Medical Education as a Vehicle for Improving Healthcare

1. Medical Education as a Vehicle for Improving Healthcare John Norcini, Ph.D.

2. Major Demands in Healthcare • Capacity • There is a shortage of healthcare workers • Relationship between mortality/morbidity and worker density • Shortfall of 4.3 million workers • Migration • Maldistribution • Poor production • Low income countries are particularly affected • Quality • Quality is often compromised • Relationship between mortality/morbidity and healthcare quality • 40% of US admissions result in harm to patients • Race/income disparities • Absence of evidence-based standards • Continuity of care lacking

3. Some responses to the demands are beyond the reach of education • Healthcare system reform • Financing of education and the healthcare system • Migration • International trade agreements Health Professions Education

4. Health Professions Education • Some responses are within the reach of health professions schools • Selecting different students • Admissions • Expanding institutional capacity • Use/creation of open educational resources (OER) • Faculty development • Reforming education • Formative assessment and feedback • Requiring lifelong learning

5. Admissions • Capacity and quality are limited because the healthcare workforce does not match the patient population • Geographically, ethnically, racially

6. Representative workforce leads to • Improved access to care • Greater opportunity for concordance • Ethnic, racial, language • Increased trust between patients and doctors • Diverse faculty/students that enhance cultural competence Admissions: Evidence Saha, S., Shipman, S. (2006). The Rationale for Diversity in the Health Professions: A Review of the Evidence.

7. Strategies for changing admissions • Address inadequacies in primary and secondary education • Not fixable in the short term • Change the admissions process • Broaden the criteria used in admissions • Use diversity as one important basis for making admissions decisions • Expand those involved in the admissions decision Admissions: Strategy

8. Change the admissions process (cont) • Create relationships between health professions schools and primary-secondary schools • Provide help to potential students • Financial support Creative programs that combine these features can be found in Canada, Australia, Philippines… Admissions: Strategy

9. Representative healthcare workforce • Improves access to care • Increases provider-patient concordance • Increases trust in providers • Provides better education for students Strategies for change • Change the admissions process • Create relationships with lower schools • Provide help to potential students Admissions: Summary

10. Lack of high quality educational material limits capacity and quality OER movement provides free access to high-quality educational content • For users of the resources • Increases knowledge through courses that • Are not readily available locally • Can be tailored to local needs • Can be used to improve local resources • Can be used across health professions Open Educational Resources (OER)‏

11. For creators of the resources • Faculty • Builds awareness of unique contributions • Fosters connections with international colleagues • Creates a record of teaching innovation • Institutions • Builds global awareness of the institution • Improves recruitment • Provides a resource for students, faculty and alumni Open Educational Resources

12. OER movement has many components • Some educational institutions are putting their courses on the internet and allowing free access • OpenCourseWare (OCW) Consortium • Some institutions are creating peer review processes for educational resources • MedEdPortal Open Educational Resources

13. Non-profit confederation of institutions Goals • Extend the impact of open courseware • Foster the development of additional open courseware projects • Ensure the long-term sustainability of open courseware projects www.ocwconsortium.org OER: OpenCourseWareConsortium

14. Institutions of Higher Education in Saudi Arabia • Al-Imam Muhammad Ibn Saud Islamic University • King Fahd University of Petroleum & Minerals • King Faisal University • King Khalid University • Qassim University College of Medicine OER:OCW Consortium Members

15. Consortium • 200+ institutional members in 40+ countries • 6,600+ courses • 65 sources • 12 languages Content is licensed under Creative Commons 3.0 • Work can be freely shared, distributed, adapted, and transmitted with attribution OER: OpenCourseWareConsortium

16. OER: MedEdPortal • Free online publication service • Contains peer-reviewed teaching resources • Cover the continuum of medical/dental education • AAMC and the ADEA • www.aamc.org/mededportal • Primary audience and source of submission • Educators in health education • Administrators in health education • Students in health education

17. MedEdPortal: Contents • Animations • Assessments • Cases • Computer applications • Exercises • Faculty development materials • Lab manuals • Lecture presentations • Podcasts • Problem-based learning (PBL) • Simulation scenarios • SP cases • Surveys • Virtual patients • Videos • Other media

18. MedEdPortal: Peer Review • Editor and Editorial Board are appointed • Peer review policy • Use invited expert reviewers (700+) • Submissions • 18% accepted • 53% accepted with revisions • 29% rejected • 2000+ resources • 1000 downloads per week

19. There is a lack of high quality course material for health professions education Open courseware movement can address this issue in part • It has global, institutional, and faculty benefits • OpenCourseWare Consortium • MedEdPortal OER: Summary

20. Quality and capacity is limited by a lack of health professions faculty Faculty development programs • Help address faculty shortages • Respond to issues related to faculty diversity • Empower faculty members to excel as educators • Create a community that values teaching and learning Faculty Development

21. BEME Review (Steinert et al, 2006)‏ • Faculty development participants were satisfied • Tests showed significant knowledge gains • Changes in teaching behavior were reported by participants and detected by students • Changes included greater educational involvement and establishment of networks Faculty Development: Evidence

22. Faculty Development Faculty development Model Programs FAIMER Institute‏ Regional Institutes Education Centers FAIMER distance learning “Education is for improving the lives of others and for leaving your community and world better than you found it.” Marian W. Edelman

23. Provide learning around a relevant project Improve population health Improve medical education Support, stimulate growth of regional medical education Create critical mass of medical educators FAIMER Faculty Development Model Identify committed and interested faculty

24. Programs: FAIMER Institute • Started in 2001 • Target is mid-level faculty • There are 60-100 applications (online) for 16 fellowships • Requires a project that has institutional support

25. Programs: FAIMER Institute • Format of Year One • 3 weeks in the US • Basic topics and meet mentors • 11 month distance learning • On-line discussion and progress reports • Format of Year Two • 2 weeks in the US • Advanced topics and meet new fellows • 11 month distance learning • Focus on publishing work, collaborative research

26. Programs: FAIMER Institute • Curriculum based on needs assessment • Educational practice • Large/small group teaching, PBL • Assessment • Educational leadership • Change theory • Project management • Scholarship • Publication, presentation

27. Programs: Regional Institutes • Regional versions of the Institute • Advantages • Regional relevance • Regional networking and field-building • Efficiency • Run by FAIMER Fellows • Funded by FAIMER plus others • Modified to meet regional needs • Regional Institutes • India • Mumbai (2005)‏ • Ludhiana (2006)‏ • Coimbatore (2007)‏ • Brazil • Brazil (2007)‏ • Africa • Southern Africa (2008)‏ • China • Shenyang (in development)

28. Single school faculty development centers • Advantages • Local relevance • Creates institutional infrastructure • Generates/sustains reform • Efficiency • Run by FAIMER Fellows • Just started • Pramukhswami Medical College Programs: Education Center

29. FAIMER will partner with a UK university to offer Certificate, Diploma, & Master’s degree • “Accreditation and Assessment in the Health Professions” • Distance learning with some face-to-face • Available March 2013 • Begin integration with FAIMER Fellowships FAIMER Distance Learning

30. Program Evaluation • Projects (N>600) • Topics • Education methods (37%) • Curriculum revision (23%) • Program Evaluation (18%) • Assessment (17%) • Alignment with the health care ‏system (17%) • Institutional impact • 56% incorporated into curriculum or policy • 62% replicated • Projects • Positive impacts • Teaching, assessment, research quality-interest • Collaboration within-across departments • Educational efficiency • Alignment with healthcare • Individual impacts • Changes in knowledge, skills, and attitudes • Promotion • Scholarship

31. Faculty Development: Summary • Quality and capacity is limited by a lack of health professions faculty • Faculty development programs address this issue in part • FAIMER is one example • There is good evidence of their effectiveness

32. Formative Assessmentand Feedback A lack of observation-feedback-assessment during clinical training limits quality Medical students Structured observation for 7-23% of students (Kassebaum & Eaglen, 1999) Postgraduate trainees 82% were observed only once (Day et al., 1990)

33. Formative Assessment: Evidence Feedback is critical to learning and has a significant influence on achievement General education (Hattie, 1999) Meta-analysis of 12 meta-analyses Feedback is among the largest influences on achievement (ES=.79) Medical education (Veloski et al., 2006) Feedback alone effective is effective in 71% of studies

34. Assessment Creates Learning Retrieval of information or a performance enhances learning Students read a passage (Roediger & Karpicke, Psych Science, 2006) Group 1 took three tests on the passage Group 2 re-read the passage carefully three times On a test one week later, Group 1 did better Students read science text (Karpicke & Blunt, Science, 2011)

35. Workplace Assessment in Training A way to include observation-feedback-assessment in clinical education Patient care Medical knowledge Interpersonal and communication skills Systems-based practice Practice-based learning Professionalism Portfolio (preliminary) Observations of clinical encounters Observations of procedures Knowledge test 360°assessment Patient record audit

36. Formative Assessment: Summary Formative assessment and feedback Lacking in clinical placements but critical to learning and quality ACGME program offers a useful strategy Methods based on observation and feedback Cover a variety of competencies Include the views of a number of assessors

37. Lifelong learning can improve quality and capacity • Healthcare workers • Keep up with advances in their fields • Acquire new skills • Healthcare workforce • Flexibility to adapt to change and local conditions • Ability to cope with disaster • Patient populations • Achievement of millennium goals Lifelong Learning

38. There is a need for lifelong learning • For doctors, performance declines with time since medical school • Systematic review of the literature by Choudhry, Fletcher, Soumerai (Ann Int Med, 2005)‏ • MEDLINE search of all papers from 1966 to 2004 plus references in the identified papers • Found 62 studies that were related to the topic Lifelong Learning: Evidence

39. Lifelong Learning: Evidence • Knowledge studies (N=12) • All reported a decline in knowledge with age • Adherence to standards for diagnosis, screening, prevention (N=24)‏ • 15 show physicians in practice longer adhere less to standards • Adherence to standards of appropriate therapy (N=19) • 14 found a partially or consistently negative association • Patient outcomes (N=7)‏ • 4 found a partially or consistently negative association

40. Conclusion of the authors “Physicians who have been in practice longer may be at risk for providing lower-quality care. Therefore, this subgroup of physicians may need quality improvement interventions.” Lifelong Learning: Evidence

41. Lifelong learning works • Meta-synthesis (Robertson et al., JCEHP) shows that continuing education is effective in creating change in a range of outcomes • Attitudes • Knowledge • Skills • Behavior • Patient outcomes Lifelong Learning: Evidence

42. Short, focused education Patient- specific tools Social interaction Access to data on practice Lifelong Learning: Strategy • Many characteristics of effective lifelong learning are captured in this model • It needs to be ongoing

43. “It is only by getting your cases grouped…that you can make any real progress with your post-collegiate education” W. Osler Lifelong Learning: Strategy • Change is more likely if the provider knows the nature of his/her practice • Aggregated data by clinical problem • Statistics on patient problems, diagnostics, and therapeutics • Track patient outcomes

44. Lifelong Learning: Strategy • Learning best occurs in the context of patient care • Patient-specific education • Evidence-based, short focused answers to clinical questions • Point-of-care tools • Reminder systems to avoid errors of omission “Be careful about reading health books. You may die of a misprint.” Mark Twain

45. Lifelong Learning: Strategy • Education should be short and focused on relevant aspects of practice • Interactive sessions offering the opportunity for practice are effective • Didactic sessions are ineffective “Some people talk in their sleep. Lecturers talk while other people sleep.” Albert Camus

46. “Leadership is the art of getting someone else to do something you want done because he wants to do it.” Dwight Eisenhower Lifelong Learning: Strategy • Provider leadership • Create non-threatening environment • Encourage information exchange • Align incentives • Partner with family and community • Peer interactions • Non-threatening discussion of practice data

47. Lifelong learning improves quality and capacity • Important for providers and patient populations There is good evidence that provider performance declines over time Lifelong learning is effective in fighting the decline • Ongoing, based on practice data, patient specific, short/focused, led by providers Lifelong Learning: Summary

48. Summary • Quality and capacity are the two biggest issues facing healthcare • Health professions education can help by • Selecting different students • Admissions • Expanding institutional capacity • Use/creation of open educational resources (OER) • Faculty development • Reforming education • Formative assessment and feedback • Requiring lifelong learning