion may no be hired or reained. Insead, hiring decisions may be made based solely on research or clinical care prioriies. The organizaional climae also may no value or suppor faculy developmen. Release ime and funding for faculy o increase heir skills in educaion may no be available. Expers in educaional research, planning and evaluaion may no be available on sie. The insiuional reward sysem may no sufficienly value educaional research, planning and delivery in he faculy promoions process, which discourages paricipaion. Faculy ime for educaion may no be proeced wih salary suppor, so ha income is los by he faculy member s paricipaion in educaion. Change will no be accepable if i comes as an unfunded mandae or imposes significan addiional burdens on he organizaion or is members. The curren srucure of he eaching program a he medical school and residency program levels may be a barrier o change. The medical school curriculum, for example, is highly compressed, and ime for he addiion of new subjec areas is limied. Limiaions on residen physician duy hours may also affec he availabiliy of ime for eaching sessions. Finally, he infrasrucure of he eaching insiuion may no suppor change. Absence of resources such as adequae eaching space or informaion sysems may make needed change difficul. Barriers a he environmenal level The curren financing mechanisms for medical educaion across he coninuum do no suppor innovaion and broad-based educaional change. For example, here is limied funding for medical educaion research and for new program implemenaion. Financing mechanisms ofen require ha ime for educaion is cross-subsidized from oher funding sreams. In addiion, he regulaory sysem, and for medical educaion accrediaion, cerificaion and licensure are no coordinaed wihin and across phases of he coninuum. This makes for poenially mixed messages, so ha compeencies are no sysemaically augh and evaluaed as he physician proceeds hrough raining and ino pracice. Finally, numerous facors in he healh sysem can ac as barriers o change in medical educaion. These include he organizaion and financing of healh care and infrasrucure issues, such as he general absence of healh informaion sysems. For ITME o be successful, i mus address educaional change in he conex of he parallel healh sysem changes ha will be required. All hese barriers can only be overcome hrough he broadbased acion of individuals and groups wihin and exernal o he medical educaion communiy. This requires a comprehensive consideraion of which sakeholders o involve in bringing abou change. 15

18 Sakeholder groups o involve in bringing abou change For each gap/area for improvemen, paricipans a he second ITME working conference lised and prioriized he sakeholder groups ha could faciliae and hose ha could impede implemenaion of desired changes. While he specific collaboraors ha were idenified varied wih he ype of gap/area for improvemen, here was general consensus ha broad-based paricipaion was necessary for meaningful change o occur. The following is a summary of he general caegories of sakeholders who were cied as imporan o involve in bringing abou one or more of he recommended changes. The specific organizaions and groups lised are mean as examples. Individual eachers and learners, including sudens, residens and pracicing physicians. There mus be explici accepance of he change by hose who will implemen i and by hose who will be affeced by i. Paricipaion of individuals who will be affeced is, herefore, criical in planning for change. Educaional program leadership. Include individuals wih local responsibiliy for educaional programs a all levels of he coninuum for example, deans and heir saff, deparmen chairs, and residency program direcors. These individuals have high credibiliy as well as deailed knowledge of heir own organizaions. Insiuional officials a clinical sies. Clinical sie adminisraors (hospial direcors) and faculy/physician pracice adminisraors are criical o ensure ha proposed changes can be implemened in eaching insiuions and ha appropriae faculy are available o paricipae. They also may provide financial and oher resources. Insiuional leaders a he medical saff level also se requiremens for credenialing and privileging. Accrediors. Organizaions ha accredi educaional programs/providers a all levels of medical educaion undergraduae (Liaison Commiee on Medical Educaion), graduae (Accrediaion Council for Graduae Medical Educaion) and coninuing (Accrediaion Council for Coninuing Medical Educaion) along wih accrediors of healh care organizaions (Join Commission), are imporan in ha hey se expecaions a he level of he medical educaion sysem. Cerifying and licensing bodies. Physicians-in-raining and physicians demonsrae heir knowledge and skills hrough he examinaions and oher assessmens used for licensure and cerificaion. These assessmens define, a a naional level, he requiremens for enry ino and coninuaion in pracice. Therefore, i is criical o include he organizaions responsible for seing hese sandards: he American Board of Medical Specialies and is member boards, he Federaion of Sae Medical Boards and sae medical licensing boards, and he Naional Board of Medical Examiners. Medical educaion and relaed associaions. Naional organizaions serve as forums o bring individuals ogeher and o serve as he voice of he profession and he medical educaion communiy o exernal groups. These include associaions represening he medical profession and medical sudens a he naional and sae levels (he AMA, he American Oseopahic Associaion, he American Medical Suden Associaion, he Naional Medical Associaion, he Naional Hispanic Medical Associaion, sae medical associaions); medical schools and eaching hospials (he Associaion of American Medical Colleges, he American Associaion of Colleges of Oseopahic Medicine, he American Hospial Associaion); and medical specialies (Council of Medical Specialy Socieies, medical specialy socieies). Leaders and represenaives from oher healh professions. If qualiy and safey in healh care depends on he smooh funcioning of he healh care eam, hen represenaives from oher healh professions should be involved in planning for medical educaion change. Ideally, for he maximum effec here should be coordinaed planning for educaional change across healh professions. Represenaives from oher disciplines. Experise from individuals in oher disciplines (such as sociology, ehics, economics, public healh) will be needed in he design of curriculum changes. Experise also will be needed in organizaional change, educaional sciences (esing and measuremen, insrucional developmen), and informaion echnology o develop and implemen he necessary ools and oher suppors needed for change o occur. Premedical advisers. Premedical advisers will be criical in creaing he inerface beween premedical and medical educaion. This includes idenifying he prerequisies 16

19 necessary for admission and geing his informaion ou o schools/colleges and poenial applicans. The Naional Associaion of Advisors for he Healh Professions and oher groups of pre-professional advisers have a cenral role in he change process. Payers for healh care and for educaion. Public ( federal and sae) and privae secor payers for healh care and educaion, including hose involved in new funding paradigms ( for example, pay for performance), should paricipae so ha incenives are appropriaely aligned. Purchasers. Naional business groups on healh, unions and oher large purchaser sysems should paricipae so as o conribue informaion abou expecaions. Paiens and he public. Paricipaion by paiens and members of he public will be imporan boh o idenify compeencies expeced of physicians and o evaluae wheher changes have had an impac on qualiy of care and saisfacion. While sampling from members of he public in general is difficul, organizaions represening broad segmens of he public or of paiens should be seleced o paricipae. To be successful, he need for change mus be acceped a he level of individual insiuions (such as medical schools and eaching hospials) and also a he level of he medical educaion sysem as a whole. Insiuional-level changes require suppor from leaders (formal and informal) as well as from organizaional members (such as faculy, saff and learners). A he sysem level, change requires acion by regulaory bodies, such as accrediors, cerifying bodies and licensing boards, as well as by funders. Those who uilize and pay for he services of physicians mus undersand and suppor educaional sysem change as in he bes ineress of he healh care ha is delivered. 17

20 Phase 3: Nex seps for ITME program implemenaion In he shor erm, ITME is beginning a series of implemenaion aciviies based on he resuls of Phase 2. Coordinaed by he ITME leadership group and he AMA Council on Medical Educaion, program design and implemenaion (Phase 3) will consis of several general seps. Selec prioriy areas. In collaboraion wih appropriae sakeholder groups, ITME iniially will selec prioriy areas for change. Teams will be creaed for each area wih relevan sakeholder represenaion. Idenify curren saus of each seleced prioriy area. For each area, informaion will be colleced on he curren sae of he ar. A comprehensive review will be conduced abou how he area currenly is being addressed across he educaional coninuum. Idenify opions for change. Wih collaboraors, idenify opions for change. In some cases, changes may be inroduced wihou addiional daa gahering. In hose cases, develop and implemen plans, and work wih collaboraors o inroduce he changes. Idenify bes pracices. When addiional daa are needed o decide among opions for change, work wih collaboraors o idenify any bes pracices and evaluae he basis for heir success. Deermine if bes pracices are generally applicable. Creae appropriae ools o suppor he recommended changes. Work wih collaboraors o design and pilo es new educaional maerials and evaluaion insrumens ha are needed o bring abou desired changes. Implemen model programs and evaluae he resuls. Idenify sies where model programs can be inroduced. Collaboraive eams from he sie and ITME will work o implemen he programs. Each change will have a robus evaluaion included as par of he mehodology, so ha he reasons for success or failure of he change can be deermined. Develop recommendaions for naional implemenaion. Deermine he sysem-level changes ha are needed o suppor naional implemenaion of he change (for example, changes in accrediaion sandards, in licensing examinaion/cerifying examinaion conen). Work wih appropriae eniies o bring abou hese changes. I is anicipaed ha he resuls of Phase 3 will be available during The following are examples of he ypes of areas ha ITME may address, in collaboraion wih appropriae parner organizaions. For each area, here already is naional-level aciviy by major sakeholder organizaions ha would faciliae he planning and implemenaion of change. I is anicipaed ha hese ypes of aciviies and collaboraions will grow during Phase 3. Ensuring ha he learning environmen is conducive o he developmen of appropriae aiudes and values, as well as skills, in physicians-in-raining. Medical sudens and residen physicians learn boh from formal course work and from heir role models (eachers, supervisors and menors). Ofen called he hidden curriculum, he informal lessons learned by physicians-in-raining have a powerful influence on heir aiudes, values and behaviors. Boh he Liaison Commiee on Medical Educaion and he Accrediaion Council for Graduae Medical Educaion currenly are addressing how he learning environmen should be designed o suppor he developmen of desired professional aribues in physicians. ITME believes ha reform in he learning environmen is key o bringing abou change in he oucomes of medical educaion. This addresses Recommendaion 7. Teaching and evaluaing learning in new conen areas. Alhough he medical curriculum has, a many insiuions, become more inegraed and inerdisciplinary, i has been difficul o incorporae new conen areas no based in he radiional basic and clinical sciences. Areas such as paien safey/qualiy improvemen; ehics and professionalism; healh dispariies, healh lieracy and culural compeence; and healh sysems/healh economics ofen are relegaed o he saus of add-ons ha do no fi seamlessly ino he curriculum. Even if augh as longiudinal curriculum hreads, such 18

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