Gordon T. Moore

Comparison of television and telephone for remote medical consultation.

Television and telephone communications were randomly used to compare their effectiveness in allowing consultation between a hospital-based physician and remote nurse practitioners. Visits using television for consultation averaged 50 minutes as compared with 40 minutes for telephone. This difference was caused by longer work-ups before the consultation, longer delays after it was requested, and longer consultations, themselves, on television. However, television consultations resulted in significantly fewer immediate referrals of patients to hospital physicians: 6 plus or minus 1 as compared to 12 plus or minus 1 per cent (mean plus or minus S.E.M) OF ALL TELEPHONE CONSULTATIONS (P SMALLER THAN 0.005). Although no overall difference in satisfaction was documented between the results of television and telephone consultations, participants preferred the former for medical decision making and cited it for allowing more social interaction than telephone. These findings suggest that television may have its greatest value in remote sites where the sense of isolation is great and the need to reduce long-distance referrals offsets the costs of the system.

Educating interprofessional learners for quality, safety and systems improvement.

Most health professionals in training, as well as those in practice, lack the knowledge and skills they need to play an effective role in systems improvement. Until very recently, these competencies were not included in formal (or informal) educational curricula. Interprofessional collaboration – another core competency needed for successful systems improvement – is also inadequately taught and learned. Achieving Competence Today (ACT) was designed as a new model for interprofessional education for quality, safety and health systems improvement. The core of ACT is a four-module active learning course during which learners from different disciplines work together to develop a Quality Improvement Project to address a quality or safety problem in their own practice system. In this paper we describe the ACT program and curriculum model, discuss our strategies for maximizing ACTs interprofessional potential, and make recommendations for the future.

A Self-instructional Model to Teach Systems-based Practice and Practice-based Learning and Improvement

BackgroundWhen mandated as resident competencies in 1999, systems-based practice (SBP) and practice-based learning and improvement (PBLI) were new concepts to many.ObjectiveTo describe and evaluate a 4-week clinical elective (Achieving Competence Today—ACT) to teach residents SBP and PBLI.DesignACT consisted of a four-week active learning course and follow-up teaching experience, guided and supported by web-based materials. The curriculum included readings, scheduled activities, work products including an improvement project, and weekly meetings with a non-expert preceptor. The evaluation used a before–after cross-comparison of ACT residents and their peers.ParticipantsSeventy-eight residents and 42 faculty in 18 US Internal Medicine residency programs participated between 2003 and 2005.Results and Main MeasurementsAll residents and faculty preceptors responded to a knowledge test, survey of attitudes, and self-assessment of competency to do 15 tasks related to SBP/PBLI. All measures were normalized to a 100-point scale. Each program’s principal investigator (PI) identified aspects of ACT that were most and least effective in enhancing resident learning. ACT residents’ gains in knowledge (4.4 on a 100-point scale) and self-assessed competency (11.3) were greater than controls’ (−1.9, −8.0), but changes in attitudes were not significantly different. Faculty preceptors’ knowledge scores did not change, but their attitudes became more positive (15.8). PIs found a ready-to-use curriculum effective (rated 8.5 on a 10-point scale).ConclusionsACT increased residents’ knowledge and self-assessment of their own competency and raised faculty’s assessment of the importance of residents’ learning SBP/PBLI. Faculty content expertise is not required for residents to learn SBP/PBLI.

The effect of compulsory participation of medical students in problem-based learning

Summary. Problem‐based learning (PBL) is an instructional method that has attracted many advocates since its introduction in medical education almost 20 years ago. PBL features the use of student‐directed tutorials, medically relevant problems to set study objectives, and independent learning. Educators have worried that not all students will do well with this method. This study compared a group of students who had chosen to be in a PBL curriculum with a group who had not, as they undertook a curriculum that contained both PBL and lecture‐based courses.

The "teaching HMO": a new academic partner.

Health care reform is a potential threat to the academic missions of medical schools and academic health centers. But managed care, the source of much of their concern, may also represent a way for medical schools to improve their future academic outcomes. Harvard Medical School and the Harvard Community Health Plan, a large health maintenance organization (HMO) in greater Boston, recently formed the first medical school department to be based in a freestanding HMO. This arrangement is an example of a model that replicates, in a managed care organization, the long-standing and highly successful teaching hospital academic structure in academic medical centers. The authors describe this model in detail, show how the Harvard collaboration works, and explain the benefits each institution saw in creating a joint entity, the rationale for making that new entity an academic department, and the implications for other academic health centers. They conclude that the Harvard experience shows that alliances between medical schools and large HMOs can create vibrant practice settings for teaching and research in academic areas (such as prevention and primary care medicine) that have been relatively neglected in recent times, and that the “teaching HMO” may have the potential to transform academic medicine in the next century just as the teaching hospital transformed it in this century.

Health Maintenance Organizations and Medical Education: Breaking the Barriers.

Academic medical centers (AMCs) are under pressure to increase ambulatory medical education, but their capacity for such teaching is limited. Health maintenance organizations (HMOs) are a large and growing institutional setting that could participate in clinical education. Until now, relatively few HMOs and AMCs have reached agreements about teaching, because traditional suspicions have blocked collaboration. Responding to a case prepared as the basis of discussion, about 450 academics and HMO medical directors explored the barriers to and incentives for cooperation between AMCs and HMOs in clinical education. The two groups identified different issues as barriers to collaboration, leaving considerable room to negotiate agreements. AMCs, especially, need to be prepared to offer meaningful academic and financial inducements to attract HMOs to participate in teaching.

Time to learn: the outlook for renewal of patient‐centred education in the digital age

Major forces in society and within health systems are fragmenting patient care and clinical learning. The distancing of physician and trainee from the patient undermines learning about the patient‐doctor relationship. The disconnection of care and learning from one successive venue to another impedes the ability of trainees to learn about illness longitudinally.

Health promotion and disease prevention: integration into a medical school curriculum

Summary: Many authorities have identified deficiencies in the education of medical students in health promotion and disease prevention. This report describes an attempt to address this problem through the longitudinal integration of health promotion and disease prevention into several major courses in the student curriculum at Harvard Medical School. We used adult learning theory to develop the curricular approach, and designed educational experiences to match the professional development of the student at different phases of medical education. Primary, secondary, and tertiary prevention were particularly germane for students in the first, second, and third years, respectively. During clerkships in the third and fourth years, especially those with a focus on ambulatory patients, students built upon earlier experiences to integrate health promotion and disease prevention into clinical practice. By unifying the teaching of disease prevention with several major required courses, we aimed to create an environment in which students could experience their learning about disease prevention in the same manner that we aspired to have them practise it: integrated throughout clinical medicine.

The case of the disappearing generalist: does it need to be solved?

The proportion of generalist physicians in the United States has declined steadily over 50 years, bringing it to the lowest percentage of trained primary care physicians of any developed country; the trend toward subspecialization is accelerating. Many analysts believe this imbalance between generalists and subspecialists to be a major cause of Americas high health care costs, heavy dependence on biotechnology, and consumer dissatisfaction. Others argue that sub-specialists can provide excellent primary care services, and the decrease in the number of generalists is not a problem. Three contrasting views on the implications of this trend state that todays generalists are an important and scarce resource that must be bolstered; that subspecialists can replace generalists as providers of primary care; and that the free market will determine the best manpower mix. A final view, on the marketplace option, posits that generalism will not recover until it creates a vital, and unique, role in handling the primary care challenges of the twenty-first century. These competing viewpoints are used to clarify assumptions underlying our major policy options in the arena of health manpower.

The Clinician‐Teacher in Managed Care Settings

Managed care has grown tremendously over the last decade.1 In 1985, there were fewer than 8 million members; in 1995, there were more than 53 million members. Increasing numbers of doctors are now working in managed care, and most new graduates of residency programs will spend their careers in capitated managed care practices. Ten years ago, we wrote about the benefits of affiliations between academic health centers and health maintenance organizations (HMOs).2 What was then an interesting idea now has become a necessity. Curricula in medical schools and residency training programs have begun to address the changes in medical practice, but they have not kept pace with managed care practice development. In fact, in many parts of the country academic institutions have been insulated from the changes in practice. The well-described gap between skills emphasized in residency training and those necessary for practice continues to widen.3–5 As a result, HMO medical directors consider the majority of primary care physicians to be “poorly qualified” for managed care practice.6 There is an alarming growth of physician dissatisfaction in practice. A recent study by the California Medical Association revealed the dimensions of the problem. On the basis of their current work experiences, nearly 40% of California primary care physicians under the age of 40 would not again choose careers in medicine. Physician claims for disability, another symptom of physician distress, are at an all time high. The majority of these discontented physicians attributed career dissatisfaction to negative experiences with managed care practice.7 Residency training program directors must ensure that their graduates do not suffer from these negative attitudes. Patients also express dissatisfaction that can be attributed to deficient training. When patients say that their doctors don’t listen, are rushed, devalue their opinions, and treat them like objects, they are indirectly criticizing the programs that have trained the doctors. These concerns reflect the current problems of primary care practice and medical education. Building excellent managed care practices that incorporate the training of future physicians can serve to correct these deficiencies. Learning to practice in real managed care sites—where residents and medical students interact with role models and participate in authentic clinical work—may be the best way to prepare doctors to provide high-quality care in a cost-effective manner and to take pride and pleasure in their work.8,9 In this article we will present the results of nearly 25 years of experience in the graduate medical education of primary care internists in one managed care organization, Harvard Pilgrim Health Care (HPHC, formerly Harvard Community Health Plan). We have chosen to describe our experience in depth rather than to survey the small number of programs that have addressed the challenge of teaching in managed care settings. We will present our view of the elements of clinical competence that excellent managed care practice requires. We will describe the roles of clinician-educators in HPHCs primary care program, and discuss the challenges they face in balancing clinical practice and teaching responsibilities. Finally, we will describe the value of graduate medical education to our organization, and the challenges that must be met in order to sustain training in a busy managed care setting.