George C. Xakellis

Physician Practice Change I: A Critical Review and Description of an Integrated Systems Model

The long lag time between medical discovery and when Americans benefit from that discovery has a huge cost in terms of morbidity and mortality. Medicine needs more effective methods for moving discovery to practice. In this article, the authors first offer a critical review of the models of structure and change process gleaned from the physician change literature. Next, they describe the Integrated Systems Model (ISM) that they derive from this review. The ISM has four major components: superstructure, change motivators, change process, and functional interactions. The ISM considers the physician practice to operate as a complex adaptive system requiring diversion of resources from reserves to make a change. In the ISM, resource return is a function of improved quality of care and reimbursement for services. Changes decreasing the resources of the system (parasitic) will be harder to make than those that increase resources (symbiotic) because of resistance to resource loss. The authors extend the ISM to the individual level and describe the need to consider whether individuals within the practice have sufficient reserves to fulfill their part in making the change. Any given change is generally competing with other changes for adoption. Finally, the authors consider the strengths and weaknesses of their model, concluding that by keeping patient welfare, quality care, and finances in the forefront, the ISM provides a more complete picture of forces affecting medical practice change.

Physician practice change II: implications of the Integrated Systems Model (ISM) for the future of continuing medical education.

In a companion paper, the authors provide the development and description of the Integrated Systems Model (ISM). In this article, they describe 14 general implications of the ISM for continuing medical education (CME). They discuss how applying the ISM would change CME by describing (1) how CME and the larger health care environment would be restructured if they were based on the ISM and (2) how the ISM would impact CME under the current environment of health care in the United States. They close by describing how the ISM can be used as CME moves to address the long lag between discovery and practice and begins to decrease its dependence on pharmaceutical companies. The ISM helps not only explain why the current health care system in the United States (or anywhere) produces what it produces, but also predict what that system would produce if it changed. At present, the ISM is a conceptual model, but with more research into measures of its various elements, it could become a more quantitatively predictive model. In its present form, however, the ISM can serve Marinopouloss call for a “sound conceptual model of what influences the effectiveness of CME” and address Grimshaws concern that current research lacks “a theoretical base to support the choice and development of interventions as well as the interpretation of study results.” The statistician George Box said, “All models are wrong, some models are useful.” The authors believe that the ISM is useful and that maybe it will prove Box wrong.

A strategy for teaching students concepts of population-based health care for older persons.

The authors present a strategy for organizing and teaching the concepts of population-based health care for patients over the age of 65. The key ingredients are a case study based on a representative sample of 5,000 Medicare recipients and a student guide containing the sample groups demographics, clinical characteristics, and utilization patterns. As part of the case study, three subgroups within the sample are described: the basically healthy 50% that consume only 3% of medical resources, the most severely ill 10% that consume 70% of medical resources, and the moderately ill 40% that consume the remaining 27% of medical resources. These categories introduce the concepts of severity of illness, highlight the clinical challenges facing providers of care to the elderly, and contrast the divergent needs of individual health care consumers in an aging population. Armed with this succinct and manageable information packet, students are asked to play the role of an interdisciplinary team that is responsible for effectively managing the care of this population of 5,000 lives. Included in this article is a description of learning resources provided; sample group discussion questions; one strategy for caring for the population developed by a faculty-student group; and a brief description of the educational implications of the model. At the end of the article the reader is provided a Web address containing a description of the case and supporting materials (http://healthyaging.ucdavis.edu/education/continuing/ManagedMedicareTeachingCase.pdf). Readers are invited to view, print, and/or utilize the case in their own academic settings.

Psychological Interpretation of Labels Used to Evaluate Third-Year Medical Students.

No abstract available.