The primary care specialties working together: a model of success in an academic environment

Across the divide: "Primary care departments working together to redesign care to achieve the Triple Aim"

BACKGROUND

Primary care is considered the foundation of an effective health care system. However, primary care departments at academic health centers have numerous challenges to overcome when trying to achieve the Triple Aim.

METHODS

As part of an organizational initiative to redesign primary care at a large academic health center, departments of internal medicine, general pediatrics and adolescent medicine, and family medicine worked together to comprehensively redesign primary care. This article describes the process of aligning these three primary care departments: defining panel size, developing a common primary care job description, redesigning the primary care compensation plan, redesigning the care model, and developing standardized staffing.

RESULTS

Prior to the initiative, the rate of patient satisfaction was 85%, anticoagulation measurement 65%, pneumococcal vaccination 85%, breast cancer screening 79%, and colorectal cancer screening 69%. These rates all improved to 87%, 75%, 88%, 80%, and 80% respectively. Themes around key challenges to departmental integration are identified: (1) implementing effective communication strategies; (2) addressing specialty differences in primary care delivery; (3) working within resource limitations; and (4) developing long-term sustainability.

CONCLUSIONS

Primary care in this large academic health center was transformed through developing a united primary care leadership team that bridged individual departments to create and adopt a common vision and solutions to shared problems. Our collaboration has achieved improvements across patient satisfaction, clinical safety metrics, and publicly-reported preventive care outcomes.

IMPLICATIONS

The description of this experience may be useful for other academic health centers or other non-integrated delivery systems undertaking primary care practice transformation.

Facilitating collaboration among academic generalist disciplines: a call to action

To meet its population's health needs, the United States must have a coherent system to train and support primary care physicians. This goal can be achieved only though genuine collaboration between academic generalist disciplines. Academic general pediatrics, general internal medicine, and family medicine may be hampering this effort and their own futures by lack of collaboration. This essay addresses the necessity of collaboration among generalist physicians in research, medical education, clinical care, and advocacy. Academic generalists should collaborate by (1) making a clear decision to collaborate, (2) proactively discussing the flow of money, (3) rewarding collaboration, (4) initiating regular generalist meetings, (5) refusing to tolerate denigration of other generalist disciplines, (6) facilitating strategic planning for collaboration among generalist disciplines, and (7) learning from previous collaborative successes and failures. Collaboration among academic generalists will enhance opportunities for trainees, primary care research, and advocacy; conserve resources; and improve patient care.

Instrumental strategy: A stage in students' consultation skills training? Observations and reflections on students' communication in general practice consultations

OBJECTIVES

To explore and examine students' abilities to communicate with patients during a general practice course in the final year of the curriculum and to analyse and consider this experience in relation to earlier consultation training.

SETTING

General practice courses in the undergraduate curriculum.

DESIGN

Qualitative data analysis was used. A special focus-group interview of experienced supervisors was performed and analysed (editing analysis). Credibility of data was tested at local seminars and conferences. Authors' experiences of observing student consultations over many years were also used.

RESULTS

A main theme, 'open invitation', emerged based on categories 'initially attentive' and 'listening attitude'. In contrast, the second main theme was 'instrumental strategy', based on the following categories: 'one-sided collection of medical facts' and 'relationship-building lost'. The students also had difficulties in devoting attention to patients' life experiences. An hourglass metaphor of students' and young physicians' progression of communication strategies is presented. The narrow part of the hourglass corresponds to an instrumental strategy at the end of undergraduate clinical education.

CONCLUSIONS

An instrumental strategy may be a stage in student's consultation learning progression that interferes with communication training. A question is raised: is training of a patient-centred approach throughout the clinical curriculum needed for optimal development of consultation skills? Further research is needed to test this hypothesis.

The views of U.S. medical school deans toward academic primary care

PURPOSE

To understand the views of U.S. medical school deans about their primary care faculties.

METHOD

In 2000, the authors mailed a questionnaire containing 43 multipart items to deans of 130 U.S. allopathic medical schools. The questionnaire assessed the deans' attitudes about and evaluation of primary care at their school and their school's efforts to strengthen it. Deans were asked to compare family medicine, general internal medicine, and general pediatrics with nonprimary care clinical departments at their schools.

RESULTS

Of the 83 (64%) deans who responded, 82% reported their school had departments or divisions of family medicine, general internal medicine, and general pediatrics. Deans rated general internal medicine and general pediatrics higher than nonprimary care faculty on clinical expertise and productivity (p < .001) and family medicine equivalent to nonprimary care faculty. Deans rated all three primary care faculties superior to nonprimary care faculty for teaching skills (p < .001) and programs (p < .05), but lower than nonprimary care disciplines for research productivity (p < .01) and revenues (p < .001). They rated family medicine and general pediatrics lower for research skills (p < .001), but 73% of deans stated research was equally important for primary care and nonprimary care departments. Deans considered overall financial resources to be equivalent for primary care and nonprimary care departments, but 77% of deans felt primary care departments or divisions needed financial support from the medical school to survive. Most deans attempted to strengthen primary care by changing the curriculum to promote primary care and by providing financial support.

CONCLUSIONS

Deans ranked primary care faculty high on clinical and teaching measures. Although they considered research to be an important activity for primary care faculty, they evaluated it low relative to nonprimary care departments.

The case for interdepartmental research in primary care

Research problems in human biology, clinical medicine, and health services delivery are complex, and increasingly require collaborative approaches. Despite the commitment of general internists, general pediatricians, and family physicians to comprehensive, coordinated, and longitudinal care, their substantial overlap in research topics, methods, and data sources, and their shared emphasis on research conducted in community-based settings, the three primary care disciplines rarely collaborate in research. The research enterprises of most primary care departments and divisions in the United States are small "cottage industries," while interdepartmental research units are rare. Interdepartmental research units can develop and maintain the critical mass of investigators, trainees, and staff that is necessary for an intellectually vibrant and financially sound primary care research enterprise. The University of Colorado Health Sciences Center School of Medicine has developed a successful interdepartmental research effort in primary care that includes joint fellowship training and faculty development programs and a Primary Care Research Unit that supports the analysis of secondary databases, practice-based research networks, and interdisciplinary research projects. Key elements of this collaboration include shared projects among faculty and trainees, proactive negotiation about resources, and shared research space, staff, and faculty. Such a collaboration provides the breadth of perspectives necessary to address complex health care problems, and the pragmatic infrastructure necessary to sustain research themes and careers.

A collaborative model for supporting community-based interdisciplinary education

Development and support of community-based, interdisciplinary ambulatory medical education has achieved high priority due to on-site capacity and the unique educational experiences community sites contribute to the educational program. The authors describe the collaborative model their school developed and implemented in 2000 to integrate institution- and community-based interdisciplinary education through a centralized office, the strengths and challenges faced in applying it, the educational outcomes that are being tracked to evaluate its effectiveness, and estimates of funds needed to ensure its success. Core funding of $180,000 is available annually for a centralized office, the keystone of the model described here. With this funding, the office has (1) addressed recruitment, retention, and quality of educators for UME; (2) promoted innovation in education, evaluation, and research; (3) supported development of a comprehensive curriculum for medical school education; and (4) monitored the effectiveness of community-based education programs by tracking product yield and cost estimates needed to generate these programs. The model's Teaching and Learning Database contains information about more than 1,500 educational placements at 165 ambulatory teaching sites (80% in northern New England) involving 320 active preceptors. The centralized office facilitated 36 site visits, 22% of which were interdisciplinary, involving 122 preceptors. A total of 98 follow-up requests by community-based preceptors were fulfilled in 2000. The current submission-to-funding ratio for educational grants is 56%. Costs per educational activity have ranged from $811.50 to $1,938, with costs per preceptor ranging from $101.40 to $217.82. Cost per product (grants, manuscripts, presentations) in research and academic scholarship activities was $2,492. The model allows the medical school to balance institutional and departmental support for its educational programs, and to better position itself for the ongoing changes in the health care system.

Changing face of medical curricula

The changing role of medicine in society and the growing expectations patients have of their doctors means that the content and delivery of medical curricula also have to change. The focus of health care has shifted from episodic care of individuals in hospitals to promotion of health in the community, and from paternalism and anecdotal care to negotiated management based on evidence of effectiveness and safety. Medical training is becoming more student centred, with an emphasis on active learning rather than on the passive acquisition of knowledge, and on the assessment of clinical competence rather than on the ability to retain and recall unrelated facts. Rigid educational programmes are giving way to more adaptable and flexible ones, in which student feedback and patient participation have increasingly important roles. The implementation of sustained innovation in medical education continues to present challenges, especially in terms of providing institutional and individual incentives. However, a continuously evolving, high quality medical education system is needed to assure the continued delivery of high quality medicine.