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chapter 3 THE ACADEMIC HEALTH CENTER AS REFORMER: A THE EDUCATION ROLE The forces described in Chapter 2 demand a change in the approaches and attributes of clinical education in the 21st century. Demographic changes, technological and scientific advances, and continued cost pres- sures necessitate a reexamination of how health professionals are prepared for practice. The committee finds the following: AHCs have played a major role in the education of health profes- sionals, successfully teaching the latest procedures and interventions for relieving the symptoms and suffering of sick patients. They have empha- sized in particular the education of physicians at the undergraduate and graduate levels, relying on the hospital's inpatient and outpatient settings as primary training sites. The AHC role in education for the 21st century will require more than the direct training of health professionals. AHCs will be expected to demonstrate leadership in the design and development of educational ap- proaches for health professionals throughout the continuum of education. Doing so will require much more than curricular reform, requiring consid- eration of how the clinical settings in which students are trained reinforces the attributes desired of health professionals in the 21st century. All teaching environments will need to provide a sound base of knowledge that includes not only the emerging sciences, such as genomics, but also the social, behavioral, and other sciences that are important to 45

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46 ACADEMIC HEALTH CENTERS improving health. Providing a broad-based scientific and humanistic foun- dation will require that all teaching environments reexamine the content, methods, and approaches used at all levels of clinical education, including undergraduate, graduate, and continuing education. As part of their education role, AHCs need to work with educators and other resources within their parent universities to develop the evidence base for clinical education so that the approaches used will be based on sound educational principles that improve understanding of the quality of clinical education. As university-affiliated, academic organizations, AHCs need to take a leadership role in meeting these challenges. The first section of this chapter examines the need for new approaches to clinical education to provide the new skills required for the health care workforce of the future. This is followed by a discussion of the factors that affect the ability of AHCs to reform clinical education. The final section describes some implications for the future. NEED FOR NEW APPROACHES TO PROVIDE NEW SKILLS As noted above, the trends and developments described in Chapter 2 will create a different set of expectations for practice and require different types of skills from health professionals. Shifting patient needs, the evolving science of medicine, and changes in the organization and financing of care will all affect how health professionals should be prepared for practice. Health professionals trained today can be expected to reach their peak of practice around 2040, a health environment that is sure to be very different from that of today. There is no question that additional skills will be required. For ex- ample, the greater understanding of the mechanisms of disease that will be possible with genetic and other scientific advances will improve diagnosis and treatment, but also make them more complex. Analysis of disease at the molecular level will move diagnosis to that level as well (Pollard, 2002). Clinicians will require skills in differentiating genetic, other, and combined sources of illness. This requirement will alter the skills needed for diagnosis; moreover, treatments will have to be individualized to accommodate ex- pected responses to treatment given a patient's genetic profile. These skills will not be demanded only of specialists; genetics will also redefine how primary care and preventive medicine are practiced. Changes in the organi- zation and financing of care will require that health professionals demon- strate safe, efficient, and effective practice styles. Changing patient needs will necessitate increased emphasis on skills required to manage chronic conditions, including, for example, understanding the course of illness and

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AHC AS A REFORMER: THE EDUCATION ROLE 47 the patient's experience outside the hospital, with a focus on prevention, behavioral change, and maximizing of functioning. The education of health professionals for future practice involves more than identifying needed skills, however. In health care, students learn through a combination of classroom experience and supervised clinical practice. In fact, the bulk of health professions training is in the latter venue. Although the situation is changing, the first 2 years of medical school are focused most heavily on learning the basic sciences in a class- room setting. The last 2 years consist of clinical rotations, followed by at least 3 years of residency, also in a clinical setting. Therefore, the clinical experience represents about 70 percent of medical training. In nursing, it is estimated that about 50 percent of training for baccalaureate-prepared registered nurses is in clinical settings, and the proportion increases with advanced training (Helen Bednash, personal communication, Jan. 10, 2003). The clinical learning environment, sometimes referred to as the informal curriculum, communicates values, culture, personal development, priorities, and the language of the field to students (Accreditation Council for Graduate Medical Education, 2002). It influences their relationships with each other and with patients. To prepare health professionals for practice in the coming decades, therefore, the clinical experience must be addressed. It is not enough to say what should be taught to students; it is also necessary to consider the context in which it is taught and the approaches used, and how knowledge, skills, and attitudes are both acquired and taught. A focus on skills consid- ers the competencies required of students at the conclusion of a training program, while a focus on the clinical experience considers the "competen- cies" or capabilities of the training program itself, focusing on what is conveyed, and how, during the clinical experience. As noted in Chapter 2, the changing environment of health care will have at least three consequences that can be expected to affect the educa- tion of health professionals. First, patients will exert more influence over their care decisions, both because they will bear the costs of care and because they will be faced with making more choices as technology expands treatment options. Second, there will be increased calls to measure and manage care as costs increase in the face of concerns about quality and access and as information technology makes it more feasible to do so. Third, improving health will require a broader view in which the discover- ies of science and the new biology combine with those of the social and behavioral sciences to affect the determinants of health and illness. Given these trends and directions, the committee identifies three ap- proaches that will need to be considered by all training programs in the coming decades: interdisciplinary approaches that ensure a broader view of health, tools and methods for managing information, and training in

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48 ACADEMIC HEALTH CENTERS nonhospital settings. Each is briefly discussed below. It should be noted that although some progress is being made toward implementing these approaches, current educational programs are focused at the departmental and discipline-specific levels; as a result, varied levels of commitment and resources are devoted to such approaches, even within a single AHC. Sig- nificant advances in health professions education will require a clear com- mitment and adequate resources across the entire AHC. Interdisciplinary Approaches and a Broader View of Health Interdisciplinary education occurs when "faculty learn, work and teach together" (Gelmon, 1996, p. 218) to prepare students to work as a team driven by the health needs of patients and the goal of providing the services necessary to improve health to the extent possible (Bulger, 2000; Gelmon, 1996). Interdisciplinary education involves more than simply defining the roles of various clinicians (Osterweis, 2001). Health professionals that are well prepared for practice in the 21st century will collaborate across depart- ments and disciplines, and even settings of care, to meet patients' needs. The term "interdisciplinary" as used here refers to the involvement of different disciplines, such as medicine, nursing, and pharmacy; the term is not used to denote different specialties within a single discipline, such as internal medicine, cardiology, and endocrinology. The notion of interdisci- plinary education will assume increasing significance in the future. For example, the needs of people with chronic conditions (who, as noted in Chapter 2, represent a growing proportion of the population) cannot be met by any single health professional. Similarly, applying the latest bio- medical advances will increasingly require the expertise of specialized health professionals, such as genetic counselors. Additionally, if patients are ex- pected to be more accountable for maintaining their health and to assume responsibility for self-care in managing chronic conditions, they also need to be recognized as a key member of the health care team. Yet team interac- tions in practice often fall short of expectations, in part as a result of current approaches in clinical education that emphasize hierarchy, indi- vidual decision making, and the organization of work around professional roles rather than patient needs (Institute of Medicine, 2001b). Indeed, the implementation of more interdisciplinary educational approaches will require a level of cooperation that has rarely been demonstrated. As one observer notes, interdisciplinary training is a "goal often espoused but rarely pursued" (LeRoy, 1994, p.337). As suggested above, clinical education in the 21st century will also need to take a broader view of medicine and health, with greater emphasis on understanding the social, behavioral, cultural, and environmental factors that influence health and disease in addition to understanding the biological

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AHC AS A REFORMER: THE EDUCATION ROLE 49 basis of disease (LeRoy, 1994; Josiah Macy, Jr. Foundation, 1999; Young and Coffman, 1998). Developing this understanding will in turn require that biomedical science be better integrated with a patient- and population- based approach that addresses the determinants of disease and health, and places greater emphasis on prevention (LeRoy, 1994) and the identification of risk factors and how to mitigate them. The focus on the biomedical basis of disease that characterizes the current model for clinical education assumes that ill health is fully ex- plained by disease, so that the core of medical science is the diagnosis and treatment of disease (Cassell, 1999). American medicine, however, is being asked to move beyond this model to address issues related to population health, resource allocation, new means for caring for chronic disease, and the management of health information, all areas in which physicians have traditionally not been trained (Schneider and Eisenberg, 1998). Medical schools in particular are believed to produce physicians well equipped to deal with specific organ systems or pathologies, but ill equipped to deal with the behavioral causes of chronic diseases or the social context of illness (Cantor et al., 1993). According to one survey of young physicians, fewer than half reported receiving excellent or good preparation in coordinating patient care with community services, providing cost-effective care, or man- aging the needs of the frail elderly (Cantor et al., 1993). Nursing tends to be more oriented toward health promotion and disease prevention. Advanced- practice nurses in particular are focused on establishing knowledge partner- ships with their patients, educating them about their conditions, and engag- ing them in illness prevention and health promotion (Mundinger, 2002). There are a number of barriers to conducting interdisciplinary educa- tion, including turf battles, academic credit, recognition of faculty, and scheduling (Gelmon, 1996; Osterweis, 2001). Each college, even each de- partment, guards its own curriculum, and bringing different students to- gether can be viewed as virtually impossible (Kaufman, 1999). The differ- ing academic schedules of schools can also create a significant obstacle (Osterweis, 2001). Although 60 AHCs have identified an individual with responsibility for interdisciplinary education, only about a dozen have es- tablished significant activities in this area; most of the latter are public and community-based, have multiple health professional schools, and fall under the broad jurisdiction of an AHC leader (Osterweis, 2001). Another potential barrier is that faculty may have neither the skills nor the incentives to pursue interdisciplinary approaches to education. Faculty who themselves have not been trained through interdisciplinary approaches may find it difficult to teach that way and be unable to undertake the educational innovations required to implement such approaches. More- over, interdisciplinary education is not as strongly rewarded as the efforts of independent scientists working in their laboratories. A concern is that

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50 ACADEMIC HEALTH CENTERS students are not being taught explicitly to work in interdisciplinary teams, but implicitly through the work environment (Conway-Welch, 2002; Larson, 2001), which often has not fostered the types of positive, construc- tive interactions desired across the disciplines. Strengthening efforts to im- prove the health of patients and populations will necessitate the develop- ment of new educational models. Conducting rounds with students in multiple disciplines is one ap- proach used for encouraging interdisciplinary interactions, but this ap- proach becomes more difficult to implement as hospital stays shorten. It may be relatively easy to design interdisciplinary education for the class- room, but doing so becomes more difficult in a clinical setting, especially as training diversifies into nonhospital clinical sites. Interdisciplinary ap- proaches also become more difficult to implement when attempted across settings of care. For example, there may be opportunities to foster interdis- ciplinary training between doctors and nurses in a hospital, but it is less clear how to bring public health into the training model. Some have recom- mended that public health training be incorporated into medical and nurs- ing schools and that schools of medicine and nursing partner with schools of public health to develop interdisciplinary and joint programs (Institute of Medicine, 2003c). Examples of improved public health training for medical students can be found at Duke University, the University of California at San Francisco, and the University of Southern California (Institute of Medi- cine, 2003c). Information Management Health professionals will need to be prepared to manage information so they can deal with a constantly growing evidence base, serve as an information resource, support decision making by patients, and measure care so they can manage it effectively. Technological and biomedical advances are expanding the evidence base for health and medical care exponentially. The number of clinical trials published in the literature grew from approximately 1,000 in 1966 to more than 10,000 in 1996, with half that growth experienced in more recent years (Chassin, 1998). This growth in information, which will only intensify in the future, will challenge traditional approaches to educating health professionals. Some have even suggested that the traditional empha- sis on a core of knowledge is questionable in light of the expansiveness and dynamic nature of the science base (Weed and Weed, 1999). Rather than the traditional approach based on teaching facts, students should be pre- pared for the types of problem solving they will face in practice (Weed, 1981). Health professionals will have to know how to obtain and manage new

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AHC AS A REFORMER: THE EDUCATION ROLE 51 knowledge as it continually emerges. The concept of evidence-based prac- tice is that a clinical problem is defined, and published evidence is obtained, appraised, synthesized, and applied to the problem (Welch and Lurie, 2000). However, there are virtually an unlimited number of clinical strategies, and resources for evaluation are limited. Educators need to teach the evidence where it is certain, and students need to learn to how to obtain and apply evidence as it develops, as well as how to make clinical decisions when the evidence is absent or weak (Welch and Lurie, 2000). The increasing complexity of disease and expanding treatment options will require that health professionals be able to serve as an information resource for their patients. Health professionals will need to bridge the gap between the evidence base and patient knowledge, evaluating the evidence and turning it into information that can be explained to patients so their preferences can be expressed. They will need to synthesize, explain, and interpret information to support patient decisions and self-management. In some cases, the health professional's primary role may be serving as an information consultant and resource to guide and support decision making by more informed patients, rather than performing a clinical intervention. There is some evidence that patients whose informational needs are not adequately met are likely to make more visits and use more resources in their care (Mundinger, 2002). Indeed, some have suggested that this infor- mation role is one of the most important therapies provided to patients, with health professionals serving as coach and adviser to support patients' increased direction over their care (Schneider, 2002). This role should be incorporated into the education of all health professionals, but also rein- forced through interdisciplinary training that recognizes the varying contri- butions different team members can make to a patient's care. The increasing costs of care and concerns about the quality of care will result in growing demands to measure and manage care. The management of information must include a focus on measuring care so it can be continu- ously improved. Research, patient care, and therefore health professions education will become increasingly reliant on evaluative disciplines, such as clinical epidemiology, informatics, health services research, outcomes analy- sis, and value management (Detmer, 1997; Wennberg, 2002). Managing information to the extent that will also be required in the future cannot be done without more-advanced information systems to ac- quire and manage the level of information that will be needed for practice. Part of delivering state-of-the-art care in the future will be the use of clinical and other information systems. Students will need to be prepared to use information technology as a more central component of health care. Clini- cal education programs that fail to incorporate state-of-the-art information systems into their training will be unable to prepare students for practice today, let alone tomorrow.

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52 ACADEMIC HEALTH CENTERS Nonhospital Training Experiences To prepare health professionals to deliver care in the 21st century, education should correspond to care delivery. The majority of care is deliv- ered to patients in noninpatient and nonhospital settings. Nearly a billion ambulatory visits were made in 1999, compared with 32 million hospital- izations (Eberhardt, 2001). Ambulatory care as discussed here refers not only to hospital outpatient departments, but also to offices, community health centers, managed care organizations, public health departments, long-term care facilities, and even patients' homes. Any location where care is delivered should be considered a potential training site. The predominant model of education today, especially for physicians, consists of training in the inpatient setting, delivering tertiary care. The advantage of hospital-based training is that students can learn from the most challenging and difficult cases. Hospitals that see a larger volume of similar patients (e.g., cardiology or cancer patients) are also more likely to demonstrate higher-quality care in that field, which is desirable to teach (Institute of Medicine, 2001b). In addition, seeing patients who are admit- ted for ambulatory-sensitive conditions or for certain chronic conditions should give students an opportunity to learn what factors contributed to the condition so they can not only treat the symptoms but also consider how patients might be able to avoid such hospitalizations in the future. It is easier to conduct education in the inpatient setting because the acute prob- lems seen are more readily specified, and therefore, the educational content is easier to define (Showstack, 1999). Finally, inpatient settings offer a cluster of faculty, other students, and an infrastructure to oversee the edu- cational process. The inpatient model for clinical education will be increasingly ineffec- tive in the coming decades, however. The rate of hospital admissions has been declining; lengths of stay are becoming shorter; many diagnostic prob- lems are being handled outside the hospital; patients in hospitals have the most complex conditions and therefore present a relatively narrow spec- trum of diseases; and the sicker patients admitted require increasingly tech- nical care (Kassirer, 1996; Goroll et al., 2001). These trends give the learner less time to establish a relationship with the patient and to understand the multiple medical, social, psychological, and other factors that affect not only the course of disease, but also the individual's health and well-being. A short hospital stay provides a poor learning opportunity to understand the influence of behavioral and social factors on health or to foster shared decision making (Ewan, 1985). Furthermore, most patients admitted elec- tively to the hospital have been worked up prior to admission, so they arrive not only with a chief complaint, but also with the results of diagnos- tic and laboratory tests, and sometimes, a diagnosis. The intellectual chal- lenge to the learner is incomplete, and the learning opportunity is affected.

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AHC AS A REFORMER: THE EDUCATION ROLE 53 Training in the inpatient setting, therefore, does not sufficiently prepare health professionals for practice or provide adequate exposure to alterna- tive settings of care. A survey of young physicians revealed that more than half believed there was too little training in physician offices, organized care settings (e.g., health maintenance organizations), or long-term care facilities (Cantor et al., 1993). People with chronic illness that is managed effectively may often avoid hospitalization for the condition altogether. Even more care can be expected to move out of the inpatient setting as biomedical advances affect when an illness is identified and how it is treated. Finally, in the marketplace, there is a trend toward the provision of nonspecialized care in community hospitals and other settings; specialty care is becoming more concentrated in AHCs (The Commonwealth Fund Task Force on Academic Health Centers, 2000). As AHCs become relatively more focused on specialty care and caring for patients with specialized needs, they be- come less able to prepare health professionals for everyday practice. It has been estimated that, on average each month, less than 1 person in 1,000 is admitted to an AHC (Green et al., 2001). There has been some progress in increasing the amount of training provided in ambulatory settings; however, the majority of ambulatory train- ing remains within hospitals, and only a small proportion takes place in nonhospital settings. Primary care physicians can be expected to practice predominantly in nonhospital settings, and they undergo about two-thirds of their training in ambulatory settings; however, only about one-quarter of their training is provided in community settings and about one-tenth is in managed care settings (Brotherton et al., 2000). Among nonprimary care residents, just over one-third of training is in ambulatory settings, but only about 6 percent is in community settings and about 6 percent in managed care settings (Brotherton et al., 2000). Furthermore, the proportion of train- ing time in nonhospital ambulatory settings (community and managed care settings) showed a decline between 1997 and 1999--a trend in the wrong direction. Among undergraduate medical education programs, teaching in outpa- tient settings in required clinical clerkships occupied one-third or more of the time in primary care program areas compared with one-quarter or less in nonprimary care program areas (Barzansky and Etzel, 2001). On the other hand, between 1984 and 1994, the percentage of all medical students who participated in one or more clerkships increased from just under half to almost three-quarters, and the average number of weeks in ambulatory settings increased as well (The Commonwealth Fund Task Force on Aca- demic Health Centers, 2002). Baccalaureate nursing programs are also offering more opportunities for clinical training in noninstitutional community settings, including visit- ing nurse agencies, home care, schools, and hospices (National Advisory

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54 ACADEMIC HEALTH CENTERS Council on Nurse Education and Practice, 1996). To a lesser extent, train- ing is also provided in such settings as nursing centers, senior citizen cen- ters, and homeless shelters. Shifting training to ambulatory settings involves more than simply moving or adding training slots. Ambulatory settings will not provide a good learning environment without additional preparation. As a learning environment, they can be unpredictable in terms of the types of patients seen, limited in terms of continuity of care, and variable across sites (Irby, 1995). Short patient visits can make it difficult to provide the observation and feedback needed for teaching (Bowen and Irby, 2002). There is also concern that students in ambulatory settings may lose the conferences, faculty, and general educational surroundings offered by the institutional environment (Kassirer, 1996). Indeed, students rate the quality of their instruction in ambulatory settings lower than that in inpatient settings (The Commonwealth Fund Task Force on Academic Health Centers, 2002). FACTORS THAT AFFECT THE ABILITY OF AHCS TO REFORM EDUCATION The preceding discussion is not intended to imply that clinical curricula have been static over time. Indeed, there are many examples of efforts aimed at accomplishing the very types of changes outlined above (Associa- tion of American Medical Colleges and the Milbank Memorial Fund, 2000; The Commonwealth Fund Task Force on Academic Health Centers, 2002). The Association of Academic Medical Centers recently launched the Insti- tute for Improvement in Medical Education to examine ways to improve medical education curricula, reform the clinical education of medical stu- dents and residents, enhance public health education in medical schools, promote professionalism during medical education, engage in international medical education activities, and better meet the need for continued profes- sional development of physicians once they enter practice (Association of American Medical Colleges, 2003a). And more than half of medical schools (58 percent) reported having a major curriculum review or change under way in 2001 (Barzansky and Etzel, 2001). Many examples of changes in health professions education can be found at individual AHCs. In one example described at the committee's January 2002 workshop, Hundert (2002) described reforms in the medical educa- tion curriculum at the University of Rochester1 through which the clinical and basic sciences are interwoven throughout the 4-year curriculum. He highlighted a course called Mastering Medical Information that is taught in 1Dr. Hundert has since joined Case Western Reserve University.

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AHC AS A REFORMER: THE EDUCATION ROLE 55 the first 4 weeks and last 2 weeks of the first year, in which students learn how to access and navigate through information, gaining skills in data analysis, biostatistics, and epidemiology. Another unique element of the curriculum is a 1-month clerkship in the fourth year called Community Health Improvement. Several years ago, the University of Rochester added a fourth mission to its portfolio--to make Rochester, New York, "the healthiest city in America." The content of the clerkship is determined by the health department's assessment of local health needs, and varies from providing the pneumococcal vaccine in nursing homes to working with teenagers to get them to quit smoking. The academic content of the clerk- ship is focused on public health and epidemiology. The Undergraduate Medical Education for the 21st Century (UME- 21) program was a 5-year national demonstration project funded in Octo- ber 1997 by the Health Resources and Services Administration and admin- istered by the American Association of Colleges of Osteopathic Medicine (2003). Eighteen schools were funded to initiate curricular innovations in undergraduate medical education aimed at supporting graduates in prac- ticing high-quality, population-based, cost-effective medicine while main- taining a commitment to care of the individual.2 The areas addressed in the reforms included health systems finance and organization; the practice of evidenced based medicine, with emphasis on population health; health care ethics; patientprovider relationships and communication skills; lead- ership and interdisciplinary teamwork; quality measurement and improve- ment; systems-based care; medical informatics; and wellness and disease prevention. At the graduate level, the Accreditation Council for Graduate Medical Education (ACGME) has led a major undertaking to move its accreditation processes toward assessment of competencies or outcomes of the education process (Batalden et al., 2002). Six areas of competency are identified: patient care, medical knowledge, practice-based learning and improvement, professionalism, interpersonal skills and communication, and systems-based practice. These six areas will be used to guide residency program directors in curricular development and residency program requirements as defined by the residency review committees. The American Board of Medical Spe- 2The medical schools involved are Dartmouth, University of California at San Francisco, University of Miami, University of Nebraska, University of Pennsylvania, University of Pitts- burgh, University of Wisconsin, Wayne State University, Case Western Reserve, Eastern Vir- ginia University, Jefferson Medical College of Thomas Jefferson University, Medical College of Pennsylvania-Hahnemann, University of Connecticut, University of Kentucky, University of Massachusetts, University of Minnesota, University of New Mexico, and University of North Carolina at Chapel Hill.

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56 ACADEMIC HEALTH CENTERS cialties (ABMS), the organization for certifying boards of practicing physi- cians, has accepted these same competencies, thus offering the potential for coordination and reinforcement of skills at the levels of graduate and con- tinuing education. Nursing educators also have recognized the need for reform in nursing education. The National Advisory Council on Nurse Education and Prac- tice (1996) has recognized the changing nature and responsibilities of regis- tered nurses. Registered nurses will be asked to manage care along a con- tinuum, work in interdisciplinary teams, integrate clinical knowledge with knowledge of community resources, adapt to changing technologies, dem- onstrate an ability to communicate, and analyze data. Also recognized is the need to prepare the registered nurse workforce more adequately in the use of nursing informatics to support clinical decision making, consumer education, and interactions with other providers (National Advisory Coun- cil on Nurse Education and Practice, 1997). Specific programs to support change have also been undertaken. For example, the American Association of Colleges of Nursing (2002a) has undertaken a major initiative to support gerontology curriculum develop- ment, with support from The John A. Hartford Foundation of New York. Objectives include redesign of existing gerontology curriculum, faculty de- velopment, design of innovative clinical experiences, and development of new leaders in geriatric practice. The grant will assist nursing schools in adapting their gerontology curriculum and clinical experiences at both the graduate and undergraduate levels. The expectation is that newly identified competencies will be incorporated into advanced-practice nursing programs and will lead to the development of models of excellence for adoption by the broader nursing education community. The progress made to date reflects the determination of those directing educational programs, who face a number of obstacles in trying to move clinical education forward. Even when AHCs agree with the goals de- scribed in this report, a number of factors affect their ability to implement educational reform. The first of these relates to the accreditation and over- sight of education programs. Program requirements should support move- ment toward the attributes desired for clinical education in the 21st cen- tury. The second factor relates to faculty development and organization. If students are to have different educational experiences, faculty must be prepared to impart those experiences. The third factor relates to the weak evidence base for clinical education, which makes it difficult to know which changes will have a positive effect on student preparation for practice. The fourth factor relates to financing. Methods of financing for all AHC roles are discussed in Chapter 6, but here we consider the effect of financing on the design of educational programs.

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AHC AS A REFORMER: THE EDUCATION ROLE 57 Oversight of Education Programs It is estimated that more than 50 groups are involved in the over- sight of undergraduate and graduate training programs in the health profes- sions (Gelmon et al., 1999). Some of these groups are identified in Box 3-1. The list intentionally includes the accrediting group for programs in health administration. Although the focus of this chapter is on clinical education, the challenges described also face administrators in terms of both their own education and their support for reform efforts in clinical education. Fur- thermore, clinicians ought to have knowledge of administrative issues, so it is important to consider programs in health administration when looking at coordination across disciplines. Continuing education requirements are overseen by yet other groups. Accreditation of continuing medical education programs is offered by the Accreditation Council for Continuing Medical Education. The American Osteopathic Association has a separate council for continuing education. The American Nurses Credentialing Center of the American Nurses Asso- ciation administers the association's credentialing programs, providing both accreditation of continuing education programs and certification for spe- cialty nursing practice. Unlike undergraduate and graduate training, which have clearly defined requirements, requirements for continuing education vary within disciplines. Some physician specialty boards require continuing medical education hours to maintain specialty certification, whereas other have no such requirement (Federation of State Medical Boards, 2002). The proliferation of oversight groups has serious implications for re- forming the education of health professionals. There has been a tendency toward expansion in recent years as more specialties have been recognized, a phenomenon that tends to increase subspecialties (as they seek recogni- tion) and extends the length and cost of training (LeRoy, 1994). However, the approaches proposed in this report are not discipline specific, but apply to everyone. As a result, it may be necessary to ask 50-plus groups to amend their standards. For example, achieving a goal such as interdisciplinary education would require not only that each group make changes, but also that the groups work together in making those changes. That is likely to be a time-consuming process, and it is not clear that there is a mechanism for the purpose. Coordination across the continuum of education is also poor. Coordi- nation of oversight of education has been called fragmented and duplica- tive (Gelmon, 1996). Responsibilities for undergraduate, graduate, and continuing education reside for the most part in separate organizations (Enarson and Burg, 1992). As a result, accreditation divorces residency training programs from professional schools (Hanft, 1988). Feedback loops between the levels of education could improve all. For example, if one of

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58 ACADEMIC HEALTH CENTERS BOX 3-1 A Sample of Accrediting Organizations for Health Professions Education Oversight of health professions training occurs through a combination of public and private regulatory activities. A variety of private agencies accredit the educa- tion programs for undergraduate, graduate, and continuing education. Accredited programs are eligible to receive public funds to support their activities. Individuals who complete such programs are then eligible to receive a license to practice from a state, or after graduate training and thereafter, to sit for certification or recertifica- tion. These processes are interrelated educationally in that education programs are expected to prepare health professionals to pass licensure exams, and licen- sure exams are intended to reflect expectations for practice as defined in the scope-of-practice laws (Safriet, 1994). In general, the purposes of these functions are to ensure minimum levels of quality and to protect consumers through assur- ance of compliance with established standards of quality. It is also hoped that these processes offer the programs and individuals being evaluated an opportuni- ty for self-evaluation and improvement (Gelmon et al., 1999). The U.S. Department of Education "recognizes" private organizations that car- ry out education accreditation. In the case of nurse education, the U.S. Depart- ment of Education may recognize a state agency to accredit programs. On behalf of the U.S. Department of Education, accreditation agencies may also be recog- nized by the Council on Higher Education Accreditation (see www.ed.gov/offices/ OPE/accreditation). Accreditation is applied to entire institutions and/or individual programs, departments, or schools of a larger institution. Undergraduate allopathic medical education: Accreditation of allopathic medical schools is overseen by the Liaison Committee on Medical Education (LCME). The majority of its membership is from the American Medical Association and Associ- ation of American Medical Colleges, but students and the public are represented as well. Substantive changes in LCME's standards must be approved by the Coun- cil of Medical Education of the American Medical Association and the Executive Council of the Association of American Medical Colleges (see www.lcme.org). Graduate allopathic medical education: Accreditation of graduate medical educa- tion is overseen by the Accreditation Council for Graduate Medical Education (ACGME) for allopathic education, an umbrella organization with membership from five organizations: the American Board of Medical Specialties, the American Hos- pital Association, the American Medical Association, the Association of American Medical Colleges, and the Council of Medical Specialty Societies. ACGME accred- its residency programs through its residency review committees. There is a resi- dency review committee for each specialty board that sets the standards and guidelines by which a residency program will receive accreditation (see www.acgme.org).

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AHC AS A REFORMER: THE EDUCATION ROLE 59 Osteopathic undergraduate and graduate medical education: The American Os- teopathic Association (AOA) is the accrediting agency for osteopathic medicine. The AOA Bureau of Professional Coordination coordinates accreditation across the continuum of education through several councils. The Council on Predoctoral Education focuses on undergraduate medical education. The Council on Postdoc- toral Training focuses on internships, residencies, preceptorships, and other post- graduate medical education programs. The Council on Continuing Medical Educa- tion approves programs and credits for continuing medical education. The Council on International Osteopathic Medical Education and Affairs address international training concerns. Osteopathic graduate training is organized around community- based training consortia, known as Osteopathic Postdoctoral Training Institutions. These consortia consist of at least one medical school accredited by AOA and several hospitals that are accredited by AOA's Bureau of Health Facilities' Accred- itation (see www.aacom.org) Nursing education: Accreditation of nursing programs is provided by two groups. One is the National League for Nursing Accrediting Commission (NLNAC), an in- dependent entity within the National League for Nursing. NLNAC accredits all types of nursing programs, from the diploma through the doctoral level (National League for Nursing Accreditation Commission, 2001). The other is the Commission on Collegiate Nursing Education (CCNE), established by the American Association of Colleges of Nursing. CCNE focuses only on nursing programs in universities and 4-year colleges (American Association of Colleges of Nursing, 2002c), providing accreditation services for programs at the baccalaureate and graduate degree lev- els. Accreditation for programs for nurse practitioners is also becoming standard- ized, although four different groups will have unique certifying exams (Phillips et al., 2002). Public health education: Schools of public health, community health education pro- grams, and community health/preventive medicine programs are accredited by the Council on Education for Public Health (Council on Education for Public Health, 2002). The Council is a private, nonprofit organization with two members: the American Public Health Association and the Association of Schools of Public Health. The primary professional degree is the Master of Public Health (MPH), but other master's and doctoral degrees are offered as well. Health Administration: The Accrediting Commission on Education for Health Ser- vices Administration (ACEHSA) is the organization authorized by the U.S. Depart- ment of Education to accredit master's level health administration programs in the United States and Canada. Graduate programs in health care administration are housed in various schools and departments on university campuses. These pro- grams are found in schools of business, medicine, public health, public administra- tion, and allied health sciences, as well as schools of graduate studies. The de- grees awarded by these programs include MA, MBA, MHA, MHSA, MPH, MS, and others (Accrediting Commission on Education for Health Services Administration, 2001).

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60 ACADEMIC HEALTH CENTERS the purposes of continuing education is to supplement areas in which undergraduate or graduate training has been deficient (Waxman and Kimball, 1999), such information should be provided systematically to those education programs so the deficiencies can be addressed. The current fragmentation inhibits these interactions. A recent Institute of Medicine report (2003a) calls on all education oversight organizations (accrediting, licensing, and certifying bodies) to work together to revise their standards. Faculty Development and Organization The school and its faculty are the strongest influences on the design of curriculum and students' educational experiences. Accrediting groups de- fine standards for the structure, performance, and/or functions of the schools, but do not prescribe specific courses or educational experiences. The latter is the responsibility of each school as it designs its own curricu- lum within the guidelines of the pertinent oversight bodies. Even with a bounty of standards, it is known that schools vary in terms of emphasis, resources, costs, size, centralized or decentralized curriculum, frequency of curricular change, and other factors. Faculty are being asked to assume new duties in areas in which they may not be adequately prepared to teach the next generation. Faculty teach- ing today may themselves not have been trained in nonhospital settings, computer-based systems, or interdisciplinary approaches to care (Wilkerson and Irby, 1998). They may not have learned how to develop curricula, evaluate students, or manage educational programs (Gelmon, 1996). Most medical teaching occurs through one-on-one encounters between physician and patient, reflecting the comfort level and expertise of many faculty (Kaufman, 1999). As a result, faculty may be unsure about their own skills for implementing aspects of a new curriculum (Sachdeva, 2000). Being a knowledgeable clinician (or basic scientist) does not necessarily translate to being an effective teacher. There are also concerns about the availability of faculty in terms of both supply and time. As noted earlier, teaching faculty are under pressure to see patients and conduct research, leaving little time for teaching (The Commonwealth Fund Task Force on Academic Health Centers, 2002; Ludmerer, 1999). Although this concern is often voiced about medical faculty, it has been suggested that as nursing practice plans develop, a similar pattern will ensue. Nursing faculty will also face constraints on time for teaching as the pressure to see patients and raise revenue increases (Conway-Welch, 2002). Furthermore, particularly in nursing, there are con- cerns about the adequacy of the supply of faculty (American Association of Colleges of Nursing, 2002b; Association of Academic Health Centers, 2002).

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AHC AS A REFORMER: THE EDUCATION ROLE 61 The pressures on faculty preparation and time are likely to intensify as training is expanded to encompass a range of sites. More faculty with more- varied backgrounds could enhance the educational experience for students but could also result in even greater variability in student training. Faculty development will be needed to ensure that the faculty available at all train- ing sites are prepared to teach students effectively (Weed, 1981; Griner and Danoff, 2000). Some have suggested using a smaller, full-time faculty (Hanft, 1988), perhaps moving with the students rather than the clinicians in each site taking on faculty duties. In medical schools, the decentralized structure of faculty with powerful department chairs is viewed as a force that can inhibit educational innova- tion (Cantor et al., 1991; Regan-Smith, 1998; Petersdorf and Turner, 1995). Faculty identify predominantly with their own department and focus on training in their own discipline, hindering a broad, integrated view of clini- cal education. The strong departmental structure can also make it difficult to incorporate broad-based education courses that are not departmentally defined; for example, population health or "evaluative" sciences, such as biostatistics or epidemiology. Some schools have moved toward a more centralized curriculum to overcome the problems of a departmentally orga- nized model, and although improvements are seen in terms of curricular reform, they also tend to raise costs because of the increased time needed for faculty coordination (Reynolds et al., 1995). Weak Evidence Base The evidence base for clinical education is not as strong as it should be to support the reforms described in this chapter. Better information is needed on the effectiveness of various teaching approaches for clinicians, on how principles of adult education can be applied appropriately to clini- cal education, on what types of teaching technologies are most effective and under what circumstances, on the characteristics associated with high-qual- ity clinical education, and on the cost of training various health profession- als. Good quality measures in clinical education do not currently exist (Blumenthal and Bass, 2001). The Cochrane Collaboration has been working for many years to de- velop the evidence base for clinical care, but there is no comparable re- source for the evidence base in clinical education. When the Cochrane Collaboration attempted to conduct a systematic review of educational interventions for teaching evidence-based medicine, only one article was found that met their criteria for inclusion (Hatala and Guyatt, 2002). Two relatively new groups are making such an effort at developing an evidence base. The Campbell Collaboration (formally established in 2000) prepares and maintains systematic reviews of the effects of social and

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62 ACADEMIC HEALTH CENTERS education policies and practices (see www.campbellcollaboration.org). For example, a systematic review is being prepared for problem-based learning for health professionals (Davies and Boruch, 2001). The second group, Best Evidence Medical Education, is a collaboration of individuals and organizations committed to the dissemination of information to people involved in medical education; the production of systematic reviews of medical education; and the creation of a culture of best-evidence medical education among teachers, institutions, and national bodies (see www. bemecollaboration.org). The group has been meeting since 1999. Both groups are international, with a strong European representation. There is also a lack of information on the actual cost of education programs and its relationship to the quality of education (Henderson, 2000). Spending patterns for public funds are known, but how much training costs is not understood. Medicare payment per resident is known to vary, but it is believed to reflect historical accounting practices rather than true differ- ences in the cost or quality of programs (Young and Coffman, 1998). Many schools have not budgeted systematically for clinical education (The Com- monwealth Fund Task Force on Academic Health Centers, 2002). Because current information is so poor, it is difficult to estimate the costs for educa- tional reform or identify areas in which savings might occur (The Common- wealth Fund Task Force on Academic Health Centers, 2002). For example, costs might be incurred to implement computer-based instruction, but could reduce faculty time in some areas. Financing As discussed in more detail in Chapter 6, current financing methods for clinical education are not viewed as being supportive of the types of changes advocated in this report (LeRoy, 1994). The current methods have encour- aged increases in the number, size, and duration of residency programs (Henderson, 1999, 2000) and programs for the training of specialists in tertiary settings (Young and Coffman, 1998). These methods have also hindered training in nonhospital settings (Henderson, 2000). Moreover, funding is not linked to any workforce goals, whether they be the types of changes described here or other goals related to the supply and mix of the output of the programs. Interdisciplinary training is also discouraged by variation in how the education of different professions is supported. When Medicare began, educational costs for nursing and allied health professionals were allowable expenses for hospitals. Since 1965, however, many hospital-based training programs have been eliminated. For example, in 1965, 80 percent of train- ing programs for registered nurses were in hospital-operated programs;

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AHC AS A REFORMER: THE EDUCATION ROLE 63 today the figure is only 7 percent (Medicare Payment Advisory Commis- sion, 2001). Medicare currently supports diploma nursing programs, pro- grams for nurse anesthetists, and training for allied health professionals that are hospital-based programs. About one-half of hospitals with resi- dency training programs also receive money for nursing and allied health training (Medicare Payment Advisory Commission, 2001). However, AHCs offer few hospital-based training programs, so the training support pro- vided for medicine and that for nursing and allied health are going to different organizations, discouraging an interdisciplinary perspective. An- other difference is that services provided jointly by a medical resident and supervising physician may be reimbursed, whereas the same is not true for other students. Therefore, nonmedical students do not offer the same ad- vantages in cost recovery to the hospital sponsoring a training program; the result, again, is an emphasis on medicine. IMPLICATIONS FOR THE FUTURE There have been many calls for reform of clinical education, especially medical education. A recent Institute of Medicine report (2003a) urges an overhaul in health professions education. Likewise, in their survey of medi- cal school deans, Cantor, et al. (1991) found that 68 percent believed fundamental change was needed in medical education. This was true for their own institutions, as well as for medical education overall. Petersdorf and Turner (1995, p. 541) report that the education given to students is "dated and arcane" and not in tune with societal needs. In interpreting their survey of young physicians, Cantor et al. (1993, p. 1035) find that "while medical training has remained largely unchanged, the demands placed on practicing physicians have changed dramatically." At a workshop spon- sored by the committee during the course of this study, Hundert (2002) described the current process of medical education as one that can "take altruistic other-oriented people and turn them into bitter cynics, in four short years." The current curriculum is perceived as overcrowded and relying too much on memorization of facts, and the changes implemented have not altered the underlying experience of educators and students (Regan-Smith, 1998). Current processes of education are too static and passive and do not focus sufficiently on teaching students how to solve real, everyday problems and measure the effectiveness of interventions through such sciences as epidemiology, informatics, health services research, and outcomes analysis (Detmer 1997). The fundamental approach to clinical education has not changed since 1910, or as some have observed, there has been "reform without change" (Christakis, 1995, p. 710). Others have gone so far as to

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64 ACADEMIC HEALTH CENTERS suggest that the current model of education is so mismatched with today's complex health care environment that a "drastic overhaul" is needed (Chassin, 1998, p. 579). AHCs will need to provide leadership in effecting the broad educa- tional reforms required to prepare health professionals to meet the needs of the 21st century health system. Most educational reform to date has taken the approach of overlaying courses on the existing curriculum and struc- ture. The result has been the overcrowded curriculum noted earlier, wide variation across programs, and poor progress in some areas. What is needed is more comprehensive and fundamental reform of the educational experi- ence that spans the continuum of education and recognizes the shifting roles and responsibilities among health professionals, along with the inter- actions of those shifts. In taking up this challenge, AHCs will need to work more closely with their parent universities, using the academic and interdisciplinary resources available. Schools of education should be consulted in the development of educational methodology. Coordination of basic science and social science courses in the university should be explored in an effort to streamline the education process and foster interactions among faculty at different schools. Interdisciplinary approaches should work in both directions. University students in engineering or computational biology should have the opportu- nity to conduct work at the AHC; exposure to such work could interest them in applying their much-needed skills to health care. Similarly, students at the AHC should be encouraged to explore the resources available throughout the university, such as at a business or law school. Public policy also needs to support changes in education that respond to changes in health care. Policy makers need to consider how financing methods can support both short- and long-term changes in clinical educa- tion. Innovative approaches are especially needed in implementing methods to support interdisciplinary education, and to provide training in informa- tion management, as well as in developing nonhospital training sites.