Primary Care Education in Health Maintenance Organizations

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DOCUMENT RESUME HE 008 515

ED 132 943 AUTHOR TITLE

INSTITUTION

Infeld, Marcel D. Primary Care Education in Health Maintenance Organizations: Curriculum Content, Evaluation and Costs. A Collaborative Study. Final Report. Association of American Medical Colleges, Washington, D. C.

SPONS AGENCY

Health Services Administration (DHEW/PHS), Rockville, Md.

PUB DATE CONTRACT NOTE

Jul 76 BHM-HRA NO1-MB-44009 492p.; Not available in hard copy due to marginal legibility of original document

EDRS PRICE DESCRIPTORS

MF-$1.00 Plus Postage. HC Not Available from EDRS. Community Health; Costs; *Curriculum; Curriculum Development; Educational Finance; *Health Facilities; *Health Services; *Medical Education; *Physicians; *Preventive Medicine; Program Evaluation; Teaching Methods *Health Maintenance Organizations

IDENTIFIERS

ABSTRACT

The report is an effort to summarize and synthesize the work of six academic medical centers and affiliated health maintenance organizations that participated in the project for the development and implementation of curricula for physician training in HMO's. The selected works of the participating institutions constitute the bulk of the report. They are organized along the focal issues of the project: (1) curriculum development process; (2) curriculum content; (3) instructional methods; (4) program evaluation; and (5) educational costs. The participating institutions are: Georgetown University and the Georgetown University Community Health Plan; University of Rochester and the Genesee Valley Group Health Association; University of Pennsylvania and tbe Penn Urban Health Maintenance Program; University of Washington and the Group Health Cooperative of Puget Sound; Brown University and the Rhode island Group Health Association; and Harvard University and the Harvard Community Health Plan, (Author/USE)

* * * * * * *

Documents acquired by ERIC include many informal unpublished materials not available from other sour9es. ERIC makes every effor to obtain the best copy available. Nevertheless, items of marginal reproducibility are often encountered and this affects the quality of the microfiche and hardcopy reproductions ERIC makes available via the ERIC Doaument Reproduction Service (BDRS). EDRS is not responsible for the quality of the original ,document. Reproductions supplied by EDRS are the best that can be .made from the original.

* *

* *

PUNARY CARE EDECAT1ON 1N liN0s,= CUKRACLLPI CONTENT, CVALLAT I_

AND COL;]

Contract No. UM-URA NIOL=i3-44OO9 July 1976

viE At 1,4 NT OELFAW.L. FOLICAT T!00,4AL, INSTIIUTF OP

$ PEPAR1

(WC A T iON

Final Repo

PRIMARY CARE EDUCATION IN HEALTH MAINTENANCE ORGANI

TIONS:

CULIIM CONTENT, EVALUATION AND COSTS

A Collaborative Study

Prepared By Marcel D. Infeld ASSOCIATION OF AMERICAN MEDICAL COLLEGES One Dupont Circle, N.W., Suite 200 20036 Washington, D.C.

Submitted To Mrs. Dorothy Reese Project Officer and Chief, Special Programs Staff Bureau of Health Manpower, Health Resources Administration Department of Health, Education and Welfare Building 31, Room 5C-12 9000 Rockville Pike Bethesda, Maryland 20014

July 1976

Project for the Planning, Development and Demonstration of Educational Programs for Medical Students and/or interns_and Residents In Health Maintenance Organizaitons

Contract No. BIU1=HRA NO1-MB-44009

Directed By

ASSOCIATION OF AMERICAN MEDICAL COLLEGES James I. Hudson, M.D., Project Director and Director, Department of Health Services Marcel D. Infeld, M.P.H., Project Coordinator and Staff Associate, Department of Health Services

Conducted By

Georgetown University and Georgetown University Community Health Plan, Washington, D.C. University of Rochester and Genesee Valley Group Health Ass ciation, Rochester, New York University of Pennsylvania and Penn Urban Health Maintenance Program, Philadelphia, Pennsylvania University of Washington and Group Health Cooperative of Puget Sound, Seattle, Washington Brown University and Rhode Island Group Health Association Providence, Rhode Island Harvard University and Ha ard Community Health Plan, Cambridge, MassaOnisetts

Supported By

Bureau of Health Manpower, Health Resources Administration, Department of Health, Education and Welfare

TABLE OF CONTENTS PAGE

FORE ORD

ii

PREFACE

iv

OBJECTIVES AND METHODS OF THE PROJECT Letter of Invitation Appendlx 1. Appendix 2. Conference Agendas 2.

GEORGETOWN UNIVERSITY AND GEORGETOWN UNIVERSITY COMMUNITY HEALTH PLAN (GUCHP) Staff Interview Form Appendix 3. Appendix 4. Patient Interview Form

8

UNIVERSITY OF ROCHESTER AND GENESEE VALLEY GROUP HEALTH ASSOCIATION (GVGHA)

15

4.

UNIVERSITY OF PENNSYLVANIA AND PENN URBAN HEALTH MAINTENANCE PROGRAM (PENN UMB)

21

5.

UNIVERSITY OF WASHINGTON AND GROUP HEALTH COOPE-__TIVE OF PUGET SOUND Appeudix 5. Memorandum of Understanding

24

6.

BROWN UNIVERSITY AND RHODE ISLAND GROUP HEALTH ASSOCIATION (RIGHA) Appendix 6. Memorandum of Understanding The HMO Reader Appendix 7. Description of RIGHA Electives Appendix 8.

37

HARVARD UNIVERSITY AND HARVARD COMMUNITY HEALTH PLAN

41

7.

(HCHP-CC) Appendix 9.

Behavioral Science Component: Sample Pre/Post Test Appendix 10. Behavioral Science Componen Rating Scale

8.

FINDINGS AND RECOMMENDATIONS

ROSTER OF PARTICIP

54

78

TS

81

RESOURCE PAPERS

-

FOREWORD

The health maintenance organization concept, emerging from the successful experiences of selected prepaid group practice organizations and medical foundations in the United States, was defined by Paul Ellwood in the early 1970's. He characterized HMOs as those organizations which provide comprehensive health or services to voluntarily enrolled consumers, on the basis of fixed price Unique, however, capitation contracts. The concept, of course, was not new. was the accelerated interest in this organizational structure for reconfiguration of health services of the United States in general. Various elements of the HMO model, the potential for cost containment, the practical utilization of epidemiologic concepts ahd preventive health measures, the possibilities for experimentation with varied organizational assignments of health professionals, the philosophy of responsibility for the health of a defined population _.p.nted features of interest to the Administration, the Congress, and the academic medical community. Newly developed health care programs, assisted by Federal financing and organized in a fashion encompassing the concepts described above, became attractive models not only for the education of undergraduate and graduate medical students and students of other health professions, but also as organizational concepts through which the academic medical center might discharge some or all of its health care service obligations to the surrounding community. Furthermore, as a means for meeting the need for additional experiences in ambulatory care in order to accommodate ever larger class sizes correlated with increased emphasis on primary care education, academic medical center-health maintenance organization affiliations appeared attractive. By 1973, 15 percent of the academic medical centers had developed formal affiliations with HMOs, and an additional 68 percent had either definite plans to establish such or were contemplating this action. In 1973, the Association of American Medical Colleges, under contract with.the HMO Office, Health Services Administration, Department of Health, Education and Welfare (Contract No. HSK 110-72-393), developed a project which described and analyzed various prototype arrangements. A summary of that work wag completed in August 1974. It was soon realized that, although the development of a mutually agreeable affiliation was in itself a complex matter, the introduction of even minimal numbers of students into health care programs whose survival was dependent upon the very critical factors of efficiency of operations and consumer acceptance, presented problems of even greater Paradoxically, the growth of the HMO concept nationally would be complexity. dependent on the number of young physicians experienced in this concept. Consequently, a project related to curriculum development for the education of physicians in HMOs was considered to be a desirable corollary effort. The current project, supported by the Bureau of Health Manpower, Department of Health, Education and Welfare, addresses the issues of curriculum development, implementation, and evaluation and the methodologies for identifying educational costs. This report details the results of a collaborative effort of six academic medical centers and the affiliated health maintenance organ izations, and it makes recommendations for future programatic development.

At present, it is difficult to predict the rate of HMO growth in the United States. A new AAMC study currently underway indicates that in 1976, 17% of the acudemic medical centers report formal affiliation with HMOs, and only 12% report plans to develop such. Many events of the past four years have had a retarding effect upon such growth nationally. In view of current conditions, early predictions of having the HMO option available to 90% of the U.S. population by 1980 appear naive, overly optimistic, and unrealistic. Furthermore, because of continued economic uncertainties, it is difficult to predict the immediate effect of the recent HMO Legislative Amendments. The reader should be aware, however, that the major issues addressed in this project - the development, implementation, and evaluation of curriculum, and the development of methodologies for calculating educational costs are themselves generic issues not necessarily confined to the HMO concept. These are issues of obvious concern to those charged with the planning of primary care education in general, and for those chaged with arranging ambulatory care experiences in particular. As such, it is to be hoped that this report will provide useful information to those charged with curriculum development, to faculty preceptors, and to health systems administrators involved with teaching programs.

James I. Hudson, M.D. Project Director

- iv -

PREFACE

This report is an effort to summarize and synthesize the work of six academic medical centers and affiliated health maintenance organizations that participated in the project for the development and implementation of curricula for physician training in HMOs. The selected works of the participating institutions, presented as resource papers following Chapter 8, constitute the bulk of the report. They are organized along the focal issues of (1) curriculum development process, (2) curriculum the project content, (3) instructional methods, (4) program evaluation, and The first chapter describes the purposes (5) educational costs. of the project and its methodology and the six subsequent chapters summarize the institutions' accomplishments. The final chapter is an effort to synthesize these achievements, and present our findings, conclusions and recommendations.

This project is indebted to the members of the project advisory committee, Drs. Samuel J. Bosch, Joel J. Alpert, Jack D. Myers, Mitchell T. Rabkin, John P. Utz and Eugene Vayda, for their dedication, advice and guidance in designing and directing the project; to the special consultants, Drs. Christine E. Bishop, Arthur S. Elstein and Edwin B. Hutchins, for producing excellent results under trying circumstances; and to the Project Directors for the institutional projects and their staffs, without whose toil, dedication and cooperation this project would not have succeeded=

Chapter 1

OBJECTIVES AND METHODS OF TEE PROJECT

This project was conceived in the early 1970's when HMOs first gained national prominence and active support from the federal government as a new and viable alternative to the current health care system.

Predictions

were made at the time that, "The current 5-7 million HMO enrollees could increase to approximately 40 million by 1980.

Physician requirements

would increase from 7,000 full-time equivalents in 1973 to about 40,000 by 1980.

This figure represents about 10% of the expected number of physi-

cians practicing in 1980.

[1].

Although the need for physician man-

power in HMOs today is not as great as predicted (less than 6 million people were enrolled in HMOs in 1975 [2])

primary care education in the

HMO is no less important today than it was several years ago.

:The increasing pressure in recent years on medical schools to produce

more primary care physicians has resulted in eff-rts to develop new and appropriate sites for primary care training at both the graduate and undergraduate level_ of medical education.

An organized system of care

such as an HMO has the advantage of providing an alternative approach to health care over the traditional hospital outpatient department or the office practice.

Mo eover, although the nationwide shortage of primary

care physicians willing to practice in the HMO is not as great as once predicted, the geographic maidistribution of primary care physicians has resulted in acute regional shortages, especially in ru al areas.

In fact,

a recent report cites the inability to obtain physicians as a major cause for.recent failures of HMOs [3].

- 2-

The overall goals of the project, then, were: (a)

To encourage the establishment of HMOs by developing training programs that would help in Increasing the "supply of appropriately trained,

oriented, and motivated physicians to allow major growth and expansion of the HMO concept in the U.S." [4]; and To develop "educational programs with major emphasis on primary and comprehensive care to train physicians to function effectively in the HMO health care team setting" [4].

The Association of American Medical Colleges (AAMC) entered into contact with the Bureau of Health Resources Development (presently Bureau of Health Manpower), Health Resources Administration, Department of Health, Education and Welfare in.May 1974.

The contract called for the AAMC to solicit

proposals,and. select, with the assistance and:guidance of a:project'

advisory committee

six medical schools sponsoring or affiliated with HMOs

and willing to develop HMO-based educational programs for medical students and/or residents.

By September 1974, six medical schools and their affil-

iated HMOs had been selected for participation.

In June 1974 the AAMC invited medical schools to submit,on a competitive basis,proposals outlining their interest and qualifications.

A copy of the . To

letter of invitation is presented as Appendix 1 following this chapter.

qualify, a medical school had to have an affiliation with a local HMO and a

history of activitis in and understanding of primary care issues. of interest and support from the HMO was also required.

A letter

Up to "40,000 for

program development and staffing was offered to each institution selected for participation.

Eleven medical schools submitted proposals and, of these,

- 3the following schools and HMOs were selected: 1.

Georgetown University and Georgetown University Community Health Plan (GUCHP), Washington, D.C.

2.

University of Rochester and Genesee Valley Group Health Association (GVGHA), Rochester, New York

3.

University of Pennsylvania and Penn Urban Health Maintenance Program (Penn Litt)), Philadelphia, Pennsylvania

4.

University of Washington and Group Health Coopera_ ve of Puget Sound, Seattle, Washington

Brown University and Rhode Island Group Health Association (RIGHA), Providence, Rhode Island 6.

Harvard University and Harvard Community Health Plan - Cambridge Center (HCHP7CC), ,cambridge

Massachusetts

The most important selection criteria were the clarity and specificity of the curriculum objectives, the appropriateness of the curriculum development process, and the feasibility of the proposed study.

In November 1974, the AAMC subcontracted with each participating mediu., school to develop, during the calendar year of 1975, the curriculum specified in its proposal, to develop appropriate evaluation mechanisms and to estimate the cost of _ education in the HMO.

For monito ,ng purposes, the

institutions were required to submit a work plan, quarterly progress report and a final report by December 1975.

The major milestones and activities

the project are presented on the following page.

ii

- 4

Pro ect to Develop Curriculum for

Physician Training in HMOs

TI1IITABLE

Milestones

Date

Project begins

May 1974

First meeting of project advisory commit

(PAC)

June

Letter of invitation mailed to medical schools

June

Submission of Proposals

August

Second PAC meeting; selection of participating institutIons

September

Orientation session, Washington, D.C.

November

.

Curriculum development activities begin

January

Second meeting of project participants, Rochesier, N.Y.

March

Site visits

April-J-1113

Third PAC mee ing

June

Thi d meeting of project participants

Cambrdge, Mass.

September

Meeting on curriculum evaluation

November

Presentation of symposium at AAMC Annual Meeting

November

Termination of curriculum development activities

December

Submission of institutional reports to AAMC

February 1

.

Submission of AAMC report to DREW and project termination

July 1976

- 5-

The instItutIons accomplished much more than required.

The Bureau of

Health Manpower (BHM) required the development but not implementation of curricula.

Nevertheless, virtually all groups not only conStructed HMO-

based cur i ula but they field-tested and implemented them during the course of the project.

In addition, most of the groups designed evaluation tech-

niques for assessing the effectiveness of the educational programs or developed cost methodologies for estimating the cost of education in the HMO, neither of which was required under the terms of lie BHM contract.

Two institutions, the Universities of Rochester and Washington, worked on both evaluation And costs=

The projects benefited from three conferences 'that were held during the course of the contract.

The initial conference, held at the AAMC head-

quarters in Washington, D.C. in November 1974, was an orientation session for participants.

No further meetings were planned but at the orientation

session participants expressed a strong desire to meet again soon to share With the approval of the BIM

information and ideas amongst each other.

Project Office, the AAMC arranged two additional conferences.

The first of

these two-day conferences was hosted by the Rochester group in March 1975 and the second was hosted by the HarVard group the following September.

Both of these conferences focused on three malor issues--curriculum content and design, program evaluation, and education costs--and provided forums for sharing skills and ne- ideas.

The conference agend

are

presented as Appendix 2 at the conclusion of this chapter.

As the proje

progressed, it became evident that special assistance 1 3

- 6-

was required on three issues--instructional methods, evaluation and costs. Dr. Arthur S. Elstein, a medical education specialist from Michigan State University, was employed by the AAMC to provide assis ance in instructional methods.

He presented his ideas at the Rochester conference and later

prepared a paper on the subject, which is presented as Resource Paper No,- 7.

With regards to evaluation, a consensus vas reached at the Cambridge conference that there was a need to coordinate efforts in curritulum evaluation and to produce, if possible, a core evaluation design based on shared educational objectives in the HMO setting.

Dr. Edwin Hutchins, consultant

to Penn Urb and a nationally recognized authority in medical education and evaluation, was chosen to head this effort.

A small meeting

f:participanta

0

vas held in November 1975 to consider the Implications of long-.term_evaluation and to identify evaluation methods or materials suitable for sharing.

The result was the development of tentative evaluation instruments presented in Resource Paper_No._9.

To provide assistance in the development of a cost methodology,

the

AAMC employed,in September 1975,Dr. Christine E. Bishop, a health economist from the Boston Universi-y School of Management.

Dr. Bishop attended the

Cambridge conference but there was not enough time,for her to assist the participating institutions who were developing cost data.

Instead,

Dr. Bishop was asked to develop the conceptual framework for measuring the costs of education in the HMO.

The results are presented as Resource Paper

No. 14.

Monitoring was accomplished through periodic progress repo .s and site

14

-7visits.

Each participating institution submitted a work plan and two

progress reports and was site visited once by the AAMC staff and members .

of the project advisory committee.

The project received cons derable publicity at the AAMC Annual Meeting in November 1975 where project participants organized and presented a

ympo-

slum entitled Teaching Primary Care in the_EMO:Designt_ Evaluation and-Costs.

The papers presented at the symposium have been for the Most part

rewritten and are included among the resource papers In this report.

15

REFE_ NCES TO CHAPTER 1

1.

2.

MecLeod, Gordon K., M.D., and Jeffrey A. Prussin, M.A., "The Continuing Education of Health Maintenance Organizations," New England Journal of - Medicine, March 1, 1973. U.S. Department of Health,- Education and Welfare, Public Health Service Health Service Administration, BureaU of Medical Services, Division of' Health Maintenance Organizations,:"Health Maintenance Organization Program Status Report: December 1975," HEW Publication No. (HSA) 76-13022-, 1976.

U.S. Department of Health, Education and Welfare, Health Services Administration, Bureau of Medical Services, Division of Health Meintenance Organizations, "Preliminary Summary of Unsuccessful BMO Feasibility Grants," Address by George Strumpf prepared for presentation to the Group Health Institute, Denver, Colorado, June 13, 1976. 4.

U.S. Department of Health, Education and Welfare, Health Resources Administration, Bureau of Health Resourtes Developmenti ,%ontract for the Planning, Development and. Demonstration of Educational Programs for' Medical Students and/or Interns and Residents in Prototype Health Maintenance Organizations," Contract No.'N01-MB-44009, May 1974.

16

Appendix 1 ASSOCIATION OF AMERICAN MEDICAL COLLEGES

June 24, 1974

MEMORANDUM #74-18

TO:

Council of Deans Council of Teaching Hospitals

FROM:

John A. D. Cooper, M,D., President

SUBJECT: Contract for the Development of Curriculum for Physician Training in HMOs.

The Association of American Medical Colleges has been awarded a contract by the Special Program Staff of the Bureau of Health Resources Development, Health Resources Administration, DHEW to.support the development of curriculum for physician training in academic medical center related HMOs. This 21-month project is complementary to a previous AAMC project for the development of prototype HMOs which will terminate on June 30, 1974. These -endeavors reflect the. Association's ongoing effort to promote medical school and teaching hospital involvement in improving the ambulatory-health care system of the nation. Whereas the prototype HMO project focused on the unique Aspects of planning and developing an academic medical center related HMO, this BHRD contract will allow the- AAMC to stimulate the planning and development.ef If HMOs are to 'expand curriculum for training-physicians in the HMO setting and become a: viable alternative system of health Care, appropriately trained Without the necessary personnel, even existing manpower must be.available. HMOs.may be unable to expand their enrollment to meet demand. Within the framework of this project, the Association will work closely with si,x ,(0'selected institutions by providing technical assistance, centralized coordination and limited support funds to develop educational-. .programs (with major emphasis on.primary, continuing, comprehensive care) which would train physlcians to function effectively in HMOs. 'The prindipal Objective of the BHRD contract is to assist in developing curriculum for medical students or house staff that are based upon and oriented' towards medical.practice As stated in the BHRIJ contract, the primary requirement requirements of HMOs. for_participating institutions should be the development of A plan including a Curriculum for the establishment of an education-training program for medical students or interns and residentt which utilizes as a primary learning tool an HMO which the university health science center sponsors or with which it has formal affiliation. This effort will hopefully establish a mutually beneficial relationship betwrA the HMO and the medical school/teaching hospital fer VUrposes of clinical educdtion es well is patient care. If you would like to have your institution.considered for par icipation in this project, please submit a proposal of no more than twenty pages which should include but not be limited to:

17

Appendix 1

continued)

a.

Definition ot primary care.

b.

Description of institutional activities in primary care education.

c.

Educational objectives of the proposed curriculum, taking into consideration the desired end results in terms. of -students' skills, attitudes and knowledge. Basic elements of such a curriculum should include: patients, students, faculty and setting.

d.

Description of the_process for developing an appropriate curriculum for traiiiing medical students or house staff in an HMO setting.,

e.

Realistic plans for implementing the curriCulum.

f.

A plan to develop criteria for selection Of Medital students .and house staff who elect to train in the HMO setting. Evidence of a relationship between your.institution and an operational or nearly operational HMO (including a 'description' of the HMO). In case of affiliation with anHMO, please include a letter of support from the Executive Director and. the Medical Director of the HMO.

h.

Institutional resources and capabilities available for developing such acurriculum. A budget,

The AAMC has established a project advisory committee that will select the six participating institutions. It is anticipated that participating institutions would receive up to $40,000 to develop its proposed curriculum during the period January 1 through December 31, 1975. The BHRD stipulates that institutions must meet the following basic requirements in order to be eligible for consideration. 1.

Each participating institution shall include a universi y sponsored or affiliated HMO.

2.

Preference in consideration will be given to programs whose HMO service component is operational or nearly operational.

3.

The curriculum to be developed must be directed primarily at medical students or house staff. Proposals should include the development of a process for relating medical student and house staff HMO education and training experiences to career selection.

Appendix 1

continued)

Following the selection of the six participating institutions, negotiations will be undertaken on the amount and type of support that can be provided, under the contract. If your insti u ion wishes to participate in this project, you should send your proposal to: James I. Hudson, M.D. Director, Department of Health ServicesAssociation of American Medical Colleges One Dupont Circle, N.W., Suite 200 Washington, D.C. 20036 Neither the AAMC nor the 8HRD is under any obligation to award a contract on . the basis-of any proposal submission or otherwise pay t.he costs incidental to the preparation 'of proposals.

As a condition of participation, institutions may not include more than 8% of total direct costs as "overhead" or indirect costs in their budgets.We arp also asking that you identify, by name, in your proposal the following individuals who will be relating to your HMO educational development program (if selected for. participation 1.

Project Director

2.

Fiscal officer for the project Institutional contracting officer

Proposals should be postmarked by Friday,August 21, 1974. f you have any questions, please do not hesitate to call Dr. Hudson (202/466-5131) or Ms. Lily O. Engstrom (202/466-5118).

Appendix 2

THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES

-togethet wk the UNIVERSITY OF ROCHESTER

dnd the Medieat Gtoup o

th e

GENESEE VALLEY GROUP HEALTH ASSOCIATION

Ptesent a ConeMnce 6on Pap&n.t6 £i the P/to jecI to

DEVELOP CURRICULUM FOR PHYSICIAN TRAININGIN HMOS

Rocheter, New Yerk

Thutsday and Paday, Mvtck 13 and 14, 1975

AGENDA

Appendix 2 (con

Thuuday, Match 1 3, The Anda4on Room, Medic Univeuity MedicaZ Centet, UniveAs

nued)

EduCation Suitding o6 Rocheztet Dr. Hudso

10:00 AM

WELCOMING REMARKS

Dean Orbison;

10:10 AM

OVERVIEW

Mr. Infeld

10:20 AM

PRESENTATION OF PROJECT WORK PLANS Limited to 15 minute.4 pet pte4entation...A que4tion and answelt petiod witt 6ottow each,pte4entation

Project Directors

12:30 PM

Luncheon. Seued in ptivate /wom one gight above Andet4on Room Reactor Panel

EDUCATIONAL METHODS AND'EVALUATION IN THE HMO Paneti4t4: Vt. Atthut Eatein, Modetatm

1:30 PM

Vt. Paut aove4 MIL. John Simon

IMPACT OF PROPOSED MANPOWER LEGISLATION ON HMO TEACHING PROGRAMS Question and An4wet Petiod

3:00 PM

Mr. Bowsher

Coffee Break

4:00 PM

Dr. Boufford

4:15 PM

A MODEL FOR PRIMARY CARE RESIDENCY TRAINING Quation and Answet Felciaa

5:15 PM

Dining Dom, CocktailS at the Chancetea The Happy Hour. Univet4.ity Facutty Ctub, Dougas Buitding, lUve,k Campus

6:30

-

8:00 PM

Dinner (4ame ptace a4 above)

FAiday, MaAch 14, The Gene4ee Vattey Gtoup Heath A44ociation (GVGHA), JaSeph C. Witson Heath Centet, EOVCaAtet.StIceet, Rochestet, New Volda GVGHA'S TEACHING PROGRAMS FOR HOUSE STAFF AND NURSE CLINICIANS: OVERVIEW AND ANALYSIS Quebtion and An4wet Petiod

Dr..Gardner.

10:15 AM

COST FINDING METHODS HMO TEACHING PROGRAMS: Question and An4wet Petiod

Dr. Gilson; Dr. Lawrence

11:30 AM

NEXT CONFERENCE

Participants

9:00 AM

.

Conttact 6und4 au avaitabte to hoid one additiona meeting. Shoued anothet meeting be hetd? when, and 6ot what putpo4e4?

12:00 Noon 12:30 PM

Guided Tour of the Wilson Center

ADJOURNMENT

21

Whete,

Appendix 2

con inued)

SECOND CONFERENCE

,Project to Develop Curriculum for Physician Training in HMOs Harvard Faculty Club Building Ha-vard -University Campus, 20 QuincY Street Cambridge, Massachusetts September 29-30, 1975

Monday, September 29 8:30 A.M.

J. Hudson, M. Infeld

Introductions Workshop I.

CURRICULUM CONTENT AND DESIGN S. Bosch J. Simon, H. Gardner

Moderator: Facilitators:

Siesta

Noon

2:30 -

5:30 P

Workshop II.

COST METHODOLOGIES

Undergraduate Level: Graduate Level:

G. Patason R. Lawrence, R. Watkins

Tuesday, September 30 8:30 A.M.

Workshop ill. APPROACHES TO CURRICULUM EVALUATION Facilitators:

11:30 A.M.

FINAL REPORT

1:00 P.M.

Adjournment

-

P. GroVer, M. RaVitch

Objectives, Con ent

Format

M. Infe_d

Chapter 2

GEORGETOWN UNIVERSITY and

GEORGETOWN UNIVERSITY COMMUNITY HEALTH PLAN (GUCHP)

The Georgetwn group's major achievements were:

(1) the development

of a unique curriculum planning process; (2) the preparation of an HMO manual; (3) designing and implementing-a preceptor training program; and (4) preparing a manual for the preceptor training program.

Items 2 and 4

are presented under separate covers as Resource Pa-ers 2 and 7.

The study

was conducted by the medical school's Department of Community Medicine International Health with dle collaboration of the GUCHP medical staff and three sophomore medical students.

BACKGROUND

Georgetown University's medical school is part of a larger Health Sciences Center which includes a teaching hospital, a dental school, and aschool of nursing.

In 1971 the medical school implemented a major curricu-

lum revision and thereafter rapidly increased the size of the entering class to its current level of 205 students.

The resulting stress placed

upon teaching resources, particularly in ambulatory care, motivated the medical school to establish a health maintenance organization, the Georgetown University Community Health Plan (GUCHP).

initiated by the Department of CD (DCMIH)

In fact,tGUCHP, which was

unity Medicine and International Health

was authorized by the medical school with the understanding that

the HMO would provide a resource f or primary, care education and research.

3

-8-

GUCHP is a pre-paid group practice type HMO which opened for services in November 1972.

Although it is legally an independent corporate entity,

most of the makhers of the board of directors are appointed by the University President, and the Chancellor of the Medical Center serves as Chairman of the Board, while the Dean serves as Vice-Chairman.

OUCH? presently serves

over 20,000 "pre-paid" enrollees and an additional 6,000 "fee-for-

service" patients in three primary care facilities in thaWashington me politan area.

o-

One center is located in Reston, Virginia, and serves a

predominantly white upper middle class population; the second center, located in Edgewood Terrace Housing Complex in Northeast Washington, serves a predominantly black, low and moderate income population; and the third

center in Kensington, Maryland, serves a relatively-stablesUburhan_middle class community in the greater Washington area.

Each center utilizes a

local community hospital for general inpatient care and Georgetown University Hospital for tertiary care.

GUCHP -as heavily involved in, education even prior to the initiation of this project.

Educational experiences at GUCHP included a 6-month field

training for two physician assistant students from Northeastern University (both were later hired by GUCHP); a physician assistant training program for pre-medical and first year medical students; a six-week elective clerkship in primary

-e; and rotation of senior psychiatric residents under the

supervision of the faculty of the Department of Psychiatry.

However, these

educational experiences were offered unrelated to each other, without an overal: curriculum plan or mechanisms for evaluation.

Hence, Georgetown's initial

objective was not so much the construction of_a curriculum, but rather the development of a rational curriculum planninA process, as it indicated in its final report to the AAMC: "If you_think you're He didn't know where he didn't know where he didn't know where

confused, consider poor Columbus. When he got there, he was going! he was. And when he got back,. he'd been." Anonymous

In many ways, the task of curriculum building for physician.training in health maintenance organizations is similar to the experience of: Columbus. There are'groups of doubters, there is a dearth offunds, and the waters are uncharted. A major outcome of our project has As a result, when we get been a mapping of where we are going. there we will know where we are and with the use of evaluation, know where we have been. In essence, the major accomplishment of our project has been to establish a curriculum planning process, rather than a finalized, polished, discrete set of courses.

THE CURRICULUM PLANNING PROCESS The curriculum planning process developed by the Georgetown group based on an analysis of the skills, knowledge and attitudes required by competent practitioners in the HMO setting.

Since a comprehensive, func-

tional analysis of physician performance in HMOs was beyond the scope of this project, an abbreviated approach, represented in the schematic diagram below, was developed.

The ultimAte result of this approach is a list,

or "mastery description," of professional responsibilities which the competent practitioner has "mastered," or should have mastered.

These are

then converted to educational objectives which the student must master or gain competence in. schematic diagram.

The process involves the five steps'defined in the A description of their implementation at George own is'

presented below.

25

SCHEMATIC REPRESENTATION OF DYNAMIC CU

ING PROCESS

MASTERY DESCRIPTION

-STAFF TRAINING -STUDENT HMO CURRICULUM

DOUBLE ARROWS:

-RELEVANT COMPONENTS OF G.U. cuRRIamuu -RELEVANT COMPONENTS OF OTHER SCHOOLS' CURRICULA

indicates a one-to-one relationship

MASTERY DESCRIPTION:

a list of professional tasks or responsibilities that a competent primary care practitioner must master

STAFF TRAINING:

the identification of such tasks or responsib lities currently missing from our HMO primary care practitioners and training of staff in these areas

HMO CURRICULUM:

the educational objectives and instructional activi ies derived from the mastery description as modified by

O.U. CURRICULUM:

what is relevant and already learned somewhere else in the Georgetown currieulum complemented with

OTHER CURRICULA:

successful and relevant educational opportunities implemented by other schools

Source=

a.

The Georgetown Unive-- ity final report

December 1975.

Mastery Description - The object is to obtain a list of professional

tasks or responsibilities unique to primary care practice in the HMO involving in the process all parties concerned: cians and nurse

nursing students

by

the practitioners (physi-

the recipients (patients), and the students

medical and

of primary care.

Three medical and three nursing students were hired for the summer to

*

conduct interviews with GUCHP physicians, nurses

and patients.

A team

of one medical and one nprsing student was assigned to each of,the three _:GUCHP centers,

stpdents_prepared

After_an_intensive,literatpre_search

an initial list of physician and nurse professional competencies and then interviewed physicians, nurses and patients, using the questionnaires

presented at the conclusion of this chapter as Appendicesand 4

Initial

analysis of the data indicated a need not only for a student guide and a

preceptor training programbut also for teaching experiences in telephone

medicine; developing a good'"chairside manner; and a primary,eare.team clerkship.

Further work on the mastery list has been temporarily dis-

continued, but the study staff hopes to resume their efforts as the value of such a process gains added support within the medical school.

b.

Staff Training - The physician interviews helped in identifying a

need,for'a training program to develop the teaching skills of the,ainical staff.

Since the development of such a program was not within the scope of

the original study design, Georgetown University requested and obtained AAMC and DREW approval to extend the project for six --onthr7

o June 1976.

On the basis of the a- u ptions,presented below, Georgetown University impleMented a six-hour Preceptor Preparation Course for L2 GUCRF staff physicians.

The materials prepared for the course have, been organized as a ,1

manual entitled A Role_Guide and Resource Book for Clinica

Preceptors, and

is presented as Resource paper T under separate cover.

The nursing component was funded by another agency and concerned multidisciplinary training of medical and nursing students inprimary dare teams..

ASSUMPTIONS OF PRECEPTOR PREPARATION PROGRAM HMO physicians are usually recruited and hired for their clinical competencies, not their teaching abilities. Teaching skills are not necessarily innate, but rather can be learned.

HMO physicians who act as instructors must be otiented t_ the overall goals and approach of the educational program. Approaches for student learning in the HMO (based on the requirement of provider productivity and consumer voice in management) will require methods of instruction unfamiliar to the traditionally trained physician. There are a variety of teaching roles and responsibilities HMO preceptors can and must fulfill if a well-planned curriculum is be successfully implemented. Source:

c.

Georgetown University final report, December 1975.

Curriculum Development - The first step in curriculum development was

the offering of an experimental course entitled A Practical IntroductioHMOs.

Designed for testing teaching materials, instructional methods and

preceptor-student interrelationships, the course involved didactic sessions, guest speakers, field vIsits to local HMOs, and research projects under the supervision of GUCHP staff.

A major result of the course was the develop-

ment of A Medical Student's Guide to Health Maintenance Or anizations sented under separate cover as Resource Raper'2.

pre-

The 50-page guide,

designed by medical students for medical students, describes the nature of ilMOs and presents the

a

r'issues affecting HMOs today.

Of particular

value are the self-assessment and group discussion questions included in each chapter.

The guide is already being used by several institutions

including-a medical society group.

Relevant Components of Medical School Curriculum - The four-year G.U. med _cal curriculum was examined for primary care-ambulatory care experiences -presantly offered so as-to avoId duplicat,"_

_

Relevant Curricula from Other Medical Schools - This involved a review of published literature from other schools and continual communication with the other institutions participating in this project.

29

Appendix 3 STAFF INTERVIEW FORM

Center

Education.and Ex.erience Background 1.

What field was your treining in? Residency'Fieldl (R.N.):

B.S.N.

Diploma

A.D. M.S.

Nurse Practitioner Fie d Yes

No

Are you Board certified? Yes

No

Are you Board eligible.

Are you certified as a nurse practitioner?

R.N.: 2.

No

Yes

What kind of patient care practice have you been in since the end of your formal training? Military

Group

Solo

Hospital

HMO

Clincial or Neighborhood Health Center

For how long? Type of patients:

Adult

Adolescent

Family

Other

Geria'-ic

Child

Relationship with_OUCHP 3.

How long have you worked for GUCHP?

4.

What made you decide to come to work _or GUCHP?

S.

How do you define primary care?

6.

(a)

What do you find satisfying in working in primary care?

(b)

What do you find unsatisfying in working in primary care?

7

Could you compare working in this HMO setting with your previous health care settings in relation to: a) (b)

how is primary care different?

how is the HMO setting different?

Appendix 3 (continued)

Do you see a difference in the health care needs of clients in the HMO setting from those in your previous experience? Do you feel that enrollees abuse the health care services because of the prepaid nature of the practice? 9.

What kinds of things do you do in the health center?

10.

Are there any tasks you would like to be freed from doing in orde- to use your training more fully?

11.

Do you have professional skills you feel you should be using that you aren't employing?

12.

Do you use POMRs?

Yes

No

If you're using some variation could you explain it and why you prefer it?

Were you instructed ln the use and preparation of GUCHP medical records?Yes

No

Where:

When:

by Whom: 13.

Do you feel you have enough time to spend wlth each client? Yes

No

How would you spend the extra time if it were available? 14.

Is there anything else that would facilitate your provision of services to your clients?

15.

How do you think patients feel about the care they get here?

16.

Who is responsible for educating individual patients in coping with their health problems? Why?

17.

How do you handle follow-up?

18.

What preventive care do you provide?

19.

Do you think the quality of care is affected if a client sees If so, how? No Yes different team members each time?

20.

What kinds of things have you encountered in primary care practiCe that your education didn't prepare you for? Patient management skills: eg. Telephoning: Counseling: Physical Assessment: Supervisory skills: Relating to other professionals: Interviewing ambulatory patients: -Teaching 'students:

Appendix 3 (continued)

Role Perception 21.

How do you view your own role in this setting?

22.

What do you see as the nurse practitioner's/doctor's role on your team?

23. Wat do you feel are the most important factors which influence your role relationship with the physician/nurse? 24.

How are the roles different from your previous experiences and relationships? .

25.

Do you see an overlap between the nurse practitioner and M.D. If yes, where do you see'this? No responsibilities? Yes

What is your opinion of it? 26.

Do you have any supervisory responsibilities? What are they?

27.

To whom are you responsible?

28.

Who is responsible for managing the center on a day-to day basis?

29.

Who decides which patients are seen by you?

30.

Who determines the lengths of appts. and how many patients will be Seen each day?

31.

How are you affected by these decisions?

32.

Do you have any professional relationships with the other GUCHP centers? No Yes If so, what? If no, is there a need for this?

Yes

,

Why?

How do you, as a provider, perceive your relationship --ith the McArthur office?

Appendix 4

PATIENT INTERVIEW FORM Center

Interviewer

Sex

Patient

Day

Parent Of Child

Adult

Time

Adolescent PRE-VISIT INTERVIEW Introduction

Explanation

Yes

1.

Is this your first visit to the Health Center?

2.

How long have you been coming to the Health Center?

3.

How many times have you visited before?

4.

If you feel comfortable in answering, what brought you to the Health Center today?

6.

Is this the person you've seen on your past visits?

Who do you-regularly see?

No

Yes

Do you know who you're scheduled to see today?

Other

Nurse

Doctor

No

Yes

No

Yes

7.

Do you like beinvable to see the same person?

8.

What do you want to happen during your visit today.

9.

Do you have any questions on your mind you want to ask the doctor or Yes No nurse today?

POST-VISIT INTERVIEW 1.

Was your visit with the doctor

or nurse

2. Was this the same person you've seen before? 3.

No

Yes

What things were satisfying about your- visit with the doctor/nurse?

What things were not satisfying about your visit with the doctor/nurse? happen?

Generally when you come does 5.

Can you think of anything else the doctor/nurse could have done to improve your visit?

6.

Do you feel you had enough time with the doctor/nurse today?

7.

Did you get allyour questions-answered? Didyou..ask all your luestions? Yes'

Yes No

No

Chapter 3

UNIVERSITY OF ROCHESTER SCHOOL OF MEDICINE AND DENTISTRY and

THE

ENESEE VALLEY GROUP HEALTH ASSOCIATION (GVGIIA)

Although the University of Rochester group dealt with each of the three major components of the project (curriculum content, evaluation and costs), it devoted most of its energies to evaluation.

Two papers

one of

which has been published in the Journal of Medical Education, were prepared on the subject.

The group designed, implemented and evaluated an HMO-based

curricultp for first-year medical students.

It is presently in the process

of conducting similar efforts for a course for fourth-year students.

The

project was conducted jointly by the medical school and HMO under the direction of the Associate Dean for Medical Education.

BACKGROUND In recent years the University of Roches er medical school has pladed increasing emphasis on primary care in its curriculum.

An ambulatory care

expe ience, either at the University's Strong Memorial Hospital or in other extreme -1. ambulatory care settings, is now required of all fourth-year students.

The Division of Family Medicine now offers three electives for

pre-clinical students. and the Department of Preventive Medicine and Community Health offers a wide-ranging first-year elective entitled Introduction to Preventive Medicine and Community_ Medicine, in which students are placed in community health facilities.

One of these facilities is the JoSeph E.

Wilson Center of The Genesee Valley Group Health Association _(GVPHA).

GVGIIA was one of the first successful HMOs sponsored by Blue Cross.

Located in an att active 52,000-square-foot facility, it opened for services in August 1973 and rapidly increased its enrollment to its present 20,300 members.

An_additional_2,000 persons are served on a fee-for-service basis. _

GITCHA has no formal ties with the medical school nor was the latter involved in

s development.

The two institutions have cooperated in the educational

arena, however, eVen prior to the initiation of this project.

Within the'

first year of its existence the HMO was host to medical and nursing students participating in a medical school sponso ed elective, and several fourthyear medical students took an ambulatory care elective there.

The two instituti ns workvell together. the medical director and staff physicians, was

The HMO team, consiating of responsible for curriculum

content and design while the medical school was primarily concerned with the evaluation component.

THE CURRICULUM The AAMC proJect provided the two institutions an opportunity to develdp a rational approach for introducing education to the HMO and evaluating the results.

An ideal course for this purpose was the preventive medicine

course mentioned above for it 'enabled the evaluator not only to evaluate

the student before and after the course, but to compare him with students assigned to other institutions.

The stated goals of the introductory course in preventive and community medicine were that students learn about the role and responsibilities of primary care physicians in prevention; the relationshiP betWeen availabili y, accessibility, cost, and quality of care; the incidence, magnitude and

severity of a health problem; and the:psychological,political, economic

_

and social relationship to illness and the delivery of health services.

Each student was assigned to a health or social service i-stitution for one-half day per week for fourteen weeks.

Participating institutions an

included institutions such as the Association for Retarded Children inter-city neighborhood health center, Planned Parenthood, a venereal disease clinic, a family court, and GVGHA.

Students met for a series of

seven lecture-se inars and combined exercises called "recall" sessions.

A total of twelve students chose to be placed at GVGRA in the spring semester of 1975. It was for these students that a curriculum was constructed, field tested and evaluated.

Aside from the overall course

objectives, the study group defined additional objectives for the students assigned to GVGHA. They included learning HMO concepts and changing attitudes concerning primary care and HMO practice.

A detailed list of the

cognitive and affective objectives as well as other components of the curriculum are presented in Resource Paper 3.

The students met at the Wilson Center one-half day per week for The first 45

fourteen weeks, with each session divided into three parts.

minutes were devoted to one- o-one interviews between the student and a department head.

By the end of the semester, each student had personally

interviewed the chiefs of the departments of medicine, pediatrics, ob/gyn, eye services, urgent visit clinic/surgery, X-ray, labo story, business

office, pharmacy, and medical record /co unications center.

The students then convened for a one-hour seminar to discuss an HMOrelated issue or the case history of a student's patient.

36

Most of the

seminars were led by the medical director, although occasionally a guest lecturer was invited.

The third part of the session consisted of an

observation period with a physician preceptor.

Three students were assigned

to a patient, whom they visited with the preceptor at least once during the course and were responsible for presenting his/her case history.

Detailed descriptions of the case histories as well as the seminars

are also presented in Resource Paper _3.

EVALUATION

The evaluation design was developed with three major goals in

nd:

(1) to identify changes i- knowledge and attitude; (2) to-analyze correlations between demographic/personal characteristics and outcome measures so as to identify possible predictors of cognitive and affective achievements; and (3) to compare the results with control groups.

For comparison purposes, three groups of students, all of whom participated in the community medicine course, were selected.

Group I

consisted of the twelve students based at GVGDA; Group 2, called related, consisted of ten students,assigned to other primary care organizations; and Group 3, called non7related, was made up of students assigned to com-

munity agencies not involvedd- primary care.

Knowledge and -_titudes were tested with two pre-post tests, presented as Farts A and B of Resource_Paper 12, and through semi-structured interviews with an evaluator.

The personal characteristics assessed for

correlation included sex, hometown size, physician parentage, undergraduate major, Medical College Admission Test (MCAT) score and the Edwards Personal

Preference Schedule which measures fifteen normal personality characteristics.

At the completion of the course, all 33 students completed an

activity summary and a course evaluation form, also presented in Resou ie Paper 12.

To complement and validate the sources of evaluative information,

the evaluator attended all seminars, conducted interViews, and observed student/patient interactions.

A detailed description of the evaluation

methodology is presented in Resource Papers 10 and 11,-entitled An_HMO Rased Prim-r

are Curriculum for First .7ear_Medical Stude-

Desi n

Evaluation and Discussion, and.Issues_and_Methods In Curriculum.Evaluatio respectively.

The latter was published in the December 1975 issue of the

Journal of Medical Education, and the former was recently submitted for publication in the same journal.

Using a variety of sophistica_ed statistical techniques, the evaluator found that therewere few significant differences between pre and post test scores within a group or among the three groups.

As anticipated, the GlIGHA

based students made considerable progress in their knowledge of and attitude towards HMOs; but the experience did not produce any great shift in individual career plans.

The career choIce results showed an overall general trend

among all groups towards various f;rms of primary care. student activity forms

An analysis of the

ndica 7_d that the WiGHA group had more patient and

provider contact than the control groups.

COSTS

A consultant to GVGHA conducted a cost analysis and determined that the course costs GlIGHA a total of $1,880 per semester.

or opproximately $157 per student

The costs inci-Je the extra stai''

time needed for s udent

teaching, but excludes overhead and space cos s.

Space costs were not

included because the conference room used for the seminars is not presently used to capacity.

To determine the extra stff time needed for teaching, sampie studies were conducted in the Pediatrics Department and the Urgent Visit.Clinic. Preliminary data indicated that students caused little disruption in patient care.

For example, in the Urgent Visit Clinic it took 140 minutes

to see 9 patients without students present and 144 minutes with students present; in the Pediatrics Department it took 43 minutes to see 5 patients without students and 51 minutes to see a comparable set of patients with students present.

3.Z Chapter 4

UNIVERSITY OF PENNSYLVANIA and

HEALTH MAINTENANCE ORGANIZATION

PENN URE)

The major accomplishments of the UnIversity of Pennsylvania group, described in the enclosed resource papers, include the development of a unique iterative curriculum planning process involving educators, clini-'

clans, and other professionals; the preparation of curriulum modules; the design of an evaluation methodology and related instruments; and fieltesting of the curriculum and evaluation instruments.

The cur iculum

development process developed by:tbe group is described in Resource

,

Paper 1, entitled Designing a Curriculum in a_Clinical Setting:_An Iterative_Process; the curriculum itself is presented as Resource 17.22kF 4,

and the evaluation methodology together with evaluation instruments are presented as Resource Paper 9.

Since these papers aptly present the

group's achievements, this chapter is brief.

Penn Uri) is a multi-disciplinary primary care center sponsored and

supported by the University of Pennsylvania, although it is legally a separate entity.

It opened for services in 1974 in a small (5,500 square

feet ) renovated facility and presently provides 18,000 patient visits per

year on a prepaid capitation and fee-for-service basis.

The project was managed by Penn Urb under the direction of its medical director and with the active participation of the entire professional staff. Day-to-day pr- ect activities were coordinated by a medical educator.

40

Both the curriculum development process employed by the U.P. group and the curriculum they designed were Unique in several respects.

The develop-

ment process involved educators and clinicians and the entire professional staff of Penn Urb.

From the beginning the curriculum was,designed in

modular form so that any module could be added to existing courses or, that Matter, removed frot the curriculum if taught elsewhere.

The modules cover virtually all concepts that one can learn in an

_

They include; -

primary and comprehensive care

-

the health care team

- 'consumer participation quality of care

economics of HMOs change and innovation A task force consisting of at least one educator and one provider was established for each issue with responsibility for defining behavioral objectives, recommending methods of instruction, developing a bibliography and identifying prerequisites.

The curriculum development process is

described in detail in Resourceyaper_i, and the curriculum itself is presented in Resource Psper 4.

The curriculum was offered as a field test in an inter-session course entitled Introduction to Comprehensive Health Care Systems.

The course is

an intensive one-week, 35 contact-hour experience offered to medical, nursing, allied health professions, health_care administration, and social work students twice a year during inter-sessions.

41

Sections of the currIculum

were also field-tested with one medical student who clerked at Penn Urb one session per day for four weeks.

To assess the effectiveness of the curriculn_ instruments were designed and field tested in the inte -ses __n- course... indicated in Resource Paper No. 9, Rejort of Effor ts to Deve o

Standard-

ized Test of Knowledge and Attitudes Relevant to :he HMO Setting, the evaluation methodology and related tools were designed for applicability in other HMO settings.

Although this effort was organized by the Penn alp staff,: t

other institutions participating in the project also contributed to its development

Chapter

THE UNIVERSITY OF and

GROUP HEALTH COOPERATIVE OF

SOUP

A unique feature of Group Health has beenjts involve_ education almost since its inception 30 years ago. dical students and residents had

Training Oograms for

been operating at Gioup Health several

years prior to the initiation of this project .

tasks was to review and assess these programs, attempt to determine their costs

The major accomplishment of this project

included a surimy of existing medical student courses; the development of a curriculnm for a third-year 'clerkship; the preparation of an integrated set of evaluation instruments

d the ini iation of a cost study.

BAGKGROUND

In the past ten years the University of Washington has been increasingly focusing its attention on the proble

of mildistribution,pf:- dical-resources

and the training of primary care physicians.

A major curriculum revision took

place in 1968 and the Department of Family:Medicine w

established in 1971.

More recently the University became a regional center in medical education by establishing the WAN progra: -- academic sites in the states of Washington., Alaska, Montana, and Idaho, devoted to primary care service and training.

The outcome of these efforts has been that more than half

the

graduating Medical students are-entering primary care training,programs the entering class has been: increased,from 85

'an&

-o 175 students.

tife medical school has found itself in,need _f additional clinical training 'sites in primary care,

Group Health Cooperative of Puget Sound, with

strong orientation towards primary care, represents-

ortant clinical:,

teaching resource.

Group Health is a nonprofit,

_nsumer-owned cooperative established

in 1947 and presently serving approximately 200 000 members.

It owns

operates nine outpatient facilities and a 300-bed general hospital with:a staff of 2,700, including 200 physicians.

Group Health has been involved in student edUcation almos- sinde its inception.

Over the years, educational programs have expanded to such a

degree that one of:the first activities of this project was to identifY the extent and scope -f education at Group Health.

Medical Students have

been training at Group Health forovpr 12 years, although the bulk of cou for medical students Were n-t initiated until 3 years ago

The fIrst family

practice residency training program was initiated in 1973 with the siing of a Memorandum of Understanding between the University's Department of Family Medicine and Group Health.

The Memorandum,,presented as Appendix 5

at the end of this chapter, provides for the exchange of family practice re idents for training at each other's institution ana for medical student teaching at Group Health.

4,1

sea .

The AAMC-sponsored project was welcomed by the University and Group Health as an opportunity to examine the HMO's role in the education of Medical students and to develop, if possible, an integrated, cost-effective curriculum.

Specifically, he major objectives of the study

were.:

To conduct a survey and evaluate existing medical :student

courses at Group Health;

If necessary, to develop a comprehensive cu riculum that could be applicable to other HMO settings;

To develop appropriate evaluation instruments for assessing the curriculum's effectiveness; iand

To examine the costs of medical student teaching at Group ,

Health so that future pregress could be designed in

cost-

effective manner.

The study was conducted jointly by both institutions, with the medical school's Assistant Dean for Curriculum ind Group Health's:Director of Medical Education serving as project co-directors.

A major role was assigned

to educators from the Dean's Office of Research in Medical Edupa ion, who provided consultation in research design, curriculum development and evaluation and teaching methodology.

Two physicians, one from each institution, collab-

orated in the cost study.

SURVEY AND EVALUATION OF EXISTING COURSES

The survey of existing courses at Group Health revealed that over

570 students, including students in nursing, public health, medcal technology

pharmacy-and medical students from 11 institutions were training at Group Health facilities.

Of these, 180 wete medical Students enrolled in seven

different courses, as shown in the table on the fellowing page.

The first:.

four of these courses were selected fOr careful study and.eValuation

Since there was insufficient time to evaluate all seven course7, onlythose with the major impact in terms of time commitment, numbers of students, or those offering a unique _1(perience to medical students were chosen for investigation.

Prior to the initiation of this study, the University already had a, well established evaluation system for many cour es in the medical school d at Group Health.

Such an evaluation system typically included three I--

components: (1)

Evaluation of the course - by students, faculty and,a course committee. .

Evaluation of faculty - by students, course commit ee and faculty self-ratings.

(3)

Evaluation of student performance - by the preceptors, patients and student self-ratings.

As part of this study, the evaluation systems of the four courses were also investigated to assess their effectiveness and identify possible problems or flaws.

The reassessment indicated that the courses provided students wjth a useful primary care experience and that students and faculty alike were pleased with the experience.

It should be pointed out that the courses

46

UNIVERSITY OF WASHINGTON

MEDICAL STUDENT TEACHING ATGROUP HEALTH

Total

Length of

Med

student

year

401

Department

1

Outpt - FP

2

Outpt - FP

Radiology

3

420*

GHC

Association (years)

students at::

Time involved for

students in

Group Health.

each student

past year

x # of student

12

66

Number of students

# daYs/yr

number of

per session

0-6/quarter

1/2:.day/wk/qua ter

1

3-4/year

1/2 day/wk/e qtrs.

4

0-4/mon h

1 day every 2 wks

60

421

422 16

2

124

372

for 4-6 weeks Hospital'

2

124/quarter

2-3 1/2 days/quarter for 3 quarters.

5

3-4

Ob-Gyn

1

18

4 weeks - 8 sessions/

3/4 weeks

quarter Peds

12

0-2

5 days/wk

1-4

5

HS 531

3

25

1 quarter ies: 1/2 day/wk 5 days/wk - 4 weeks

0-2 years

1 week

variable amount of .time at 'Group Health

,

1

NOTE:

*

1

3,8

student only present for 2 quarters.

2

This is a crude attempt to measure quantitative impac 100 days or 100 students present for ten days 3

*4

*5

See Appendix B - 401 - Introductory 493 denotes 4th year electives in clinical or la 465 denoted basic clerkship ip ob-gyn

Med., etc.

1000 = 10 students present for

were not designed to teach the unique features of HMO practil_ provide a primary care experience.

bu

Since the courses have bee

for s_me time and will be Continued in the future,

they are d

rather

offered

c ibed below

in some detail.

Introduction to Clinical Medicine (Human Biology 41 These thtee sequential courses, each one quarter of .a yea-

n duration

are required of all first yeat students and lare Conducted largely at -Group Health Hospital.

They provide the students wjth their first

exposure ,to patients and are designed to introduce basic,skills interviewing, history taking and physical exatinations..

The cou ses

involve didactic, demonstration and experimental techniques, and a series of patient interviews.

In

uctional strategieEvinclude an ekten ive syliabUs of printed

material coVering all aspects of the medical interview; conventional t

didactic presentations; small group discussions with the preceptors; and an intensive orientation week with lectures

demonstrations, small

group discussions, interviews with paid actors, and audio-video tapes for performance evaluation and lecture demonstrations.

The evaluation system features student-designed and administered questionnaires and extensive student-faculty coordination. the previous:two years

During

evaluatIon focused on the adequacy of the

course objectives, instructors, and learning resources, and selfratings of skill and satisfaction.

49

On the whole, the students we-e

highly satisfied with the courses and felt that they were some of te most valuable components of the first year curriculum.

Faculty

evaluation was also highly favorable and no changes were proposed.

Family.Medicine Freceptorship (Family.Medicine 401). This is a one quarter elective,for first year stUden the student observes a practicing physician one-half day per Week and is introduced to concepts of family practice. 15-25 students elect the course each quarter.

Approximately

During the 1975 winter

quarter, six of 25 preceptors were Group Health physicians and eight students were assigned to Group Health facilities.

'The other precep-

tors were solo practitioners or physicians practic ng in other settings.

The evaluation procedure for this course consiss of a brief, openended questionnaire in which students evaluate their rireceptore, identifypositive and negative features of their,predeptorship,. And.provide sug-.

gestions for improvement.

This provided an opportunity for comparing

the results and performance of students at Group Healthwith,those-in, other settings.

An analysis of the etudent questIonnaIres, however,

indicates that there was little difference in the responses of the two groups.

3.

Family Medicine Continuity C _erkship (F- Ily Medicine 420,421, and 422).

This'new cOUrse, offered for the first time in 1974-75, is designed for - second year students, most of whom take it for three consecutive quarters.

50

Students meet with a practicing physician one-half day per week and are given the opportunity to work up and follow selected patients.

site

experience is supplemented with weekly university-based lectureidiscuss on on various aspects of family.practice.

Of the 24 students taking the:

course last year, four were assigned t- Group Health precepto Course objectives include exposing the student to the concept of continuity of care and simple office procedures.

Preceptors generally

try to guide the student toward clinical practice so that by,theend of the course the student functions in this capacity about 50% of the rime.

A co prehensive evaluation system was developed for this course utilizing input from students, faculty and patients.

The system consists

ix components:

Daily activity logs completed by students; (b)

Site visits by preceptors;

(c)

An open-ended evaluation qUestionnaire completed by

(d)

A student evaluation form completed by the patient;

(e)

A productivity impact questionnaire completed by the preceptor

tudents;

for identifying productivity loss and teaching preparation time; (f)

A student performance form completed by the preceptor in,which the student is rated on dependability, initiative and interest, ability to communicate with patients, relationships with patients and staff, and competence in eliciting and synthesizing jnformation from patients.

51

The resulting evaluation data was analyzed to examine differences between the HMO and other settings.

It was found that the only signi-

ficant difference was in productivity loss.

Group,Realth preceptors

Showed a productivity lOss of 62% or 6.2patients per 3 hodt session, while all preceptors (including Group Health preceptors) averaged a productivity loss 9f 25% or 4 patients per session.

Preparation

time was also greater with Group Health preceptors who repOrted an

average of 50 minutes per week of preparationwhils all preceptors reported an average of 30 minutes.

An analysis of th_ student activ

logs revealed that Group Health studentS'saw fewer-patients, but

-

tended to receive more intensive exposure and were alloWed somewhat greater levels _f responsibility.

4.

Independent

(Public Health and Community Medicine, PH-CM 531).

This is an independent study elective which relies heavily on one to one discussions between student and preceptor.

The student and faculty ad-

visor arrange for special projects at community-health agencies such as Group Health

THE PROPOSED CURRICULUM

The University and Group Health held a series of joint workshops to consider the results of the survey, to discuss the University's training

needs- and to construct a curriculum best suited to the needs of both insti-tutions.

It was decided to develop curri-Llum for an intermediate clinical

clerkship designed.for thi d year studen s who wOuld spend approximately six weeks full time in the HMO.

In addition

it was decided that the major thrus

of the cu riculum would be on the development of-clinical skills and knowledge Which'could be most effectively and efficiently taught in the HMO but-:which are not necessarily unique to it. A complete and detailed'outline of the_ course including goals and objectives, instructional methods methods, are presented as Resource Paper

and evaluation

e this curriculum was designed

primarily for third year clerkships, sections of the curriculum might be _

used in other existing courses.

Group Health is examining the possibility of offering other dlinical courses.

A list of approximately 90 courses presently offered by the

medical school in other clinical settings has been circulated to Group Health' preceptors to identify those courses

which can be effectively:taught at

Group Health.

PROPOSED EVALUATION INSTRUMENTS

In conjunction with the proposed curriculum, a series of evaluation instruments, designed to evaluate the performance of both students and pre7:

ceptors, were developed and-are presented asResource Papor 13

The autho

description of these instru -nts is presented on the following page.

SUMMARY OF COST STUDY The proliferation of educational programs and cours s at Group Health was a primary motivating factor for undertaking the cost study.

In fact,

the Univer ity had originally proposed to do only a cost study, and to do

r

DESCRIPTION OF PROPOSED EVALUATION INSTRUMENTS* Completed

by the Student.

Student Lo9 Recording Form and Com uter Summary Report. Exhibit 1: -5Eaents will be as 1ed to og patient prob ems and procedures encountered in the clerkship experience and to submit the logs on a weekly At the end of the clerkship, the students and.preceptors will schedule. receive computer-generated summaries of the student's individual experience. A summary report analyzing all student-patient encounter experiences will also be produced. These reports are to be used by the various course committees to assist them in their evaluation of both the course and faculty. They are to be used by the faculty for the purpose of selfevaluation and by the student as a record of accomplishments. Student Progress Report. Exhibit 2: Approximately midway through the quarter students will be asked to complete this brief form to help the course committee and preceptors evaluate the course from the students' point of view. Exhibit 3: Student Course Evaluation. This form is to be completed by stu ents at the end of the course to

evaluate the course's stragths and weaknesses. Exhibit 4- Student Assessment of Preceptor and Training Site. eend of the owar y This form wi preceptor and training site. course and is to be used,for evaluating the

asoecompee

esuen

compieted by the Preceptor Preceptor Progress Report. Exhibit 5: This brief report is to be filled ou-t periodically as an informal method for the course committee to keep abreast of the course from the preceptor's point of view. Course Achjevement/Grade Report. Exhibit This will be used by the Preceptors to rate student performance on each It instructional objective and_on selected professiOnal attributes. should serve as the principle medium for documenting student achievement. Completed by the Patient Patient Feedback to Students. This form provides the means,for patients to record their impressions of students and for students to evaluate their lwn strengths and weaknesses. This form should be used sporadically or in lome way mutually determined After a few weeks in the office, students by preceptors_and students in other settings have appreciated the reassurance that has come from patients' positive remarks on these forms. Exhibit_ 7:,

Completed by the Cotrse Committee. Exhibit 8: SIte Visit Re ort involved in a site visit by the course Th s form out nes t e proce ure:. Since time may not permit a office. administrators to a preceptor's uill probably be conducted on a random site visit to each office, they The visits and basis or in response to reported qr .4.1spected problems. and reports thereof, are used to faciiiLAe evaluations of the course the preceptors.

*Sourc

The University

Washington la

Ll' eport.

for medical students only.

However, at the urging of the Project Advisory

Committee, the university agreed to expand the project and also include a cost analYsis of its family practice residency training program.

The stuay

is presented in its entirety as Resource Pa er No, 15.

The study presents cost data for the medical student courses described above and for the family practice program. such as salaries

Costs that are e_ ily measured,

space, equipment, and supplies, and costs and benefits

not so easily measured, such as job satisfaction and impacts'on quality of care and enrollment, are discussed.

Data was collected by a variety of

methods including structured interviews with preceptors, students, administrators and consumers; questionnaires; clinic records; daily activity logs; and a time-motion study.

A summary of the data f_

presented in the table on the following page.

medical students is

Data for the family practice

residency training program is presented in Table V-6 of Resource Paper_No. 15, The annual cost $15 000.

of training one resident was found to be approximately

However, this does not appear to include the value of the resident(s

services performed in the "coverage" setting.

As ale authors themselves

indicate, this study is preliminary in nature and both the conceptual frame-

wo k and data need additionalrefine

t.

7

Cost of Medical Student Teachin

GroullealthCw"atilashintqn 1974-1975Course

Student

Student

Number of

Cost per

Level

Activity

Students in

Student-day

1st year

interviewing patients

icine 401

ist year

observing physician in

0

175 students

8

$4.30

4

79.80

Tota.,Cost OE Cease I he lIMO

]

Course

ogy 413

No. of Student Days* in year

Not available

0

50

$225

59

4,708

40

2,123

' actice

icine 420

2nd year

interviewing;

patient examinations

icine

3rd year

advanced

ed)

patient examinations

Medicine 531

r---arch

students X No. of teaching days

53.20

1

($10.00)

1

net benefit

.

.

57

APPENDIX

5

MEMORANDUM _OF UNDERSTANDING

University of Washington School of Medicine Group Health Cooperative of Puget Sound

Whereas Group Health Cooperative of Puget Sound and the University of Washington School of Medicine share common goals in the education of family physicians_and whereas both have already instituted educational programs for family physicians in training, therefore-agreement has been reached between the two institutions to share effort and resources in approaching these goals. Group .Health Cooperative is a true consumer cooperative providing a full range of medical services to its members. It recognizes benefits to its members from participation by its professional staff in residency training7-and especially in family practice residency training--because its pattern of medical care delivery has depended for many years upon the use of family practice primary care physicians. It provides, therefore, a Successful real-life operating model of the new academic medical discipline of family practice.

It shoulcLbe noted that the following educational efforts already exist at Group Health: 1.

A fully approved family practice residency geared to produce two graduates per year.

2.

Group Health physicians serve on the volunteer clinical faculty of the medical school.

3.

University of Washington medical students on elective family medicine preceptorships are assigned to individual family physicians at Group Health.

4.

?nyiicans from Group Health serve on the Family Physician Pathway Ccl.ittee of the Medical School and serve as curriculum advisors to students.

Also, the Universi y of Washington School of Medicine already has instituted the following efforts: 1.

Topics and concepts of particular relevance to family p actice have been included in the basic medical school curriculum.

2.

A Famiily Physician Pathway has been implemented in the clinical curriculum.

A Department of Family Medicine with full-time faculty and staff was established in 1971. Clerkships in the discipl ne, family medicine, have been developed.

58

Appendix 5 (eent

M of U between UW and GH Page 2

J.

An accredited Family rractice Residency Program based at the University Hospital began July, 1972. A specially designed Family Medical Center has been built at the University Hospital to serve as a clinical model for the above programs.

The University of Washington, through its School of Medicine, now agrees to provide for Group Health Cooperative of Puget Sound the following: 1.

Assistance in obtaining educational opportunities for Group Health family practice residents, particularly in fields not represented at Group Health, such as behavioral and social sciences,certain sub-specialties of medical disciplines, and opportunities for developing exchange arrangements with other family practice residency All programs or teaching units affiliated with the University. formal conferences and lectures developed at the University of Washington for University of Washington family practice residents will be open to Group Health family practice residents.

2.

Payment to Group Health is the amount of $20,000 per year, payable in four equal quarterly installments, for purposes of carrying oUt this mutually beneficial agreement.

4

Group Heal h Cooperative of Puget Sound agrees to provide for the University of Washington School of Medicine the following: 1.

Opportunities for University of Washington'family practice residents to be assigned to Group Health Hospital and Clinics for portions of their training in the unique setting of a prepaid comprehensive group practice.

2.

Making available the facilities and resources of Group Health fOr It is understood development of clerkships in family medicine. that a clerkship of the magnitude of Family Medicine 465-(as now exists in Omak and Grandview, Washington, involving two student positions regularly throughout three of the four quarters_each year) is beyond the terms of this agreement, and the-developMent of such-clerkships at Group Health Cooperative would be contingent upon additional financial support by-the University.

3.

A Group Health physician staff member will be appointed as Director of the Family Practice Residency Program at Group Health and will devote at least half time to this position. This physician will by chosen by Group Health subject to the concurrence of the Chairman of the Department of Family Medicine and in accord with the Faculty Code of the University of Washington. He will be appointed to 43n appropriate faculty title and rank without tenure

59

Appendix 5 (con

nued)

M of U between UW and GH Page 3

He will be a member of the medin the Department of Family Medicine. usual rights, privileges, obligaical staff at Group Health with the He wi_ll be that _status. tions and fringe benefits that accompany Education and Education responsible through the Director of Medical As a member of the facHealth. Committee to the medical staff of Group Medicine of the University, he will_be ulty of the Department of Family deparbuent and serve in his faculty responsible to the chairman of that and in accordance with Univerposition at the pleasure of that chairman in He will be expected to participate sity rules and regulations. teaching and administrative functions of the department consistent with the departmental objectives 63r family practice education. 4.

Agreement that rules and regulations of the University will apply to agreedthe faculty member based at Group Health except where a mutually upon exception is made, and that these will likewise apply_to Group Health residents when they are at the University. Similarly, residents from the University will abide by Group Health rules and regulations Each principal will, howwhen they are participating at Group Health. ever, continue its full support of its own residents, including_ fringe benefits and malpractice coverage, without interruption while their resinstituidents are serving in a mutually approved activity at the .other tion.

residents_f0 University faculty will be expected to provide equivalent training to University re, Group Health will do likewise for Group Health, and faculty-staff at idents at Group Health, as each provides for its own. Each will endeavor to make can-offe.r available to the other's residents the unique training opportunities each Respective faculty shall also and do so on an approximately equal exchange basis. where activities at the other institution be permitted to participate in staff that participation is appropriate to their teaching function. Medicin This cooperative activity between Group Health and the Department of Family only insofar as':. University and Medical School will affect other departments in the residents from Group Health will share the same opportunities for training experiences offered by other departments as is-open to the Medical School's own res.idents in family practice.

This agreement becomes effective upon the below written date. The Chairman of Group the Department of Family Medicine and the Director of Medical Education at. joiT Health shall review this agreement prior to each anniversary date and submit a The report shall report, or if indicated separate reports, to both principals. comment on: .

general results of the collaboration and suggested additions or deletion from the agreement,

who have been involved with - numbers of residents from each institution the other institution's program, to the residents and to - an estimate of the value of these in,erchanges each institution,

60

SS' Appendix 5 (continued)

M of U be ween UW and GH Page 4

directions the collaboration might t ke.

n

Either

party may terminate this agreement upon at least nine-months'

notice.

Effective Date:

Fur tile University of Washington:

prior

January _h_l_921

For Group Health Cooperative of Puget Sound:..

0 V min, Department of rami Ty tlelff6f6e

Dear

15Trie tor of

i di cal Educat

Chief of MedicalStaff

1/22/7

-ad, Vice Presidet for Business B Finance

written

P esident

Date:

61

oa d of Trustees

Chapter 6

BROWN UNIVERSITY and

RHODE ISLAND GROUP HEALTH ASSOCIATION (RIGRA)

Brown's major achievement was the development and field-testing of a curriculum for the RIGHA component of a mandatory* course in co- unity medicine.

Plans are also in progress for initiating innovative elective

courses at RIGHA.

The project was managed primarily by the Section on

Community Health at Brown University and the RIGHA staff.

BACKGROUND

A two-year Master's Program in Medicine initiated at Brown University in 1963 became a four-year medical school ten years later'and graduated its first M.D. class in 1975.

The medical school is uni4ue in several respects.

First, it offers a medical curriculum conducted as a program rather than an independent school or faculty.

Second, the program admits most of its

studentt to a seven-year curriculum.

Finally, it was planned from the

beginning to rely on community-based teaching facilities.

Having no teach-

ing facilities of its own, the University has entered into affiliation with local co -unity hospitals and other health care institutions.

One such-

institution is the Rhode Island Group Health Association (RIGHA).

RIGHA is a labor-sponsored

community-based pre-paid group practice

Brown University is the only one among the institutions participating in this project in which student experience in an HMO was mandatory.

plan which opened in May 1971.

It is located on the grounds of a local

community hospital (Our Lady of Fatim- Hospital) in a 13,000-square-foot, converted laundry facility. hospital.

Additional office space is located in the

As of December 1975, it had an enrollment of 15,000 members and

served an additional 2,000 persons on a fee-for-service basis.

RIGHA

partly supported by loans and grants from HEW and the Prudential Life Insurance Company.

In 1973, facing severe financial difficulties, RIGHA

entered into a management service contract with Prudential.

Prudential now

nperates the HMO and is represented on its Board of Directors together with -f

In November 1975,

representatives of organized labor and the public sector.

RIGHA became one of the first HMOs to be certified under the HMO Act of 1973.

RIGHA

interest in education dates back to 1973 when it signed a

Memorandum of Association with the University (see Appendix.8).

It views

teaching as a learning experience for the preceptor as well as the studen and believes it is a positive factor in recruiting top quality medical staff.

The first educational experience at RIGHA occurred in early 1974

when several clinical students spent a week there on an experimental basis. However, no program had been prepared for this purpose. was viewed

The AAMC progra:

an opportunitir to design a well-planned and rational curricu-

lum for teaching medical students in the HMO setting.

THE RIGHA ROTATION IN THE COMMUNITY HEALTH CLERKSHIP In the initial planning of the clinical curriculum, no specific provision was made for the teaching of primary care.

The clinical curriculum con-

sists of 48 weeks of required core clerkships

ternal medicine, 12 weeks;

63

surgery, 12 weeks; pediatrics, obstetrics, psychiat-y and community health, 6 weeks each), 10 weeks of "selected" clerkships, and 24 weeks of open electives.

When it became apparent the_ lie major clinical disciplines were

planning to use their core clerkships for the teaching of inpatient aspects of medicine, the section on community health resolved to make the teaching -f primary care one of its major objectives.

The clinical student's major experiences in primary care are embodied the Core Clerkship in Community Health. major parts:

This course consists of four

(1) patient work-ups at the Rhode Island Hospital Ambulatory

Patient Center; (2) a seminar series on current issues in community health; (3) an assigned Health Planning Problem in which students work,in groups on issues such as Planning for Obstetrical Care in Rhode Island, Meeting the Weeds of Mentally Disturbed Children in Rhode island, the Control of Hypertension Among the Disadvantaged, the Problem of Malpractice, the Rehabilitation of Stroke Pa ients in Rhode Island, and the Problem of Meeting the Needs of the Terminally I11; and (4) a set of options, 1 to 2 weeks long, such as a preceptorshfp, a tutorial assignment, or a research project.

The

6-week course is mandatory for .all clinical students and has as.a prerequisite the 12-week clerkship in internal 'Medicine.

clerkship is

The community health

offered continuo _ly throughout the year so that only eight

students are enrolled at any one time.

During the course of the year, a total of 64 third

and fourth-year

students participating in the clerkship were rotated through RIGHA.

After

experimenting with various for--mats, it was decided to restrict patient-

student Antact so as to avoid charges of patient exploitation.

64

The current

RIGHA rotation consists of a mandatory one-day seminar and an optional one

or two-week research assignment on a topic of particular interest to

the student and the medical staff.

The semInar focused on three topics:

(1) Structure and Organization of Group Practice and,Philosophy of HMOs;

(2) The History and Development of RIGHA; and (3) Basic HMO Concepts as They Relate to the Operation of RIGHA.

To supplement the seminar, a

series of resource materIals _ere prepared, including an HMO Reader consisting of eight selected articles (see Appendix_T) and an HMO Library containing over 250 articles and -onographs.

PROPOSED ELECTIVES Brown and RIGHA also developed a series of electives for students who wish to expand upoil their RIGHA experience.

The first elective

entitled

Primary Care in the HMO SetCing, is a 4-6 week course in which the student spends half his time in clinical practice under the supervision of a physician-preceptor project.

and the other half of the time on a special research

The student may -otate through several clinical departments or

stay in the same department throughout. accepted at any one time.

A maximum of two students will be

The course was approved by the curriculum com-

mittee in August 1975, and was offered for the first time in the 1976 spring semester.

A similar elective is being developed in ambulatory pediatrics

and will be submitted soon to the curriculum committee for approval. Finally, a third elective entitled Medical

a

-ent:

The Role of the

Medical DirectOr in the HMO -ill be offered next year to students interested in administrative medic_ne. presented in Appendix 8.

Further descriptions of these electives are

APPENDIX 6

ORANDUM OF AS_ OCIATION

,between

RHODE IS:AND GROUP HEALTH. ASSOCIATION

ereafter called

the

Health Care Facility".and BROWN UNIVERSITY MEDICAL EDUCATION' PROGRAM, Providence, Rhode Island, hereafter called "the Unive

yl

1. TheAiealth Care Facility and the University hereby agree that cooperative programs in medical education and research sponsored by the University and conducted in the Facility can be of mutual benefit and contribute to the broadening of educational opportunities in the University's programs and to the betterment of the services offered by the Facility. 2. The University is willing to accept respons b lity _or the supervision and direction of such programs as are from time to time mutually agreed upon. 3. It is understood that the Health *Jare Facility retains sole responsibility for the care of patients, including all administrative and 'professional functions pertaining thereto.

4. Medical students participating in such programs shall be selected by the 'University.

5. Such programs shall be conducted only under the Personal supervision 'O-f a part-time or full-time member of the staff of the Health Care Facility who shall be designated as the director of the programs. The director must have the credentials reauired for faculty appointment in the University's Division of Biological and Medical Sciences, shall be nominated by the Health Care Facility, approved by the Chief Academic Officer of the University's Program in Medicine and appointed to the faculty in accordance with the rules, regulations and practices of the faculty. 6. The director sha I be responsible for the conduct of programs within the Health Care Facility and shall report directly. to the Chief Academic Officer of the University's Program in Medicine in all matters relating to the teaching, training and supervision of medical students.

:*

7. The medical education activities contemplated Agreement include: (a) participating in the Clerkship in Community Health (b) Such other educational and/or research pro rams for students in the Universitys Medical Program as shall hereafter be mutually agreed.unon.

66

The content of education rrograms for students in the Univern ty'n Progra- in Medicine sna), require formal aopl'ov,4 t:i dical Council of the-Unive.:sity-and shall be cor.d..1cte,1 only in ctinicai areas which.have hcen pre:sly .authoriod overning board of the !_ icaith Care _

Appendix 6 (continued)

9. Continu ng medical, education programs for practicing physicians shall be selected and organized jointly by the Chief Academic Officer of the University's Program of Medical Education and the authorized representative of the medical staff of the Health Care Facility.

10. It is understood that the Univer ity is also a party to an affiliation agreement with Rhode Island 'Hospital, Roger Williams General Hospital, the Memorial Hospital (Pawtucket), The Miriam Hospital, the Providence Lying-In Hospital, and Butler Hospital and that its participation in the programs contemplated hereby shall at all times be subject and subordinate to the provisions of this agreement as the same may be from time to time amended.

11. The Health Care Facility agrees at all times to maintain in effect public liability, errors and omission and malpractice insurance policies having limits of not less than $5 million in which Brown University, its officer, employees, agents, faculty and students shall be named as insureds. 12. The provisions hereof shall remain in effect until written notice of termination given by either party to the other not less than six (6) months prior to the effective date of such termination. IN WITNESS WHEREOF, this Memorandum has been executed in duplicate this

day

of

,A-zcet44

1973

By Pierre M. Ga Vice President (Biology and Medicine)

BROWN UNIVERSITY MEDICAL EDUCATION PROGRAM By

67

Appendix 7 THE RMO READER Gordon "The Continuing Evolution of Health Maintenance Organizations, K. Macleod, M.D., and Jeffrey A. Prussin, M.D. The New England Journal of_ Medicine, 288:9 (March 1, 1973) :439-443.

This articlesoutline the key developments in the history of Health Maintenance OrganizatiOns (HMO's), starting with the recommendations of the Committee on Cost of Medical Care in 1932 and continuing through the MAclead and Prussin twentieth century to its current level of popularity. clearly describe the essential components of HMO's and briefly outline theevidence on HMO effectiveness in meeting the current deficiencies of the . health care system. 2.

"The Role of Prepaid Group Practice in Relieving the Medical Care Crisis, Harvard_Lali_ Review, 84:4 (February, Ira L. Greenberg and Michael L. Rodburg. 1971):889-921. This section of the comprehensive report published in the Harvard Law Review briefly describes the current "health care crisis" and how the HMO can correct these problems. Also contained in this section isa valuable.description of the organization and structure of health care delivery under;, The concise definition presented here- gives an excellent idea,the-HMO model. of the issues involved in the establishment and management of an HMO, including such topics as patient benefits, compensation of physicians, and the type of hospital affiliation. The various organizational models are illustrated with descriptions of the HMO's currently in existence, giVing a sense of where it is the HMO's are most successful.

"MO Performance: The Recent Evidence," Milton Roemer and William Shonick. Milbank Memorial Fund Quarterly, Health and_Society, 51:3 (Summer, 1973): 71-317.

Despite the fact that.this study is somewhat dated, it remains the most .comprehensive and objective evaluation of the evidence on HMO and Medical Care Foundation (MCF) efficiency, as it covers'all of the following areas with_respect to HMO performance: subscriber composition, participation of physicians, utilization rates, quality assessment, costs and productivi health status outcomes, and patient attitudes. Roemer and Shonick, in additional to the new evidence they present, provide an excellent literatureH review and bibliography on the subject. Perhaps the,most important sections concern the lower inpatient utilization rates in HMO's .and the savings to the consumer when out-of-pocket expenses under other plans are included. 4.

"Psychiatric Services and Medical Utilization in a Prepaid Health Plan Setting," WilliaM Follette, M.D., and Nicholas A. Cummings, Ph.D. Medical Cern, V:1 (January-February, 1967):25-35. This study highlights the importance of the.idea of comprehensive care in an HMO,in discussing the inter-relationship between mental health services and other medical services. Furthermore, the social origin of

illness behavior is clearly illustrated. Significantly, the results of this study showed that a group of members of a PPGP witha high rate of utilization of mediCal services had lower rates after psychotherapy. In comparison to this group, a sample of members with similar demographic background and_utilization rates with no psychotherapy:did-ndt.show a These findings illustrate another:Ww; decreasing rate with time.. the HMO structure-improves upon the traditional private practice fee-fo service mode of organization."Planning Health:

The HMO's Opportunity,"

Helen L.

(Mareh, 1975) :3-9.

Perhaps because of the current economic atmosphere, discussion of the:p os and cons of prepaid group practice are too often focused on -theccon0m# advantages and ignore the other facets that went into the'HMO,philoaophy. Smits' article is an important corrective of this.. The author ,points_to two factors, namely, working with a defined population and a predictable' income, which make the HMO setting uniquely suited for "genuinely participative planning which involves both provider&and consumers." In addition, the HMO presents an ideal-setting for the Continual dissemination Finally, Smits emphasizes the need for of current medical information. collaboration between the consumer, the provider,-,and other health professional, an emphasis too long neglected. ,

"The Health Maintenance Organization Act of 1973 (P.L..93-222) and Prepaid Group Practice Plins," Joseph Dorsey, M.D. Medical Care,- XII:1 (January, 1975) :1-9.

-This article contains a step-by-step evaluation of the 1973 .HMO Act, which represents a culmination .of federal interest in HMO's. DorseY Clarly outlines the benefit -package an HMO must provide-in drder to_qualify'underP.L. 93-222, and he describes how these strict regulations Will be a

disadvantage for HMO's attempting to compete with-the traditional insurera.

"Should an HMO be an Integral Part of the University:Medical Center?" ,Gerald T. Perkoff, M.D. Journal_of Medical Education 48: (April, 1973) Part 11:67-72. Dr. Perkoff's most valuable point is that the HMO is uniquely suited to fill the "gap between training, practice, and societal needs." That is, medioal.school focuses the studenta'..attention..on_specialized skills rather -The7OrableMa-Petkoff-than attending to the actual needs of a populaticin relationship are both describes in achieving such .an HMO-university Throughout his discussion, his ultiMate philosophical and financial. practitioner more effective.v goal is to "make the transfer from student to understand in discussing the current This kind of philosophy is important to into the medical school efforts 'to integrate experience in primary care education. 8.

"Critical issues in the Assessment of Quality of Care; Their Relationship to HMO's," Robert H. Brook, M.D., Se,D. Journal of Medical 'Eduoation, 48: (April 1973) Part 11:114-134. The relationship between quality of care and the HMO is an important one to consider because of the unique oPportunities the organization of services

89

Appendix 7 (-ontin- d)

Brook discusses at length some.of the:key issues in an HMO presents. involved in the current da4ate over the Methodology ofquality assessment including a critical review of some of the redeht_literature on the subje c of structure, process, and outcome modes:of measuring qUality and the-: evidence on quality 'of care in HMO's. Brook;maintains that the prepaid group practice presents an excellent',Setring in which to develop 7rieW) and more,appropriate methods for assessMent of quality of ,care." -MOreeVeti from ttie point of view:of the HMOI quality of care studies must be initiati in order to determine if the HMO does indeed representan improvement for the health care delivery system.

Appendix DESCRIPTION OF,RIGHA ELECTIVES

ELECTIVE IN PR

TRIGHA

Background.

Initially, the,focus of-RIGHA,s participation.in medical school teachbe, er,l,tirely- 414;0 .tP Preclinical

ical material.

It was, felt that

xelevant,..but-nonclin

linical-teaching-involving,actualpatient _

.

.,contact and intensive supervision. by,phyfticiana .

.

RIGHA

capability.

In late-sprin&of 19.75

staff and advisory committee.

a.,visitmas made,by:the AAHC'

At that time

feasibility,ofa clinical pathway... ,

.

Clinical medical ,care,in,an HMO, a primarily.ambula _

percent of,the care.given by,RIGHA.is given,within.the-c the entire care, over 70 percent could be defined as primary--that is

care

given by a priTary physician. It, therefore, appeared reasonable that. as an HMO, delive ing in the vast

majority of cases

care which was ambulatory in nature and primary in quality,

RIGHA's natural role in clinical teaching should be in teaching the delivery of primary care.

Such an elective will clearly meet a need in the Brown curriculum.

The

administration and faculty are sensitive to the need for more learning opp-

ortunities in the area of Trimary_careand_welcome,_RIGHes help meet this .need.

The.Section oft Community Health

illingness to

in particular, is

.pleased to be able tc offer advanced clinical work within-the.HMO context

as part of.its course offerings.

.

Thus it was with unanimity that the.Med-

ical School s Curriculum Committee approved the proposal for this elective. The primary care elective at RIGHA is a four to si2cweek elective for medical students who have finished the prerequisite medical and pediatric clerkships.

The program is offered to no more than two students at any one

7

Appendix 8 (continued) time.

Each student must be interviewed by RIGIJA staff prior to acceptance

into the clerkship.

Curriculum The elective consists of two activities run simultaneously.

,Duringjuilf .

of the -tudent's time, he or she will be assigned to the medical, surgica pediatric, and obstet ician/gynecology'departments.

The -tudent will".be A

igned to one clinical preceptor in each department.

A clerk may choase to

remain within one department or to have more emphasi- on one department rather than to rotate through all.

During the preceptorship experience, the student will have clinical responsibilities for patient -orkups.

The preceptor will asSign cases w _h

p--ticuler emphasis on those which demonstrate primary c_ e problems. Each instructor will develop an individualized program with each student.

However, at this time there are no plans to develop individual faculty-studentA contractual relationships as structu ed at many other schools.

The second part of the elective will be devoted to a small research pro ect on one area of primary care delivery at the HMO.

The field experience

described elsewhere has proven the feasibility of assigning to a student a health care project, given reasonable limitations on the scope and-nature of projects chosen.

Examples of such projects are:

quality assurance studies,

health education programs, design of screening programs treatment programs for specific disease entities.

and evaluation of

The projects will be in

the area of the student's awn personal.career interest and will be primarily clinical in nature.

Each student will be assigned a preceptor to help plan

and review the pro ect.

Each student will present the results at a staff

meeting at RIGHA which will be attended by Community Health faculty.

Appendix

continued)

FOURTH YEAR ELECTIVE,IN AMBULATORY PEDIATRICS AT RIGHA

A growing need has been felt at Brown Medical School for clerkships in ambulatory care settings.

RIGHA-will participate in a new fourth year elective

in ambulatory pediatrics beginning in 1976.

The proposal for this elective;

clerkship is outlined in this section.

Although the elective will focus only on pediatr cs, the RIGHA clerk participate in many of the same activities at RIGHA as Will the clerk in pr mary care.

The student will learn the basic skills of ambulatory pediatrics

as defined by the course sponsors, but in addition, the -tudent will be ex-

.

pected to: 1.

Participate in an independent study focusing.on some clinicallpediatric problem at the HMO (e.g

--immunization levels of the pop-

ulation, adolescent obesity problems.) 2.

Define the differences between pediatric practice in the HMO setting and in

private practice through observation of private practices as well

-as the RIGHA program.

The RIGHA participation in the ambulatory pediatric program will serve as the model for its patticipation in ambulatory teaching programs through other departments.

If successful, an attempt will be made to define clerk-

ships or other shorter learning modules in which specific skills in ambulatory care could be developed in the depart ents .of surgery, ob/gyn, and other major

specialties _uch as

orthopedics,allergy, and psychiatry.

Evaluation of this Course will be at two levels.

The RIGHA evaluation

program as deVeloped through the Section on Community Medicine will be combined with an evAluation by the Pediatric section using their own techniques.

Costing methodology will be the same as described under the section on costs.

Appendix.8

FOURTH YEAR:ELECTIVE IN

DICAL

continued

NAGEMENT AT RI

Over the past several years, there has been an increaaing demand for physicians to serve in planning and administrative functions. is due both to the growth of organizations sudh,asJIMO s

o deliver care-and::

to the g owing need to structure the entire health delivery sy The physician/administrator or_planner must have sufficien

clin cal

knowledge to be accepted by other physician clinical Practide in delivery programs.

Such a physician

much as the clinician serves individuals. The physician-administrator requires

kills and knowledge which'are

seldom taught within the medical school years fiscal administration, planning

The sciendes of managemen

and other related fields-have g own suff-

iciently to warrant the attention cif physicians -interested in administration.T

The historical pathway of assuming administrative posts folloWing years of. distinguished Clinical practice must be replaced'by_ specific graduate train7 ing.programs paralleling or following clinical residencies.-

Such .programs

are evolving in many schools, particularly in schools-of Public Health.,.13ut.,

it is also reasonable that undergraduate medical students he introduced to the,problems facing medical administ ators and to the approaches they use in solving them.

is the intention of the Section on Co

unity Health working in coil-

aboration with RIGHA to offer an elective preceptorship to senior medical' students that would focus on the role of the medical director of an HMO. This elective program would offer the student the opportunity to become familiar with the administrative functions of a medical director and thus to develop an understanding of the problems and tasks facing a physician administrator.

71

Appendix 8

The elective will be a short clinical clerkship.

ontinued)

The student will be

assigned to the RIGHA miclical director for a one-month period.

During that

time, the,student will: 1.

Observe the Medical director--attend meetings

sit in on project

planning _sessions, etc.

Study the work of other medical administrators for contrast--

physicians invublic health, hospital administration, etc. fi

Design and implement a specific independent study on an issue in health care management at the HMC4

Examples are:.

an analysis of

physician productivity, long-term care planning, hospital admission. and length-of-stay controls, etc. Preliminary discussions suggest that a small number of students would ,be

most interested in a program of this nature and. would elect the preceptorship. It is planned to: introduce this program in 1976

7b

fall) or 1977. (spring).

Chapter 7

UARVABD MEDICAL SCHOOL and

TH PLAN - CANBRIDGE CE_ ER (HCHP-CC)

HARVARD CO

The Harvard Curriculum Is the only one in this report dealing exclu7 The

sively with residents and the only one focused on clinical skills.

Harvard group developed an objective-oriented

linical curriculum and field--

tested it at the Harvard Community Health Plan - Cambridge Center on internal medicine residents participating in th-- Harvard Primary-Care,. Program. -

The curriculum focused on areas other than internal medidite,.with a special emphasis on psychiatry.

.

A preliminary cost analysis of the HMO-based

residency training was also prepared.

The p oject was performed by staff

physicians from the Cambridge Center and its affiliated community hospitals. A group of three internists was responsible for currIculum development in all areas except psychiatry and a group of three psychiatrists (known as the Behavioral sciences Subcommittee) was responsible for the psychiatric component and for planning for a psychiatric residency training progra

BACKGROUND

The Harvard Medical School and its affIliated hospitalsllave been engaged in primary care education since the mid-sixties when a Family In the

Health Program was initiated at Children's Hospital Medical Center. late sixties an occasional resident in medicine or pediatrics elected

rotations in neighborhood health centers or other ambulatory facilities.

Other primary care education efforts involved the Harvard Community Health Plan (HCHP), as indicated below.

76

The Harvard Community Health Plan - Cambridge Cen

(HCHP-CC) is the

Cambridge satellite of the Harvard Community Health Plan, the major center of which is located at Kenmore.

The Cambridge Center has been in operation

since 1973 and presently _erves over 15,000 enrollees in a new 44,000 square foot facility.

The Kenmore Centr, which has been in operation since 1969,

has already reached capacity at over 35,000 enrollees.

Residency training at Kenmore dates back to 1970-1971 when three residents in Internal Medicine and one in Psychiatry spent one afternoon per week under the supervision of a staff physician. were also offered to medical students.

Educational opportunities

A onemonth elective provided

several clinical students an opportunity to study in depth a problem in primary health care, and a course entitled The Delivery of Medical Ca e in the 1970's: Issues and Examples, was offered to first year students.

Residency training was an explicit goal of the Cambridge Center even prior to its inception.

A Robert Wood Johnson Foundation award to the

Cambridge Center in December 1972 was contingent upon the development of a residency training program.

In July 1975 four residents in Internal Medicine

participating in the Harvard Primary Care Program began their training at the Cambridge Center.

The Harvard Primary Care Program, also supported

by the Robert Wood Johnson Foundation,.supports primary care training at various ambulatory care sites in the Boston area for 25 Internal Medicine residents.

77

TIE CURRICULUM DEVELOPMENT PROCESS The major objective of the pro. ject was to prepare a curriculum for the .

.

new residents based on task analysis and -definition of behavioral objectives

and focused on areas other than internal medicine (AOTIM).. Traditionally, clinical teaching has been haphazard.

Learning objectiVes are rare/3r

specified and when they are, they are too vague to benefit either.the. preceptor or resident.

Moreover, the skills that the re identacquires

his training do not always reflect the requirements of p ivate practice and primary care.

This approach -as designed.to avoid these pitfalls.

Dr -ing upon their own experience in the AGM specialty under considerati the internists prepared a preliminary list of tasks most often encountered in primary care practice.

On the basis -f these tasks', the group delineated

and progressively refined a set of behavioral objectives, expressed in terms that can be measured and evaluated.

The objectiVe list waS then

submitted to a consultant who was asked to consider: (1) what were the most common referrals from pri ary care physicians; and (2) which of these could be treated by the referring physician?

Generally, for each specialty,

objectives were grouped as follows:

1.

Statements of history-taking and physical examination skills.

2.

Statements of psycho-motor skills.

3.

Inductive (symptom oriented) considerations.

4.

Deduc

5.

Conditions nrui-diseases that the resident must recognize and refer for treatment.

6.

Statements of important tierapeutic principles.

ve (disease oriented) considerations.

The rationale for this structure was based on convictions about the general substance of post graduate training programs, best expressed in the authors' own words:1 1.

Skills in history taking and physical examination are emphasized as crucial areas. Too often organized formal training in physical diagnosis stops:after the medical student level. Areas such as the pelvic or neurologic examinations may not:be Well developed in the house officer wiao then tends to ignore these important areas. Alternately, the physician in training may:have mislearned whole parts of the physical examination. We seek to eMphasize fundamental competence in the primary care physician both in genera1 medicine as wen as in AOTIM area other than internal medicine).

2

Within each area described below, we have identified key skills that belong in the primary physitianis repertoire. Some of these abilities should be part of any doctors' capabilities, as e.g. skills in first aid or cardiopulmonary resuscitation. However, in elis report we have focused on those skills in the AOTIK that would be commonly used by the physician. The items listed have been cross-checked with consultants in each area as being in the primary care realm and within the scope of primary physicians' practice. From the very beginning of our curriculum deliberation, we grappled with the question of using an inductive versus deductive approach. .Most textbooks of medicine-utilize the latter perspective and are .as though every siek person written as MacBryde put it -- ". carried his presumptive diagnosis labeled on his chest".2

'Matthew A. Budd et. al., Training Adult Primary Care Residents in an HMO: In Fulfillment of a Grant from the AAMC. December 1975; 2Cyril MacBryde, ed.,Signa and Symptoms, 4th edition, J.P. Lippincott Co., Philadelphia, c. 1964.

79

On the other hand, a symptom oriented emphasis more nearly reflects the manner in which patients present. There is a practical limit however to the amount of useful information that can be subsumed Nevertheless, the formula which under any given symptom or sign. says, e.g., "eleven a patient with a chief complaint of dizziness, proceed in the following way:. . ." offers a clinically useful It gives form to what otherwise may be disjoined facts not guide. easily used in patient care. Within each AOTIM objectives are contained the major_symptoms (or signs) that the primary care physician can expect to encounter in practice. The objectives are intended to reflect subsequent approaches attendant upon the given symptom or sign. 4.

There: comes a point in the diagnostic process where induttiVe reasoning generates a tentative diagnosis. Thus, a knowledge:of specific disease states is a very important part of thephysicians' cognitive skills. The AOTIM curriculum objectives haveAAAted the common entities with which the'physician,must,be conversant. With the help of our AOTIM consultants, we have defined theSe common diseases and have classified them generally into two'groupst (1) those which the primary care physician should be Able CO--recognize and treat, and (2) those which,the primary care physician should recognize and refer.

5.

Of the AOTIM diseases we have chosen to segregate those illnesses ----which though uncommonaust be recognized or suspected even ifr treatment of the illnes6 falls outside the primary care physicians' capabilities. The common denominator is the treatabil.Ity Of these conditions, which if missed generally have serious to catastrophic consequences. This characteristic justifies' the incorPoration of Some examples of these problems into a separate set of objectives. these conditions would be ectopic pregnancy, acute epiglotitis, angioneurotic edema, acute disc herniation with sphincter compromise, and acute glaucoma.

6.

Treatment is'aues are a fairly obvious part of any clinically oriented These objectives span the range of specific motor skills curriculum. (e.g. using a cock up splint) to items dealing with medication (cost/effective objectives; generic/brand issues, etc.).

The result of this process was the preparation of a set of preliminary liets of objectives in eight areas: paedics

urology, ENT, ophthalmology, ortho

general surgery, nutrition, dermatology and Ob/Gyn.

presented in their entirety in Research PAper No.

6.

They are

THE RESIDENCY TRAINING PROGRAM The program was predicated on several assumptions.

First, the primary

care physician should be able to handle the -ajority of Oroblemp brought 6.Y his_ panel of-patients.

Since these are.Often in areas other than

internal medicine; the residents' training must be broadened .accOrdingly.

Second, the cur iculum must reflect the fact that a high-proportion of patient visits concern psychological problems..

care must be an integral part of the curriculum.

Thi d ,continui.tyof Finally, thn..curriculum

itself is a dynamic product,.constantly changing as results are evaluated and conditions change.

Cur iculum implementation began

July.1975 with the introduction to

the Ca b idge center of four internal medicine residents -- two junior residents from Mount Auburn Hospital and two senior residents from Cambridge Hospital -in adult primary care.

hi, are participStidg Ln a two year residency program

The program consLsts of eight alternating three-

month blocks, half of which are spent in the ambulatory care setting, and half at the backup hospital. of each otherrs patients.

Residents are paired to facilitate coverage

The content of the hospital rotation is similar

to hospital training received by other hospital-based residents in straight internal medicine, except that during the hospital rotation, one afternoon per week is spent at the Cambridge center.

81

During his/her stay at the Cambridge center, the resident is assigned four one-half days per week to a team consisting of an internist-preceptor and a nurse practitioner.

The resident spends an equal amount of time per week with various consultants, _cotly in surgery and surgical subspecialties.- Both the

consultants and the resident are provided with the appropriate Hai Of objectives.

It helps the specialist kn

what is expected of him

what t

teach and the resident

The program includes a didactit lecture- once

a week in which consultants discuss a topic drawn-from the behavioral objectives.

week a

In addition, all internists and residents attend once a

"LMD Journal Club" in which participants select a top_c of interest

based on commonly occurring problems.

THE BEHAVIORAL SCIENCE COMTONENT The behaVioral science group was assigned the responsibility to design the psychiatric component of the curriculum for the internal medicine residency program and prepare initial plans for a psychiat residency,

_c

Utilizing the procedures of their colleagues in internal

medicine, the psychiatrists tried but soon abandoned efforts to derive detailed objectivee from correspondIng task lists. reasons for this.

There- e

e several

First, the data base in psychiatry is much softer than

in the medical disciplines.

Secondly, techniques in psychiatry ard'more

related to process than tasks.

Finally, evaluation of change is much

more subjective in this field.

Instead, the group developed a set of

three overall objectives as a general framework for the psychiatric content of the primary care curriculum.

These overall objectives are:

13

(1)

Sensitivity skills - learn to be more sensit ve to patients and their needs for treatment and understanding. Therapeutic _skills - learn how to counsel various kinds of

patients with problems complicating

causing; or resulting

from their medical (and social-psychological) conditions. Referral skills - learn to recognize serious psychiatric disorders and develop skills of referral, utilizing appropriate resources.

A further elaboration of these objectives is presented in Table 1 on the following page.

A variety of instructional methods were developed for implementing this curriculum (see Table 2).

These included a one-hour didactic seminar

per week (see Table 3); a supervisory experience where the resident sees one case per week; one hour per week of consultation where the resident observes the psychiatrist with his r-,tients; video tapes; group experience

with peers and faculty for a one and one-half hour session per week; and electives as available.

To evaluate the efficacy of the curriculum, the

group developed a set of evaluation instruments, presented as Appendices 9 and 10.

PLANS FOR A PSYCHIATRIC RESIDENCY The development of a p-imary care residency with significant behavioral science content, provides a vehicle for the training of psychiatry residents at the interface of medicine and psychiatry.

A preliminary set of objectives

benaviorai seine component Objectives and Methods

SENSITIVITY SKILLS

To educate primary care

Understand the process of normal

Didactic, Supervision,

physicians to be more

development through life cycle.

Consultation.

and their needs for

Be aware of own reactions and effect

Group, Consultation,

treatment and understanding

of treatment process.

Supervision,

Understand economic, class and

Didactic, Consultation

sensitive to patients

environmental influences on illness.

Learn to use knowledge of psychosocial

Didactic, Consultation

factors and community resources for treatment.

THERPEUTIC SKILLS

Lear] how to counsel

Understand the "psychosomatic approach"

various kinds of patients

in its broadest sense.

Didactic1 Consultation

with problems complicating, causing or resulting from

Be experienced in rudiments of history

Didactic, Supervision,

their.medical (and psycho

taking, interviewing skills, and minor

Consultation, Videotape

social conditions')

psychotherapeutic techniques.

Be able to recognize and deal with the

Didactic; Supervision,

acute (though often low level) anxie_

Consultation

and_deression_often related to illnes

REFERRAL SKILLS

Learn to recognize serious

Develop diagnostic skill for major

psychiatric disorders and

psychiatric disorders.

develop

Didactic, Consultation

skills of

referral process; utilizing

Be able to elicit data relevant to

Didactic, Consultation

appropriate resources,

suicidal or homicidal potential.

Videotape. 0

Know how to arrange for hospitalization

Didactic

when needed.

Know how to work with psychiatrists in

Didactic, Group, Supervisi

proAing proper treatment.

Understand various types of psychiatric treatment, other types of therapists,

and ways in specialized services are

4

presented.

Didactic, Supervision

TABLE 2

HERAVIORAL SCIENCE COMPONENT TEACHING METHODS

Didactic Seminars (D/S)

A series of one-hour presentations interspersed throughout the year with other medical topics. Designed to provide practical and applicable psychosocial information relevant to the physician's daily clinical case load. Supervisory Experience (S)

Specifically designed to offer the resident closely monitored experience Residents in dealing with the emotional problems of medical practice. will see patients in brier psychotherapy to learn how to deal with appropriate cases in individual or couples therapy. Each resident will see one case ner week. Consultation (C)

Each resident should learn how to utilize the services of a psychiatric Psychiatrists consultant in the management of his usual medical case load. can observe the resident's interviewing and history-taking technique, how he establishes a doctor-patient relationship (alliance), and how he attends Regularly scheduled medical patients to cues in his decision-making process. will be seen by the psychiatrist and resident. One hour each week. ,

Videotape (V)

Useful for observing how experienced interviewers talk to patients as well as for observing oneself critically in the process of learning and using new skills. Group Experience (C)

Designed tp foster interaction of peers and faculty in one-and-one-half Case-oriented hour sessions each week throughout the two year program. discussions are co-led by a psychiatrist and primary care preceptor and will include comments on and criticism of the resident's understanding Part of the experience will have as its objective to learn and skill. about oneself-reactions to patients, prejudices, strengths and weaknesses, The the_interaction of physician's personality with that of the patient. emphasis is upon the experiential (rather than substantive) side of becoming a doctor and engaging in. doctoring. Electives (E)

Residents with special interests will have opportunities in the second year to pursue these (e.g. applications of hypnosis to medical care; behavioral techniques, etc.).

86

TABLE-3 B IIAV1ORAL SCIENCE COMPONENT DIDACTIC SESSIONS

For the primary care physician to be able to care for his patients as a whole, he/she must be able to acquire the knowledge and experience which will permit him/her to compose diagnoses and treatment plans in physical, psychological and social. terms. A series of seminars, interspersed with other medical topics throughout the year is inlended to complement other learning experiences with attention to practical application to office practice. 1.

The hmotional Aspect or Common Problems Presenting to a Doctor: A Survey of Medical Practice. Why do patients come to the doctor? What do they want? Tuning your ear to the chief complaint.

2.

rhe "Psychosomatic Approach: Illness as a Unified Whole. The fa:llacy of mind-hody, organic-functional dualism. The Experience of Illness: What It Means to be Sick. Determinants of pain: cultural and social aspects.

4.

Hypochondriasis:

Isn't All Pain Real?

The Life Cycle and the Family: A Developmental Approach to the Individual Problems Related to Phases of Growth, Adolescence, Mid-life, Old Age, Death and Dying. 6

Eliciting the Sexual History: Sexual Development.

7.

"Rad leelings Suicide:

9.

An Approach to Individual apd Marital

Recognizing and Managing Depression and Anxiety.

How to Assess the Risk and What to Do'.

Habit Patterns and How to Modify Them: Uses of Hypnosis, TM, Group Therapy, Biofeedback The Health Hazards of Smoking, Obesity, Drug Abuse AlcoholisM and its Medical Treatment

10.

Psychopharmacology:

11.

Practical Tips on Interviewing Personality Diagnoses.

12:

The Physician as Psychotherapist:

13.

Referral to a Psychiatrist:

14

Community Resources and Other Therapies.

.

What Drugs for What Problems? Taking a Mental Status

Brief Techniques.

When, Why, and How?

and Making

such an experience are presented as Table 4 on the following page.

A

proposal for a psychiatric residency program is presently being negot ated with McLean and Cambridge Hospitals.

COST ANALYSIS

Robert Lawrence, M.D., a member of the internist group and director of the Harvard Primary Care Program, prepared a preliminary cost analysis of the internal medicine residency training'program at the Cambridge Center.

lie found that the average resident produces 7.1 patient visits

per four-hour session compared to 13.0 patient visits for the average internist.

However, the resident doesn't quite pay his way.

While his

stipend averages $12,000 per year, the replacement value of his production is about $9,900 p-- year for a net cost of about $2 100.

However, this

figure does not include productivity loss of the preceptor resulting from time devoted to teaching.

The cost analysis is presented as Resource Pa er No_.16.

Both the

methodology and the figures are preliminary in nature and need further refinement, especially with regard to staff productivity loss.

88

TALE 4 PSYCHIATRIC RESIDENCY OBJECTIVES

A residency track in psychiatry and primary medical care should address itself to the following objectives: 1.

Acquaint the resident with the body of knowledge which comprises psychosomati- medicine as a scientific discipline.

2.

Teach the resident the skills necessary to apply a psychosomatic approach to all of medicine. Provide an experience which includes close working relationships with non-psychiatrists as well as paraprofessionals,in what will be an interdisciplinary approach.

4

Obtain experience in a general hospital or ambulatory setting, to familiarize oneself with the spectrum of patients who are treated for acute illness by the medical profession.

5.

Work closely with a primary care physician in a typical (or simulated) office practice for maximum exchange of vieWpoints, styles, and skills.

6.

Obtain special training in behavioral modification techniques, hypnosis and other modalities which rely to some extent upon an appreciation of psychological understanding in their application to general medical complaints (e.g. obesity, smoking, accident proneness, generalized anxiety, and so on.)

7.

Devise and carry out a circumscribed clinical/research project which demonstrates the use of the psychosomatic approach and its applicability (by the primary care physician ) to general medicine.

8.

Learn and appreciate the nature of primary medical practice, including the pressures, orientation, skills, styles, rhythm, and so on'of the primary physician. Learn how to translate psychodynamic principles into comprehensible language with practical application to the common problems of medical practice.

10.

Learn how to alter the psychiatric stance and interviewing style of the psychiatric intake process to the more medically-oriented model of the practicing physician.

11.

to recognize and deal with one's own diacomforts about "returnLe.4. ing" to the medical scene, often experienced as a regression in the psychiatrist's identity as a psychotherapist and specialty consultant.

12.

Learn how to be supportive and not critical of the physician who is tying to learn how to cope, with his own anxieties, especially around the aspect of converting from an active to a more passive listening approach. The psychiatrist mustrefrain from "psycho-analysing" his "primary care colleague.

APPENDIX 9 BEHAVIOR SCIENCE COMPONENT SAMPLE PRE/POST TEST

1.

The important advantages of open-ended initial questions in an in erview are: a.

b. c.

It provides rapid access to the quality of the patient's speech and his major concerns. It improves the efficiency of the interview. It provides an Opportunity for the interviewer to present himself as a sympathetic listener. It allows the interviewer to avoid sounding judgemental.

In the previous and subsequent questions, answer:

1-if .2-if 3-if 4-if 5-if

a and c are correct a,b,and c are correct b and d are correct only d is correct all are correct

Currently available biofeedback techniques offer useful therapy fo a. _

c.

d.

Ulcerative colitis Raynaud's Phenomenon Asthma Migraine headaches

In one paragraph, define and explain the use of the word "psychosomatic". 4.

Match one or more entries in column A with those in column B A A.

Psychophysiological Disorder

1. 2.

B.

Conversion Disorder

C.

Hypochondriasis

D.

Malingering

3. 4. 5.

6. 7.

8. 9.

10. 11. 12. 13. 14. 15.

9.0

Munchausen's syndrome. "La Belle Indifference" Autonomic nervous system Inappropriate preoccupation with pathology of bodily function Symbolic meaning to the symptom Self-inflicted injury Voluntary nervous system Primary anatomic alterations Functions as a defense against painful feelings. Vomiting False pregnancy Migraine headaches .Physiological fluctuations Associated with increased suicide risk when the patient is depressed. Responds to psychotherapy.

Appendix 9

5.

continued)

A 30 year old single registered nurse presents with symptoms of tension, She reports that 1-2 months before she had trembling, and apprehension. terminated a relationship with an older, married physician on the staff of the hospital at which she works, whom she continues to see on a regular She weighs 220 pounds and admits to chronic obesity basis at her work. Reasonable explanations since age 13, despite many efforts to lose weight. for her presenting complaints include:a.

b. c.

d.

Caffeinism secondary to intake of grealer than 20 cups of coffee per day. Hyperthyroidism. Chronic amphetamine and/or diet pill abuse. Pheochromocytoma.

Answer as in Numbers 1 and 2. 6.

A Regitine challenge test- done in your office is negative. She denies smoking, consumption of caffeinated drinks and/or use of any drugs. Inquiry_into her feelings about her former paramour are fruitless, since though her eyes brim with tears, she insists she no longer has any.emotions Instead, she asks for a prescription for "medication about the_relationship. The time for her appointment to help me through the next couple or weeks". already over and your phone rings indicating that your next patient is The most appropriate measure to take at this point s: ready to be seen. a.

b. c.

d.

25, 5 mg po 'Ltd. Immediately write a prescription for ValiumWrite a consult form to Mental Health. Arrange to see the patient within a week or two to collect further history. Take another half hour to collect more data about her relationship seth the doctor before coming to a decision.

(choose the best answer) 7.

Hearing that her request for medication has been at least temporarily refused, the patient angrily replies that you don't understand her problems and She says she sees no point aren't really interested in helping people. in returning to see you under these conditions. To then write a prescription for Valium would then: .

a. b. c.

d. 8.

Touch her, and cement the therapeutic alliance. Re providing the appropriate drug anyway. Reinforce maladaptive behavior. Reinforce healthy assertiveness.

Other effective and appropriate treatments for anxiety include: a.

b. c.

d.

Assertion therapy. Transcendtal Meditation. Autohypnosis. Reassurance that there is no cause for anxiety.

(Answer as in Numbers 1 and 2) 9.

The usual minimum daily therapeutic daily dose of tricyclic,antidepressants for treatment of appropriate depressions in a 140 pound woman under age 60 is: a.

b. c.

d.

50 mg 100 mg. 150 mg 200 mg

91 1

Appendix 9 10.

(continued)

The most useffil service provided by a primary Lare physician talking with a tearful, unhappy patient is: a.

b. C.

d.

Supplying the kleenex. Reassurance Sympathetic interest, Reminding the patient there are others worse off than he is.

(Choose best answer)

U.

Match one or more treatment modalities from column A with entries from column B.

A A.

Tricyclic intidepressants

H.

Counseling by Primary Care

47 year old businessman with early morning awakening, weight loss, and anorexia who feels worse in the A.M., and whose father had severe depressions culminating in suicide.

Physician.

12.

C.

Referral to Psychiatrist

D.

No medications

E.

NAO Inhibitors

2.

23 year old single female, with tearful depression around breakup from boyfriend, who is maintaining work function and who describes fluctuations between tearfulness and cheerfulness.

3.

33 year old woman who says she has "never been happy", complains of chronic mistreatment at the hands of others, who is currently sleeping and eating more.

A 45 year old woman from a "good family" giVes a history of chronic flank pain and reports passing stones on at least one occasion. She relates to You send her to the WC to provide you in a dependent, compliant manner. a urine specimen and by accident your nurse associate bursts in on her Outraged by this deceit, dipping a bleeding finger into her urine cup. you are about to order her out of your WC and consulting room when you The best approach would be: decide instead to talk with her. a. b. c. d.

A scathing denunciation of her attempt to make a fool of you. A cool, firm confrontation, expressing your anger, in hopes of extinguishing her manipulative behavior through punishment. Expression of surprise, even irritation, alo4 with a wish to understand why she needed to tamper with her urine sample. Having your nurse talk with her while you cool off.

92

Appendix 9

(continued)

SUI IDE 1.

a. b. c.

d. e. f.

g.

h. I.

2.

(circle one ofeach pair

Suicide is more common among:

men-women young-old blacks-whites married-divorced married without children-mar ied with children Protestants-Jews rural dwellers-urban dwellers 'in the spring-in the winter ients who have never tried befor patients who have attempted suicide before

a. b. c.

d. e.

False

True

Suicide is a more frequent cause of death than: Coronary heart disease Leukemia Homicide Tuberculosis Cancer

Which of Concerns over suicide increase as patients become more depressed. the bodily symptoms listed below would increase your concern about the seriousness of the patient's depression: (circle all appropriate answers a. b. c.

d.

e. f.

h. I.

4-

Productive cough loss of appetite loss or weight sweating waking early in the morning palpitations loss of interest in and desire for sex constipation

A fittyseven year old man is seen for evaluation because of weight loss of He confides in you considerable disap20 lbs. over the last three months. pointment over the promotion of a younger employee to a supervisory position In addition, he expressed his resentment he assumed he would be asked to fill. over infrequent invitations to his three childrens' homes in the 15 months since his wife died of cancer. He acknowledges feeling quite depressed and despondent about his future. Yoft need to assess his potential for suicidal behavior.

True a.

b.

Asking directly about thoughts of suicide will put the idea in his mind. Questions about plans for suicide such as dute, place, method, allow you to assess the degree of preparedness to die.

C.

You call his daughter who tells you not to worry

9,

False

Appendix 9

continued)

True

e.

False

Painful feelings of worthlessness and hopelessness can be alleviated by letting the patient know that these are all part of getting older and having sad things happen. Your concern is increased by his lack of permission to cry combined with his guilt about enjoying pleasures since his wife died. The patient requests for pills to give him some strength to go on shows his interest in the future. The patient's request for hospitalization should be discouraged as it will only foster his hiding from reality and delay his adjusting to his losses.

HOMICIDE 1.

A 27 year old man presents asking for evaluation of a swollen wrist. Your history reveals that he and his wife have been fighting about his mother's criticism of her housework and childrearing practices. In the midst of their last argument he felt like strangling his wife, became frightened of his rage, and suddenly turned and slammed the wall with his fist. Which of the following would increase your concern about violent or murderous behavior? (Circle all appropriate items) ,

1.

Use of alcohol. Use of amphetamines, Smoking over 1 pack per day. Brutal beatings as a child. History of torturing animals, Eneuresis, history of Diarrhea. Owns a gun. Experience with weapons in armed services or sport_ club. Past arresls ibr assault. Seizure disorder. Diabetes.

m.

Loner.

n.

Suspiciousness or paranoid psychosis. Homosexuality. Preoccupation with revenge and retalia History of fire setting. Hyperventilation syndrome. Sense of powerlessness to change painful realit Sense. of acute humiliation.

a. b. c.

d.

e. f.

g.

h. i.

i. k.

o.

p. q. r. s.

t.

9:1

APPENDIX- 10

RATING SCALE

In an attempt to evaluate and monitor the personal and emotional skills,

development, and deficits of the primary ca e internai'medicine residents, the following assessment farm was developed.

The psychiatric preceptor

completes this assessment lt the beginning and end of the training period. We are considering as well its use at more frequent intervals.

The data

is collected with the preceptor observing the resident as he or she'conduc_s a complete hi tory and physical examination.

Additiorml data is drawn

upon during the training period from their Weekly sessions (see teaching methods).

It is our hope that such an instrument periodically completed

will help the preceptor discriminate areas of strength and weakness in the resident's development and that both constructive feedback ard reshaping of the subsequent training experiences can be considered.

The

use of both a narrative and visual recording of data helps in monitoring ---

progress, collecting impressions, and avoids losing sight of problem areas in a resident's generally satisfaciory perfbrmance.

,BEHAVIORAL ASSESSMENT rom (adapted Prom Personality Patterns of Psychiatrists, by R.R. Holt and L, Luborsky, N.Y, Basic Books, 1958) Name: Age: Sex: Race:

Marital Status and years: Children - age and sex: Religion: Year of Training: Past training in interview skills and psychological issues:

Past personal psychotherapy:

Intelligence:

high

average

below a

-age

Appendix 10

con

nued)

Circle the best approximate descrip ion and c mment:

While taking a medical history and doing a physical examination: A.

Shows respect for and appreciation of the meaning of the symptoms or illness to the patient a.

b. c.

11.

demonstrated variable limited

Takes a psychological history a.

b. c.

thorough superficial avoided

While taking a psychological history

c. D.

is comfortable is moderately uncomfortable is quite anxious

Makes a personality assessment when with a patient regularly has some sense of patient's personality style fails to make assessment

Uses personality assessment of patient in dealing with the patient

c.

regularly occasionally infrequently

Dees a respectfill physical examina ion, understanding issues of modesty, deformity, aging, puberty, exhibitionism a.

b. c.

II.

Shows an interest in his/her patient and is warm and empathic a c.

III.

sense is present variable absent or limited

demonstrated variable limited

Sensitive to patient cues and needs a.

b. c.

demonstrated variable limited

Appendix 10

IV.

Tolerates stress in the doct A.

a.

c. B.

-patient relationship ftom patients.

Anxiety

b.

demonstrated variable limited

Anger a.

b. c.

demonstrated variable limited

Sed ciiveness a.

b. c. D.

c. E.

c.

a. C.

demonstrated variable limited

Chronic, refractory, terminal illness a.

b. c.

H.

demonstrated variable limited

Criticism

b.

G.

demonstrated variable limited

Threats a. b.

.

demonstrated variable limited

Sadness, grief or depression a. b.

demonstrated variable limited

Distress,over uncertainty in diagnosis or outcome a.

b. c.

demonatrated variable limited

97

ontinued)

Appendix 10

continued)

:inspires confidence and trust a.

b. e.

VI.

Accepts responsibility a.

b. c.

VII.

a.

c.

a.

firm

b.

vascillates passive

Seductiveness with patients a.

b.

C. X.

b. c.

b. c.

well variable poorly: complains, gets disorganized, irritable, scared, depressed.

rinds pleasure and satisfaction in the work. a.

b. c.

XIII.

under control variable expressed loses control

Tolerates heavy work load a.

XII.

Under cont ovariable is seductive with patients

Hostility with patients a.

XI.

thoughtful and careful variable impulsive

F'irrrness

c.

IX.

easily fairly well avoids it poorly

Impulsive - Judicious

b.

VIII.

regularly variable rarely

regularly occasionally rarely

Can say "no" to patients a. b. c.

easily with discomfort area of trouble for resident

Appendix 10 XIV.

Interested in patient as a person as well as an illness/s interested in the person shown variable interest primarily in the illness

a. b. c.

XV.

good variable limited

a. c.

flexibility with patients flexible - can share controls with patient variable rigid and domineering with patient

a.

b. c.

XVII.

Sense of humor with patients good fair limited

a.

b. c.

XVIII.

Tact a. b. c.

XIX.

b. c.

b. c.

consistently variable intolerant

Communicates effectively with patients so they understand material presentec and can hear it a. b. c.

XXII.

good variable limited

Tolerant of others a.

XXI.

tact1U1 variable tactless

Insight into own personality a.

XX.

ptom

Skills in synthesizing data

b.

XVI.

continued)

consistently variable rarely

Communicates effectively with st and can hear it a.

b. c.

consistently variable rarely

99

-C so they understand material presented

Appendix 10 (continued)

XXIII.

Considers social class, ethnic, religious values as they affect patient and illness. a. b. c.

XXIV.

Curious and eager to learn a.

b. C.

X

regularly variable rarely

very variable limited

Sense of ethics a.

b. c.

high, concerned variable lack of concern

Chapter 8

FINDINGS AND RECOMMENDATIONS

It is evident from the previous chapters that this p_oject accomplished much more than it set out to do.

While the original objective was to develop

educational programs in HMO's, much more was achieved, including the followin

- the implementation as well as development of educational programa in HMOs.

- the development and implementation of evaluation methodologies and related instruments.

- the development and pilot-testing of a cost methodolo educational costs in the the development and

for measuring

O.

mplementatlon of a preceptor training program.

the development of HMO-based educational programs for different levels of medical education, including preclinical, clinical, and graduate medical education.

The collaboration among the participating institutions made possible through the three conferences that were held during the course of the project, provided each institution the opportunity to specialize in an area of its choosing to match its interests and skills.

Table 8-1 belOw lists the areas of specializa-

tion for each institution.

- 54

101

Table 8-1

SUMMARY OF ACCOMPLISHMENTS BY INSTITUTION

Area of Specialization

GU

UP

tSR

1. Curriculum Development Process

YES

2. Curriculum Content

YES

YES

3. Instructional Methods

YES

YES

UW

BROWN U.

HARVARD U.

YES

4. Program Evalua ion

YES

5. Educational Costs

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

As indicated in the Table, three institutions spent a considerable amount of time in designing a curriculum development process.

Curriculum content was

emphasized by all institutions while three institutions concentrated on instruc tional methods.

Three institutions developed evaluation methodologies

and

related instruments,while another group _f three institutions present data on the cost of teaching in an HMO.

The remainder of this chapter discusses these

accomplish _nts in detail and presents our findings, conclusions and recommendations.

102

MEDICAL EDUCATION IN THE RMO:

WHATt S IN IT FOR rHE MEDICAL SCHOOL?

Why should a medical school get involved in teaching in the HMO se: Teaching in the HMO presents a number of difficul ies as well advantages.

definite

The HMO is a services not an educational institution.

st ict cost accounting of today's HMOs, program might be a costly proposition.

ng?

,Civen the

the introduction of an educational Moreover, the number of students

that an HMO can accommodate is strictly limited by service obligations, availability of space and the willingness of clinicians to teach.

From the

medical school's viewpoint, what are some of the advantages or benefits deriVed from learning experiences in the HMO?

Medical schools have been under increasing pressure in recent years to produce more primary care phySicians.

As they respond to the challenge,

additional primary care training sites wlll be needed to accommodate the growing numbers of primary care physician trainees.

The HMO, as a pri _ry care train-

ing site, presents opportunities not readily available in the traditional primary care training sites such as the hospital outpatient department or emergency roo 1.

The HMO offers the student a primary care role model not found in the traditional setting.

2.

Since HMO enrollees tend to represent a cross section of the community, the student is more likely to encounter a wide cross section of diseases in the HMO than in the traditional training sites.

103

3.

The HMO provides the student with a unique oppo tunity to observe or learn in a setting that, emphasizes preventive care, quality of care,

and cost containment. 4.

The HMO exposes the student to an alternative health care delivery syste_

WHAT'S IN IT FOR THE HMO? Why should an HMO be involved in medical education? not an educational institution.

An HMO is a service

Even if the full costs of education are paid

high premium for by an outside agency, why should the HMO member, who pays a his health care, subject himself to the care of an medical student?

seasoned resident or

Here, too, medical education offers a nunber of distinct

advantages: 1.

Quality of Care - Although this has not been conclusively proven, many

believe that the intellectual and professional stimulation involved in teaching tends to improve the quality of care. 2

Recruitment of Qualified Physicians

Many believe that the availability

of teaching opportunities tends to attract better qualified clinicians. 3.

Recruitment Costs - This is a major benefit to the HMO and the e rollee.

The physician trainee is a prime candidate for a full-tIme, pernan nt position with the HMO upon completion of his training.

The savings in

recruitment costs include not only the cost of advertising, but also ti e spent in interviewing candidates and educating the new physician to an alternative hea th care delivery mode.

104

4.

Student supervision - As indicated in the following section (p. 64), we found that the student is closely supervised in the HMO setting, the introduction of so that the quality of care is not lowered by students.

5.

Faculty Appointments

The opportunity for faculty appointments

soci-

ated with a medical education program provides an added benefit and inducement to recruitment.

It means that a lesser amount in salaries

and'Tringe benefits is required to attract highly qualified physicians. 6.

Tertiary Care

The association with a medical school not only adds

prestige to the HMO, but also provides easier access to quality tertiary care in the university hospital.

WHICH HMOs ARE BEST SUITED FOR TEACHING?

To determine what type of H

is best suited for teaching, we examined

selected characteristics of the HMOs participating in this project, see Table 8-2, below.

We found that:

One-half of the partIcIpating HMOs are sponsored and operated by medical schools and the other half are independent or supported by other agencies; All but one of the HMOs

are relatively "young", having opened for

services in the early l970's; -

With one or two exceptions, the HMOs

have been remarkably success-

ful in meeting their targeted enrollment levels; Three of the HMOs

were utilizingtheir facilities to full capacity.

The facilities at the other'three HMOs primarily because the HMOs

105

were

were still gearing up to full enrollment.

Table 8-2

CHARACTERISTICS OF THE PARTICIPATING HMOS

Sponsor

GUCHP Washington, D.C.

Opened tor Services

medical school

Number or Enrollees (1975)

Facility

1972

10,000

3 Outpatient Facilities

1973

20,300

52,000 sq.ft.

1974

not availab e

5,500 sq.ft.

GliGHA

Rochester, N.Y.

PENN URB Philadelphia, Pa.

GHCPS Seattle, Wa

Blue Cross

medical school

1949

200,000

9 Outpatient Facilities; 300-bed hasp

1971

15,000

13,000 sq.ft

1973

15,000

44,000 sq.ft

=

Independent

RIGHA Providence, R.I.

organized

HCHP-CC Cambridge, it.

medical school

labor; Insurance Co.

106

What can we conclude from these findings?

A comparison of the group of

HMOs sponsored by.medical schools _ith the group of "independent" HMOs reveals no sIgnificant differences between ehe two groups regarding their educational accomplishments examined in this chapter.

In other words, the

"independent" HMOs performed just as well as the university-spons red ones in this project.

This leads us to the somewhat surprising eonclusion that A

the independent HMO is as well suited for medical education programs as the university-sponsored HMO.

At least one of the three university-sponsored

HMOs included in this project has been established primarily for the purpose of providing the medical school with a site for primary care education. On the basis of our experience we have found no evidence to support the establishment of an HMO by a medical school solely for the purpose of educaTrue, all but one of the participating HMOs are still in their infancy;

tion.

it is possible, and perhaps probable, that as the HMOs mature and the educational programs develop, the quality of the university-sponsored curricula would surpass that of the "independents". support this contention.

But we have found no evidence to

In any case, in the early stages of HMC development,

there are few significant differences in the educational programs of the two groups.

Another surprising conclusion is that a relatively new HMO is j capable of mounting a successful program as a more stable and mature one. For example, the Harvard Community Health Plan at Cambridge implemented its primary care residency training progra_ exactly two years after the HMO became operational and OVORA implemented its program for first year medical students less than one and one-half years after it opened its doors.

97

-

should be noted however, that with one or two exceptions, the newer HMOs included in this project have had spectacular success in meeting enrollment targets and developing a sound financial base.

This leads us to con7

elude that an HMO should not undertake an educational program if it faces

jor marketing or financial problem.,

The "younger" 11M(Ds appear to have an added advantage of having adequate

facilities for education before they reach full capacity.

However, we found

that the availability of space is not a major factor in determining the size or quality of an educational program in an HMO.

For example, Group Health

Cooperative of Puget Sound, the most established of the six HMOs and the one with the least "extra" space, has an extensive educational program. In addition, RIGHA made due with a tight space situation.

We conclude that

the availability of extra_space is not a major advantage nor is the lack of it a major impedi ent to teaching in an HMO under present circumstances of student assignment.

Should more extensive student assignments be necessary,

space limitation might pose a more serious problem.

(CONTENT)

WHAT CAN/SHOULD BE LEARNED IN AN HNO?

The question, "what

i be most effectively and efficiently taught at

an 11140?", was frequently raised at the conferences of participants.

Although

discussions usually revolved aro- d three learning areas -- HMO concepts, primary care, and clinical skills -- these were never defined or even named as such at the time.

Table 8-3, belo-

indicates the areas the institutions

finally chose to emphasize under this contract.

It should be noted,

however, that m- t2:IbstitutionS included all three subject matters in their

programs but chose to emphasize one more than another.

What do these learn ng

areas mean and what are some of the advantages and limitations of teaching them in the HMO?

108

TABLE 8-3

PRINCIPAL LEARNING OBJECTIVE OF HMO-BASED CURRICULUM BY LEVEL OF MEDICAL EDUCATION AND INSTITUTION

Aca. uirinz Knowled e .

Learning HMO Concepts

Georgetown University

preclinical students

University of Rochester

First-year medical students

Attitudes in Primary -Care

:Acquiring Clinical Skills

First-year medical students ,

University of Pennsylvania

All: Medical

Third year MediCal

students

StUdents:::

University -_ Washington

First to Third yr.:.

First:to Third'yr!

medical students-

medical stdden'ts:

Brown University

Harvard Universi y

clinical students

,Graduate students

HMO Concepts - A curriculum emphasizing HMO concepts introduces the student to concepts related to HMOs, such as the organization and management of HMOs marketing, financing and economics, the changing role of the provider, and consumerism.

is a good example of this. advantages.

Resource Paper No. 2,

The manual, A Student Guide to HMO's

Teaching students about HMIlls

It is inexpensive

offers several

it can be done outside the HMO facility

thereby avoiding interference with service, it can encompass a large number of students, and the bulk of the teaching can be done by non-physicians. As the project progressed, however, it soon became evident that teaching students about HMOs

does not fully utilize the potential of the HNO.

In

fact, the institutions that had originally chosen to emphasize this content area have either already expanded the curriculum to include other material or are planning to do so this year.

Primary Care- A curriculumemphasizing primary care introduces the student to concepts such as team practice, continuity of care, quality of care and The HMO is well suited

patient education through observation or practice.

for this kind of learning since it offers "real world" primary care role

models and a wide cross-section of diseases and conditions. hand such a program is more costly.

On the other

It requires more staff time and also a

student presence in the HNO that can interfere wIth services. tions emphasized primary care in their curriculum

Three institu-

but each of them, it should

be noted, chose to concentrate in one other content area as well.

Clinical Skills - Teaching clinical skills in the HMO Is a costly proposition and it raises the question of patient acceptability,

110

always a sensitive

issue in an institution such as an HMO.

It requires closer supervision and

a large time commitment on the part of the preceptor.

On the other h

clinical teaching in the HMO offers advantages over other settings. -For ane thing, we found that in general the student is closely supervised in the HMO setting.

This is probably due to the need to secure

the patient's acceptance and approval and tc reassure him that he's receiving proper care.

In fact, we find it pleasantly surprising that there hap been

very little resistance on the part of the patients and HMO enrollees to the education efforts.

The Group Health Cooperative of Puget Sound, which has

the most extensive experience of any of the participating HMO

in clinical

teaching, has studied this issue closely and has found wide patient acceptance Group Health, of course, takes elaborate precautions to_ensure prior patient consent.

In summary, any of these three content areas are appropriate fo= teaching, in the HMO setting.

However, teaching HMO concepts is the least costly but

also constitutes the least efficient use of HMO resources, while teaching of clinical skills is the most costly but also most rewa ding for both preceptor and student.

WHEN IS HMO-BASED LEARNING MOST EVFECTIVE?

At what level of medical education is HMO-based learning most effective? Should the student be introduced to the HMO during the preclinical, clinical or graduate years? conferences.

These questions also received frequent hearings at the

Inspecting Table 8-3, again, we notice that (1) 1I110 concepts

111

were most frequently taught to preclinical students; (2) primary care was a subject f _ all medical students; and (3) clinical skills were introduced prImarily to clinical and graduate students. st-year students

In our site visit to GVGHA we interviewed a group of

participating in the introductory HMO course designed under the auspices of thia pro ect.

We were most impressed with the depth of knowledge demonstrated by

the students.

We found that medical students are most receptive to learning dical education.

about the health care system at the earliest stage of their

Soon after his first semester, the student seems to be obsessed with the need to learn clinical skills and his interest in lea system declines accordingly.

ing about the health care

Primary care issues can and should be learned

at all levels of medical education.

The student should be introduced to these

issue's at the earliest opportunity through observation and/or didactic

sessions, an_ in later years,through clinical practice in the primary care setting.

Teaching-clinical skills in the RMO is most appropriate in the clinical years, preferably the fourth year, and at the graduate level.

Group Health

Cooperative of Puget Sound is the only institution that has experimented with teaching cliniaal skills, such as history taking and physician examinations, in the preclinical years.

This teaching was done primarily at the Group Health

Hospital and at no cost to the HMO since the costs were absorbed by the:medical school.

Under normal circumst: ces, however, clinical-teaching in the pre.,

clinical years represents an inefficient use of HMO resources.

112

HOW DO YOU TEACH IT?

(INSTRUCTIONAL METHODS)

The participating institutions used a variety of teaching methods for getting the material across to the students, with the method depending largely on the content area and the level of education.

For teaching HMO

and primary care concepts to preclinical medical students, the institutions--

generally used a combination of didactic lectures, studentinitiatect research projects, and site visits to local HMO's.

Clinical teaching usually

involved observing the preceptor at work or practicing under his supervision..

How can we teach clinical skills in a cost effective way with minimum disruption of the service mission of the HMO?

This question was addressed

by Arthur S. Elstein, Ph.D., who participated in the Rochester Conference as a

consultant t_ the AAMC. In ResoUrce Pa Some. Relevant instructional Resources

Curriculum Deve

Elstein and Maatsch describe a number

of simulation techniques that can help students improve their clinical skills' outside the pract'ce setting so as to facilitate effective and efficient-use. f the clinical experience.

These-include use of simulated or actual patients

in history taking communications skills; a variety of simulation equip int for training in different portions of the physical examination; clinical algorithms, flow charts, _omputer-based or paper-and-pencil case simulations.,_ and high fidelity simulation games, all for instruction in complex, sequential. problem solving.

For teaching HMO concepts to preclinical medical students, we recommend the University of Rochester approach which involves a combination of methods including didactic lectures, student initiated research projects, precepting,

113

one-to-one student interviews with department heads, and home visits to selected' patients

s

, pages 16-18).

Are HMO physicians competent as educators/preceptors? extended its project by six months

Georgetown University

develop and implement a program for training

physicians as edncator/preceptore;- The program, described in. Resource. Paper,No. 7,:-

A Role Guide and Resource Book for Clinical Preceptors, is highly reccromended. How much time should the student spend in the HMO setting and:over how longa period?

The answers to these questions are beyond the scope-f this study.

Student learning experiences at the participating institutions ranged from a one-day experience at RIGHA to two years at the Cambridge Center.

Al hough

spends half a we found the Rochester experience to be effective (the stndent

day per week over a period of fourteen weeks in the HMO), there has not been sufficient experience to make any recommendations in this area.

HOW AND WHERE DOES ONE BEGIN?

(PROCESS

onstructing a curriculum in the HMO setting is an unusually complicated process because it involves two institutions with divergent missions (education service).

Where does one begin and how does one proceed in this joint

educational effOrt?

Who should be involved?

should take the lead?

behavioral óbjecaVes?

Which institution pr departient,

Is a medical educator needed?

Is it helpful to define

To answer the questions we examined a set of selected

variables related to curriculum development process. Table 8-4 and described below.

114

The results are presented

Table 8-4

CHARACTERISTICS OF CU RCIJLtIM DEVELOPMENT PROCESS BY INSTITUTION

Character sties

G.U.

Institutional lead (medical school, HMO, medical school or both)

Departmental lead (at _medical school)

Community Medicine

Involvement of Curriculum Committee

Consumer Involvement

U.R.

U.P.

'U.W.

BROWN U.

both

HMO

both

.both

Community Medicine

None

Family Medicine

HAJVARDU

lIMO

Community Medicine

ne

yes

yes

yes

yes

yes

------Al Participation of Educator

yes

Defined Behavioral Objectives

Conducted Field Test

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes*

yes

yes

ye

Although U.W. did not actually implement its new curriculum it has been conducting see chapter 5 for further details educational programs in the HMO for many yea

115

Institutional lead - By ins_

utional lead we mean which institution,

the HMO or the medical school, performed most of the wnrk in initiating developing and implementing the curriculum?

It is somewhat surptising

to find that the HMO and medical school shared responsibil4insmore or 1ess on an equal basin, in one-half of the case studies other cases, the HMO

In two

(both university sponsored)-clearly took the lead,

and in one instance the medical school took the lead.'

We notathati

although the subcontract agreements were made with: the UniVersitiaa;7i

five out of the six cases the HMO was eitherthe clear leader Or an equal partner in the educational effort.

It is obVious thatthe medical

schools realized at the outset that it is essential to involve the HMO at every step of the project,

We recommend that in future undertakings

of this nature, the HMO should be at least An equal partner.

2.

Departmental lead - By departmental lead we mean the department in the _medical school which led tha curriculum development effort.

We found

that at three institutions the effort was led by the dePartment of community medicine and at another institution it was led.by the department _

.

of family medicine.

At the remaining'-two institutions faculty-members

from the department of medicine played leading roles in,the project, but the program was not initiated by the department.,

116

/64

Curriculu- committee - We note that the curriculum co_

ttee of the m di

-school-was-actively involved in this p o ect at two out of the four inst tutions in which the medical school participated.

In fact, at each Of t

two institutions, the chairman of the curriculum co _Attee directed thie project.

While the sample is too small to draw any objective con lusion

we believe that the involvement of this committee is desirable fOr legit mizing,the program and publicizing its results.

-We e- _ined the extent to which HMO enrolees were

tOnsinter-involvementF

consulted or involved in initiating or implementing this study- at'their respective institutions.

At three institutions there was no evidence o

involvement and'at the other three institutions the degree of consultati varied widely.

Group Health Cooperative of Puget Sound was the only HMC

where the Board of Directors formally approved pa ticipation in the pro Georgetown University consulted with the advisory boards and intervie ed patients; and at RIGHA the degree of involvement of the Board of Directors is.not specified, but during the site visit-the Board members showed an awareness of the educational program and its ramifications.Although few objective conclusions can be made on the basis of this samr we note that there was more consumer involvement among the independent HMOs as opposed to the university sponsored ones.-

Surprisingly, the HMC

with the most extensive consumer participation (Group Health Coopers ivt of -Puget Sound), is also the one wlth the most extensive educational prc grams.

-

o

-

We strongly recommend the early and full involvement of HMO enrolees or their representatives in efforts of this nature.

They should be

kept fully informed as to who is paying for the program, how much it costs, the degree of student supervision, and other relevant details. Pailu e to consult enrolees could lead to distrust, charges of being used as research material, or fear of inadequate student supervisIon. There is no reason to believe that a fully informed consumer would In fact, the Group Health example is evidence to

reject the program. the contrary.

Once members are made aware of the program benefits as

well as the costs

consumers tend to be supportive.

Educational staff - We note that a majority of the participating institutions employed a professional medical educator to assist in the curriculum construction process.

This is somewhat surprising since educators are tot

frequently employed in medical schools and, moreover, the employment of an educator was not a criteria, either explicitly or implicitly, for partici-pation in the project.

We found that their skills were extremely valuable

at every stage of the curriculum construction effort.

We recommend the

employment of medical educators in future undertakings of this nature.

6.

BehavIoral ohjeetives - Most of the institutions defined their curriculum objectives in behavioral terms, i.e., in:terms that can be measured and

118

eva uated.

We note the strong correlation between variables 5 and 6,

the employment of an educator and:the definition of behavioral objectiVes..,

The definition Of b4havioral objectives is the most crdtial step in the curriculu- construction process.

Defined in sufficient detail, they ;7

constitute the content of the curriculum.

7.

Conducted field test - We note that every Institution iMplemented their program although this was not a requirement of*the contract pating institutions realized that curriculum developme

The partici-

ithout field:

testing is of limited value; and that the field test is an es ential tool_ in initial evaluation.

WHAT DOES IT ALL COST?

Aa we indicated in Chapter 1, assessment of the educational costs in the HMO was not required under terms of the AAMC contratt with DHEW, but was required under the ter-s of the AAMC agreement with the institu*

tions.

The AAMC felt that it was important to determine, to the extent

possible, the cost of education, especially In an HMO.

As long as the

Costs are unknown, there will be continued ezistance-to education and justifiably so - on the part of HMO managers. MAny HMOs are operating on-a financially -arginal basis and they must keep their rates- competitive. An HMO manager cannot make an intelligent decision about the:program unless he has some idea of its costs.

The major accomplishments in costing were the development of a conceptual framework for estimating the -:st of education in:an HMO and the preparation o three preliminary cost studies.

119

The conceptual framework was developed by

Christine E. Bishop, Ph.D., and is presented as Resource Paper No. 14.

Two of the case studies were conducted by the Seattle and CambridgeFroups and are presented as Resource Papers Nos. 15 and 16.

A briefer study pre-

pared by the Rochester group is summarized in Chapter 3.

Ideally, the

conceptual framework should have been developed prior to the initiation of the cost studies.

seen circumstances

Unfortunately, because of time pressures and other

unfOre-

Dr. Bishop was not employed until the studies were well

underway.

The Conce tual Framework - An HMO-based education program produces not only costs, but also benefits to the HMO and its members.

Unfortunately, the benefi

are, much more difficult to measure and estimate than the costs

Technique& for

increased staff satisfaction,

measuring such benefits as improved quality of car

or recruitment of high quality staff, are either not known at this time or are too expensive to implement.

Bishop discusses some ways in which benefits may

be taken into accOunt.

Although costs are easier to measure, dete -ining which costs are applicable is not as easy as it seems.

To determine the cost of an education program we

must ask ourselves the following questions: 1.

Whose costs are we concerned with?

If we are only interested in the cost

of the education program to the,HMQ, then the students' transpo tation cbsts, for example, are not a program cost as far as the HMO is concerned. Neither is the medical school's administrative costs, although these cOsts are of great concern to the medical school.

To ket0 the cost issue within

manageable proportions, we decided early on in the project to consider only

the costs to the HMO. 2.

What are the objectives of the HMO? affect these objectives?

How do the costs under consideration

The principal objective of most HMOs is to

maximize the benefits to the membership, but this is not alwasy the case. The objective of a for-profit HMO is to maximize profits, while the objective of a physician-cont olled HMO might be to imprbve the physicians' professional environment or standard of living.

If the coat under consider-

ation has no impact on the achievement of the HMO's objectives, it is no considered a cost.

What are the incr

ental costs of the education progra 1

That is, what-are

the costs with the education program less the costs without the program 4.

How do we handle costs that are not easily measured?

5.

What are the short-term versus long-term costs?

For example, the space

costs for a developing HMO, in which the facility is underutilized -ight on a long-term basis, be considerably higher than current space cos A detailed discussion of these questions constitutes Bishop's conceptual framework.

The Cost Studies -

The three cost studies constitute initial steps in the develr

A

opment of a cost methodology for measuring educational costs in the HMO.

summary of selected data from the three studies is presented on Table 8-5 on the following page.

A cursory inspection of the table reveals that the data

are not comparable and great caution should be used before drawing any conclusions.

The University of Washington and Harvard University have continued

their cost studies since the preparation of the initial reports and are now in the process of refining the data and updating their repo

121

,

Table

8-5

THE COST OF EDUCATION IN THE HMO=

Costs

Number of Students

Duration

1st year medical students

12

13 half-days for 1 semester

1st year medical students

175

2 half-days/ quarter, for 3 quarters

8

1/2 day/week/ quarter

$4.30 per studen_--.day-li

2nd year medical students

1/2 day/week/ quarter

$79 per student-day orl $4,708 for the course

3rd year medical students

40 days

$53.20 peristudent7day-

Institution

Educational Level

Genesee Valley Group Health Association

Group Health Cooperative of Puget Sound

HCHPCambridge Center

TENTATIVE DATA

$157 per student o $1880 for the cour e

- 0 --

$225 for the course

or

$2,123 for the course

Family Practice Residents

12

Internal Medicine Residents

4

Not Available

$15,01 / esident/yea

6 months, full time

$2,100/resident/year

Excludes productivity loss by preceptor resulting from time devoted to teaching. This accounts, in part, for the difference in resident training costs between Harvard and Group Health.

IS THE CURRICULUM ACHIEVING ITS PURPOSES? (EVALUATION)

The importance of defining clearly the objectives of the educational program was emphasized earlier in this report.

Once the program has been

implemented, we must ask ourselves whether the objectives have been Have the students learned about! HMO'

care changed?

Have their attitudes toward primary

Have career plans changed as a result of the program?

For

if the program does not accomplish what it set out to do, either the program or the objectives need to be altered.

Although this was not required under the terms of the contract with DHEW, three institutions spent considerable time and energies in developing ev-luation methodologies and two of these institutions actually field-tested The evaluation methodologies and their results are

evaluation instruments.

presented in Resource Papers Nos. 9-13.

Brief summaries of these papers can

be found In Chapters 3-5.

The three institutions, Penn Urb, GVGHA, and Group Health Cooperative of Puget Sound, used a variety of evaluation me! each with its own advantages and limitations.

.i.ogies and instruments,

The Penn Urb evaluation

instruments, developed by Dr. Edwin Hutchins, wre designed with two major purposes in mind: (

1)

For replicability in other HMO settings; and

) For long range evaluation, especially with re:ect to career choice.

To

achieve replicability, each of the other participating institutions was requested to contribute test items that have general app1icability to HMO-based

123

/3

educational programs.

The results of the first field:test on a group of

27_students_indicated thataddltional work_and_taa4ng ia necessary. However, further developmental work was discontinued as of March 30, for lack of funding.

1976,

The AAHC feels strongly that this effort deserves

support and should be continued to its completion.

Dr. Hutchins has expresaed

great interest in this and we hope some means can be found to support the continuation of his work.

The University of Rochester group developed a series of evaluation instruments which were field-tested on first-year medical students and two control groups (see Resource Papers Nos. 10-12).

The evaluation design includes a

comparison between the group of students which participated in the program and a group of students which did not participate and the'results indicate that there were small but significant differences in a few areas.

The evaluation

methodology relies heavily:on sophisticated statistical techniquesi the analysis of which could conceivably cosl more than the program i:-elf.

The University of Washington group developed a series of nine evaluation instruments for its proposed clinical clerkship at Group Health.

Most of the

instruments were adapted from similar ones currently in use at the medical .school.

However, neither the instruments, which are presented in Resource

Paper No. 13, nor the clinical clerkship for which they were developed have been field-te-ted.

The package offers other institutions a rich selection of

evaluation instruments, including instruments designed for -tudent evalUation of faculty and course content.

1

PROJECT PARTICIPANTS

PROJECT ADVIBORY COMMITTEE

Samuel J. Bosch, M.D.,'Chairman, Project Advisory Committee; Associate Professor, Department of Community Medicine, Mount Sinai School of Medicine of the City University of New York, New York, New York Joei J. Alpert, M.D., Chairman, Department of Pediatrics, Boston Univers School of Medicine, Boston, Massachuset s Jack D. Myers, M.D., Professor of Medicine, Univer ity of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania Mitchell T. Rabkin, M.D., General Director, Beth Israel Hospital, Boston, Massachusetts John P. Utz, M.D., Dean, Georgetown University-School of Medicine, Washington D.C.

Eugene Vayda, M.D., Professor and Chairman, Department of Health Administration, University of Toronto, Toronto, Canada

PROJECT STAFF

James I. Hudson, M.D., Project Director, and. Director, Department of Health Services, AAMC

Marcel D. Infeld, M.P.H., Project Coordinator, Department of Health Services, 'AAMC

SPECIAL CONSULTANTS

Christine Bishop, Ph.D., Assistant Professor of Economics, Boston University School of Management, Boston, Massachusetts Arthur Elstein, Ph.D., Associate Director for the Office ol Medical Education,' Research and Development, Michigan State University, East Lansing, Michigan

Edwin B. Hutchins, Ph.D., Dean of Faculties, Indiana University-Northwest

125

.

PROJECT PARTICIPANTS (Cont.)

GEORGETOWN UNIVERSITY AND GEORGETOWN UNIVERSITY COMMUNITY HEALTH PLAN (GUCHP)

David L. Rabin, M.D., Project Co-Director, and Professor, Department of Community Medicine and International Health, Georgetown University School of Medicine Mr. John L. Simon, Project Co-Director, and Instructor, Department of Community Medicine and Interuational Health, Georgetown University School of Medicine Paul Lairsen, M.D., Executive Vice President for Clinical Services, Georgetown University Community Health Plan Ms. Kristin K. Spector, Planning Associate, Georgetown University School of Medicine UNIVERSITY OF ROCRESTER AND GENESEE VALLEY GROUP HEALTH ASSOCIATION (GVGHA) Sanford Meyerowitz, M.D., Project Director, and Associate Dean for Medical Education, University of Rochester School of Medicine and Dentistry Harold H. Gardner, M.D., Project Co-Director, and Director, Joseph P. Wilson Center, Genessee Valley Group Health Association Warren Glaser, M.D., Project Co-Director, Professor of Medicine and Coordinator for Ambulatory Care, Department of Medicine, University of Rocheste Paul L. Grover, Jr., Ph.D., Assistant Professor of Medical Education and Communication, University of Rochester Mr. Michael M. Ravitch, Associate, Division of Medical Education and CoiiunI cation, Assistant Professor of Education, University of Rochester UNIVERSITY OF PENNSYLVANIA AND PENN URBAN REALTH MAINTENANCE PROGRAM (PENN URB) Penn Charles G. Hertz, M.D., Project Director, and Medical Coordinator Urban Health Maintenance Program Urb, and Dean of Edwin B. Hutchins, Ph.D., Educational Consultant to Penn Faculties, Indiana University-Northwest University Ms. Stephanie Mallen, Educational Program Development Specialist, of Pennsylvania Program Mr. Thomas N. Perloff, Administrator, Penn Urban Health Maintenance Program Penn Urban Health Maintenance Patrick B. Storey, M.D., Director, Maintenance Ms. Harriet Williams, Educational Coordinator, Penn Urban Health Program

126

PROJECT P

_

TICIPANTS (Cont.)

UNIVERSITY OF WASHINGTON AND GROUP HEALTH COOPERATIVE OF PUGET SOUND Gary E. Striker, M.D., Project Co-Director, and Assistant Dean forCurriculum, University of Washington School of Medicine John S. Gilson, M.D., Project Co-Director, and Director of Medical Education, Group Health Cooperative of Puget Sound Frank Evans, M.Ed., Office of Research in Medical Educe ion, Univer ity of Washington School of Medicine Gregory L. Pawlson, M.D., Senior Fellow, Department of Medicine, University of Washington School of Medicine Richard Watkins, M.D., Staff Physician, Group Health Cooperative of Puget Sound

BROWN UNIVERSITY AND RHODE ISLAND GROUP HEALTH ASSOCIATION

(RIGHA)

David S. Greer, M.D., Project Co-Director, and Associate Dean of Medical Affairs, Division of Biological and Medical Sciences, Brown University Albert F. Wessen, Ph.D., Project Co-Director, and Chairman, Section of Community Health, Division of Biological and Medical Sciences, Brown University Robert G. Rosenberg, M.D., Medical Director, Rhode Island Group Health Association Mr. Kenneth L. Simmons, Executive Director, Rhode Island Group Health Association

HARVARD UNIVERSITY AND HARVARD COMMUNITY HEALTH PLAN (HCHP-CC) Matthew A. Budd, M.D., Project Director, and Staff internist, Harvard Community Health Plan-Cambridge Center Charles J. Hatem, M.D., Asaistant Director of Medical Education Mount Auburn Hospital Burt Johnson, M.D., Cambridge Hospital Robert S. Lawrence, M.D., Acting Chief, Department of Medicine, Cambridge Hospital; Director, Harvard Primary Care Program: Donald R. Lipaitt, M.D., Chief of Psychology, Mount Auburn HoSpital

127

1

7-

RESOURCE PAPERS

I.

Curriculum Develo ment Proce-s

DESIGNING A CURRICULUM IN A CLINICAL SETTING: AN ITERATIVE PROCESS Charles G. Hertz, M.D., et al., (University of Pennsylvania), scheduled for publication in the October 1976 issue of the Journal of Medical Education.

Curriculum Content

2.

A MEDICAL STUDENT'S GUIDE TO HEALTH MAINTENANCE ORGANIZATIONS John L. Simon,- et-al., (Georgetown University),Junej976.

A CURRICULUM FOR FIRST-YEAR MEDICAL STUDENTS: OBJECTIVES, SEMINARS, INTERVIEWS AND RECOMMENDED READINGS compiled from the University of Rochesterts final report to the AAMC, December 1975.

4.

CURRICULUM MODULES: RATIONAI,E, OBJECTIVES METHODS AND PREREQUISITES from thc University of Pennsylvania final report, December 1975.

PROPOSED CLERKSHIP FOR THIRD YEAR MEDICAL STUDENTS: OBJECTIVES, INSTRUCTIONAL METHODS AND EVALUATION Appendix J Of the University of Washington final report, December 1975.

6.

III.

CLINICAL OBJECTIVES FOR A PRIMARY CARE RESIDENCY IN INTERNAL MEDICINE from the Harvard University final report, December 1975.

Instruct onal Methods

7.

A ROLE GUIDE AND RESOURCE BOOK FOR CLINICAL PRECEPTORS John L. Simon, (Georgetown University), June 1976.

HMO CURRICULUM DEVELOPMENT: SOME RELEVANT INSTRUCTIONAL RESOURCES Arthur S. Elstein, Ph.D. and Jack L. Maatsch.

IV.

Pro ram Evaluation

REPORT OF EFFORTS TO DEVELOP A STANDARDIZED TEST OF KNOWLEDGE AND ATTITUDES RELEVANT TO THE HMO SETTING Edwin B. Hutchins, Ph.D., March 30, 1976.

V.

10.

AN HMO BASED PRIMARY CARE CURRICULUM FOR FIRST YEAR MEDICAL STUDENTS -DESIGN, EVALUATION AND DISCUSSION Rochester), submitted , Paul L. Grover, Jr., et al., (University for publication to the Journal of Medical Education, June 9, 1976!:

11.

ISSUES AND METHODS IN CURRICULUM EVALUATION Paul L. Grover, Ph.D., and Michael M. Ravitch, Journal of Medical. Education, December 1975.

12.

EVALUATION INSTRUMENTS from the University of Rochester final report, December 1975.

13.

PROPOSED EVALUATION INSTRUMENTS Appendix K of the University of Washington final report, December 1975.

Educational Costs

14.

MEASURING THE COSTS AND BENEFITS OF MEDICAL EDUCATION IN THE UNO S TT_ Christine E. Bishop, Ph.D., January 1976.

15.

COST BENEFIT ANALYSIS Section V of the University of Washington final report, December 1975.

16.

ME

URING THE COSTS OF PRIMARY CARE RESIDENCY TRAINING Part III of the Harvard University final report, December 1975.

129

- (0Resource Paper No. I

..

DESIGNING A CURRICULUM IN A CLINICAL SETTING:

AN ITERATIVE PROCESS

Charles G. Hertz,_M.D.--Medical Cco-rdinatar,, Penn.Urban.

Health Maintenance7Program; Associate. Clinical -PrOfessor ofPediatrice_-.and -CommunitY

-University-of Penn8Ylvania * Harriet Williams, B.A. Educational Coordinator Penn Urban Health Maintenance Program

Edwin B. Hutchins, Ph.D. Consultant to Penn Urban Health Maintenance Program

The'work upon which this publication is based:was perforMed pursuant to Contract # N01- - M13-44009 with the Association:of American Medical Colleges and the Bureau'Of Health-Manpower, Health Resources AdminiStration, DHBW. *

415 SoUth 19th Street

Philadelphia, Pa,

19.146

AO

ABSTRACT

A curriculum for the training of medIcal students

was

designed and implemented in a functioning clinical setting. The multi-disciplinary, Multi-professional staff of a primary care center participated with professional educators in an iterative process for curriculumslevelopment. A three stage plan was conceived:

behaviorally oriented educational objectives

were constructed, instructional methodologies to sati-fy these objectives were created, and evaluation instruments were designed. Throughout each stage, the educators facilitated the process by teaching the staff the necessary techniques for the design and implementation of the curriculum.

The curriculum that resulted

from this process is focused on those issues that are important to team delivery of primary care.

An important outcome of the

project is the increased enthusiasm and competence of the professional staff in the teaching of students in the health professions.

131

DESIGNING A CURRICULUM IN A CLINICAL SETTING: AN ITERATIVE PROCESS INTRODUCTION

The patterns of health care delivery in the United States 1.2

are undergoing major changes.

In settings such as HMOs,

teams of professionals from vari us fields are working collegially to provide comprehensive and efficient health care.

At the

same time we are witnessing the emergence of the patient as an active and knowledgeable consumer of health care. 4,6

However,

medical school education has done little in training phys cians to meet the derrwids of participation in alternative forms of

health care delivery.

6,7

As a way of encouraging medical schools to become more actively involved i- teaching the changing patterns of health care delivery, DHEW awarded a contract to the Association of American Medical Colleges "to support the development of curriculum for physician training in academic medical center HMOs "

The concern underlying this award follows:

"If HMOs

are to expand and become a viable alternative system of health care, appropriately trained manpower must be available." This paper describes the process by which one University rela-edHMO, the Penn Urban Health 'Maintenance Program

(Penn-'

Urb), met the terms of the Association of American Medical Colieges grant.

The project was an attempt to enrich-medical

education by creating a new curriculum that would prepare medical atudents to function knowledgeably and enthusiastically in multi-professional primary care settings.

132

This curriculum

was designed through the use of an iterative process involving both professional educators and health care providers in a functioning clinical setting. SETTING

The Penn Urban Health Maintenance Program is center located in urban Philadelphia.

primary care

Comprehensive primary

health care is provided to a socio-demographically heterogeneous population through both the prepaid capitation and fee-forservice financing mechanisms. Penn-Urb is a multi-disciplinarYr

multi-professional group organized in teams in the primary care disciplines: health care for adults, health care for children and adol-scents, health care specific to women, psychosocial health care, and dental health care. The multi-professional staff is composed of physicians, nurse practitioners, a physician's assistant, dentists, a social worker, an economist, a sociologist, a librarian, and an,educator, as well as clerical and technical' support staff.

Since Penn-Urb has been operational for less than three years, its clinical sta :f is sufficiently small to function as a unified group.

Currently, that staff, which consists of three

internists, two pediatricians,,an obstetrician-gynecologist, psychiatrist, four nurse practitioners, a physician's assistant, a social worker and two dentists, provides 18,000 patients visits

a year. The patient population is Currently increasing-at a rate approximately 5% a month.

Penn-Urb, wh ch is sponsored by the University of Pennsylvania,

was formed as a model unit; as such, it is a setting in which educak

ti n and research, as well as service, are integral components of the organization.

Although the professional staff considers student

education a legitimate organizational function, it regards direct patient care as its most important and challenging function. The project described here was designed to improve the quality of education offered to the students by the health care providers.

The professional educators assumed that the more

involved the'health care providers became in the process of curriculum design, the more their enthusiasm for participating

in the educational endeavors of the organization would increa e. Since at the start of the project, many of the health care

professionals regarded education of students as a burden, an iterative process served to involve them gradually in curriculum. development.

At each stage of the project, professional educa-

tors worked with small groups of health professionals to teach them the educational principles on which a curriculum is built. Frequent short meetings between the educators and the health care providers were planned for several reasons.

The demands of the

practice made long contacts difficult to schedule.

Also, the

amount of educational information to be transmitted to the providers would have been overwhelming unless presented gradually. The iterative process allowed an opportunity for the educators to reinforce the providers' growing educational competence and interest during each stage of the project.

The Association of American Medical Colleges contract mentioned earlier specified that the University "would undertake to work in the development of curricula fo-

7raining medical students

in the University Affiliated health main_enance organization (MO)."

tRq The scope of the project was broadened at Fenn-Orb, however,

to allow

the training of other health professionals in a

multi-disciplinary, multi-professional team setting. PLAN

A 3-stage plan was conceived to carry out the curriculum design project. 1.

Initial decisions would be made about the scope of the content domain.

2.

The specific ite s to be included in the curriculum would be classified according to a standard taxonomy er 9

of educational objectives. 3.

Detailed curricular plans were to be designed to meet the educational objectives.

The medical coordinator of Penn-Urb, who was also the project director, made several decisions at the outset of the project. The first was that the technical knowledge essential to the'

development of a sound curriculum should be provided by an expert in the field of education.

It was felt that health care

providers generally lacked the necessary training to design uhe truly innovative curriculum that was called for.

Further, an

explicit goal of the project was to upgrade the teaching competence of the health care professionals through their participation in the design and deliver', of the curriculum.

Therefore, a search was

conducted for a pr.)fessional in the field of medical education

who had previous experience in stimulating cooperation among educational experts and several types of health professionals.

He was to work with the project as a consultant, charged with

3

IA5 the responsibility for implementing the overall plan. The educator at Penn-Urb became the educational coordinator for the project, and assumed responsibility for the daily supervision of the project.

Another decision was made to include the entire professional staff in the project's design and implementation: A rationali

of the project was to increase the inte est of the staff in the teaching of medical students, but since these medical students were to be trained to function as members of multi-professional teams, it was also considered important for them to be expost:'i

to all professionals, not simply to physicians.

Those aspects of medical education that are part of the traditional medical school curriculum were not to be included in the Penn-Urb curricululd.

The educational focus of the Penn-

Urb curriculum was to be on the unique features of the delivery f health care in a rationally designed multi-professional *

primary care setting. As such, it would be potentially applicable to health professional students from fields

such as nursing,

social work, health care administration' the allied health professions and dentistry.

CREATION OF EDUCATIONAL OBJECTIVES Efforts were made to involve the professional staff as early as possible.

A rough outline of possible curriculum items was

generated by the educators.

The itemS were diVided into six

sections:

136

1.

Primary health care comprehen ive car and characteristics of the system. The health care team:

roles and responsibilities of

different health care practitioners in a primary health care team Active consumer participa ion in an organized health care setting. 4.

One quality.health-care for all.

5.

EconomicsofilMOs'.

6.

Sociologic viewpoint on innovation and organizational 'Change.

The curriculum items were presented.in-a_behavioral .jobjectives',

format. This rough notion of a -curriculum:was:intended. to-:H.

generate criticism and comment from the:professional staff.

The behavioral fo _at was introduced-so the educatorS could discuss with the staff the importance,ef:.behayioralli.stated

objectives as the basis of a'rationally designedClirriculum. As an example, one item in section 1 of the original-outline folio s: 1.2

.The student should .be ableto Articulate. the_impetus

for the development of organized Systems of health care delivery, in terms of 1.21

Maidistribution oi7 service.

1.22

Overspecialization

This set of objectives was presented to the staff in a series of structured interviews between pairs of professionals' and an educator.

The staff members were asked to comment onthe....,

relevance and correctness of ehch item.

They were-then asked'

egenerate othecitems they considered essential-to. the.curriculum. These-.interviews. alto provided .an opportunity for the.educators to- explain the 'rationale guiding the,. projeat

the.strategies

involved in writing behavioral objectives, d-d the steps that would be taken.to complete the project. -When the interviews were completed, .the educators rewrote

the educational objectives in-line-with the staff7s. feedback.'

This-new document was then circulated.among the stiff far: further revision and comment.

Once againt-the Penh4Urb staff

suggested many changes that were incorporated.intq-athird. version of the objectives. Its substantive comments-indicated that the iterative process had, in fact, -proved succeSsful

in inVolving them in the cur -iculum development.- ,it was obvious both to the educators- and to the health care providers that the objectives now reflected educational, material that' the providers

actually wanted to te ch to the students. As an example of the scope of the revision provided by the Profe'S ional staff, the

final form of the educational objectives for the previout example -follows:

1.2

Given an openended question on.health.care delivery in America, the student should be able to state the following factors underlying the development of HMOs. 1.21

if asked about the distribution of health care the student should be able'to indicate the range of patient/physician distribution.

1.22

If the student is asked to describe the role of the profit motive in shaping traditional private practice, he should'be able to do so.

1.23

The student should be_able to answer questiona on the U.S. commitment to health care-delivery using comparative material from other national systems.

DESIGN CIF_INSTRUCTIONAL TECHNIQUES

Meetings of the entire profesSional staff of Penn-Urb were: also used by the educators to teach the-staff-how-to-deSigif instructional modes to, meet-the educational objectives. The

process of matching instructional strategies to partiCular o

objectives was detailed, methodologies were provided.

and many examples of instructional-

The Staff Was asked to.divide into

groups, each of which was charged with refining the objectives for a specific section of the curriculum and creating the methodologies for that section.

The six groups met approximately

twice weekly until the task was completed.

At each.group meeting,

an educator was present to facilitate the progress,of-the During the group meetings, the educator's .once again described

the range of available instructional modes.

Many instructional

options were presented to the groups, including the creation .of

audio-visual materials, the construction of bibliographies, and opportunities for students to participate with multi-profesaional teams in the provision of health care.

The groups

were encouraged to match educational modes to fit the content of each objective.

The educators also stressed the advantages

of active participation, rather than passive listening, for the learning process.

.

THE_ pumummum An innovative curriculum useful in a variety o_ formats resulted from this project. The Penn-Urb- staff offers three courses to undergraduate medical students: a one-week intensive interdisciplinary lecture course, a longitudinal course in which the student participates in the care of selected families, and a one-month clerkship at Penn-Urb. The clerkship

__

was chosen as the focus' of the Cdiriduiar effort because it presents the opportunity for most intensive exposure to PennUrb.

The clerkship, an elective experience offered to undergraduate medical students who .have completed the-baeic clinical courses, now provides a structurecL intellectually stimulating ,eXperience, as well as clinical practicuum in primary care, a6 a result of the curriculum development project. The enriched

curriculum is typified by Section 4/ entitled "One quality health care for all." A pediatrician, an adult nurse.Practitioner ..and..a physician's assistant- were -responsible-for-

the-:-

design of the instructional techniques for this sectien. This .group decided that the medical students should learn_how well' the health care system in the United States meets (or does net meet) four criteria: accessibility, accountability, continuity, and comprehensiveness. To meet this objective, several strategies were adopted. A bibliography on the state of the current health care.delivery system in the United States was assembled. After the student:a complete the reading, they are asked to

Interview three patients at Penn-Urb about the quality of their current and past settings for health care with respect to the four criteria. A structured interview form for student use was created by the professional group. After the students interview

140

.

patients, they view a videotape made by the group who: de-igned-this section of the curriculum.-

The tape contains in-depth

interviews with three patients of different socio-.66onomic classes concerning their- suecesses and failures in obtaining satisfactory primarY health dare. The last step -for the students is a meeting with the members-of-the-staff:to- explore

.

reactions to the issues raised by:thi8 section-ofthe ourrioulUm. arganiiitibn-aI'iffuCfuri7TPi'-e-jeht6'aTdh14ii:d7---

opportunity for medical students to participateA.n:the team

delivery of health care, the seCtion entitled "Health..eare_ team" is a central cemPonent in the curriculUm. --There-Aw:

bibliography available on the roles of the .nonphySicianOravider6in the delivery of health carejand the .students Spend..-aPproXi--

mately 1/3 of their time at Penn-4Jrb working with thaSe*inds of providers.

The specific contribUtions of the non-physician

provider-5 to the health care of the-patients are emphasized. -Purther, the active.participation of-the. entire professional-

staff in the presentation of the curriculum reinforces the notion of nurse practitioners

physician's assistants, and

social workers as colleagues.

Although the professional staff.was asked to focus on the medical student clerkship in its curriculum.design.-efforts the instructional strategies were easily adapteef for other uses.

The staff at Penn-urb ha

offered a course to students from

several health professional schools at the University of Pennsylvania.

The course, which is entitled "Introduction to

Comprehensive Health Care Systems,"

taught twice yearly as an

intensive one-week experienpe .to medical, dental, nursing, allied

.health professions, health care administration and social work

141

-Students. 'The educational objectives served as a,guide for--

the organization of 'the course, and the.instruetional. strategies -ere-adapted for use with a large group.Wherever_posaibie.

Another benefit -fthe Curriculum:project was that .each'meMber of..the staffwas prepared to.teach some -part.ok..ibe course

.

and can therefore participate substantively In the course. .

_

,EVALUAT_ION

The iterative process used in thecur-iculUm pian_ing extended as well t6 the evaluation design.. .InitiailY, tha educators described to the provider stalItheir.previouS exper ence

with evaluation of medical students, especially with resPect to career attitudes, career choices, critical incidents, medical

school environment

and interpersonal perceptions as.measured 11/12 by semantic differential.

The staff, in dialogue with the educators, then pro-

posed areas for evaluation, based on the educational objectives of the-Curriculum.

It was decided that evaluatiOn should focus

on areas such as:

attitudes toward various types of careers within medicine,

attitude measures relating to other health care team members,

° tests of knowledge about specific asp4cts of pr mary comprehensive care and HMOs.

142

The educators specified the most appropriate formats for testing, and the health care providers assumed the responsiblity for generating the poel of questions from which the final' testing' tools were created.

The product of this iterative exerciSe is a

series of evaluations which provide diagnostic and summative evaluative data. RESULTS

The curriculum development project was successful in.mee ing the initial plan.

A curriculum for the medical student cler

was developed; this curriculum has been adapted easily requirements of the lecture course taught by the Penn-Urb staf

The objectives are an explicit statement of the curriculum conten that the Penn-Urb staff feels it should teach to'students in the health professions.

Since the educational objectives of Penn-Urb

are new specific, as new opportunities t_ bffer courses aris

Penn-Urb has available the basis of- a- -ound eurriculUm onwhich to build. Further, the objectives will serve as the core around which a curriculum for students in the other health professions will be constructed. The core contains cognitive and affective objectives that are applicable to students from many disciplines; .

_

what remains to be designed are those pbjectiVesthatAdil focus sPecifically on the roles of the nonphysician professienals in the clinical setting.

It -ould appear that including the entire..professional group in the design of the curriculum for medical students contributed significantly to -the-success of .the p on_vt. The educational objectives- embody a broader range of topics than: they would-have had they been created by the educaters- and

physicians alone.

Another cutcpme of the project is that the p ofessional staff has become more directly involved in the proceed .Of-. educating medical:students.

As the PennUrb staff has parti,

cipated more fully in the educational planning of .the organi-: zation, its commitment to providing ediication has:also inoreaSed. The overall result is that a structured, substantial.curriculum :.is now being bffered enthusiastically to students at Penn-Urb-.

144

ACKNOWLEDGEMENT

The entire professional staff of the Penn Urban Health Maintenance Program, especially Patrick B. Storey, M.D.

Thomas N. Perloff, M.Sc

arian Williams, M.S. this project.

has been instrumental in

Bate6;. B.

Ddotor-arid Nurse

Reiationshipsi: N. EngJ.Med.

Changing-±Roles-ahd 283 1970.

ana Deatba -Parker,-A.-W-The,TeamHApprOach*to-Primary:.Health-Cars, Neigbborhood-Health-tenterSeMinar:ProgramMonOgral*--Serles:13,HOniversity Extension,tniVersity.:piCalifornia,BerkeleY, 1972. Tosteson, D. C., The Right to Know: Public Education for Health. J. Med. Educ., 50: 117-123 1975. 5.

Hertz, C.G. Bernheim, J. W., and Perloff, T. N., Patient Participation in the Problem-Oriented Sys em: A Health Care Plan, Medical Care, 14: 77-79, 1976. Hi her Education-and the Nation's Health:. cies Medical and Dental Education, Carnegie Commis ion on Higher Education, New York: MoGraw-Hill,.1970.

Sheps, C. G, Faculty Tradition and the HMO., 7. of Med. Educ. 48: 34-40, 1973. Bloom, B.S. (Ed) Taxonomy of_Educational Objectives Handbook: Cognitive Domain, New York: David-McKay,, 1956.

Krathwohl, D. R., Bloom, B. S. & Mos a, B. B., Taxonomy Educational Objec-tives Handbook II: Affective Domain, New York: David McKay, 1964. 10.- :Mager, R.-. F.,-Preparing Objectives for Instruction ,Calif. Fearon,- 1962. 11.

Hutchins, E. B., and Wolins, L., Factor Analysis of Carepr Attitude Data (unpublished manuscript).

12.

Hutchins, E. B. and Nonneman, A. J., Construct Validity of an Environmental Assessment Technique for Medical Schools, Technical Report No. L661, Association of American Medical Colleges, February, 1966.

146

Resourde Paper No. 3

A CURRICULUM FOR FIRST YEAR MEDICAL STUDENTS *

Curriculum Objectives

The Seminars

StUdent Interviews with GVGHA Department Chiefs

Recommended Readings

From the University of Rochester Final Report Project To Develop Curriculum For Physician Training in HMOs

CURRICULUM OBJECTIVES

criculum 0 A.

ectives:

Cognitive Objectives - By the'c mpletion of and consistent

h the

material presented in the course, the student should be able to: 1.

Define the structure and/or describe the function of the following primary care system components:

PriMary Care Family Medicine

UrgentVisit Clinic Pre-paid Group Practice Centralized Appointments Financing, Marketing, Hospitalization Describe the function of the following personnel:

=71:47:1e't t;31;1:1=cian

Medical Social Worker Medical Secretary Receptionist Patient Advocate Dietician Medical_Speciaiist Stalf Nurse

_

Licensed Practical Nurse House Officer Intern Optometrist Physical Therapist Occupational Therapist Psychiatrist PSychOlogist

Describe and contrast in written formthe structure of at least three types of Health Maintenance Organizations, including One Closed-Panel Prepaid Group and One Open-Panel Foundation, as to: Financing Organizational Hierarchy Marketing Hospitalization Legal Basis 4.

List the standard procedural steps for a) Client Regist b) Patient Processing at the HMO.

5.

Observe and describe in writtenform the process whereby at least two clients joined the HMO including the following phases: Forms of initial contact Comparison of formats Bases for decision Administrative proe- s ng

and

UT

Collect through interview and describe in written form those expectetions which at reast one patient held for the-following HMO staff before and after receiving care:

.Primary Care Physician Medical Specialist Nurse Practitioner Receptionist Other Staff Encountered ObservehAnd describe in writtenjog. form.the. process whereby .at.leae-_ one client entered and was served by the HMO for a) routine examination and b) specific complaint, including the follówing components:::

b. c. d. e. f. g.

h.

Reasons and.timing/presenting complaint Telephone number Appointment mechanism Entry points Identifying information Sequenc of HMO personnel contacted including their decisions and actions Mechanisms to det ct unidentified illness and monitor personnel performance Any 'shift or conflict in patient expectat ono

Construct a written operational analysis of the roles and relationships of the HMO staff including: .

a...

Division .of_labor

b.

Hierarchy of patient distribution

. Referral decision points d.

e.

Ranges of diagnostic specificity Administrative accountability

Construct a written operational analysis of the tasks of the primary care physician including clinical examples of the following components: a.

b.

e. f.

g.

h. i.

The setting in which the physician/patient encounter takes place Assessing initial complaint through observation of patient's behavioral and physical characteristics Forming first order hypotheses Hypothesis testing by further interview, physical examination, laboratory and special diagnostic procedures Assessing psycho-social health modifiers Weighting complaints Describing relevant social context Identifying and classifying problems (Weed) Forming specific diagnoses

10.

Analyze deficiencies and propose corrective measures relative to availability, continuity and comprehensiveness of care, given:

he

At least two case histories containing care system inadequacies, The HMO under study Affective Objectives 1.

Attitude Questionaire - Maintain or itcrease Post vs. Pre score on:

d.

Attractiveness ranking of specializing in Internal Medicine, Pediatrics, or Family Medicine as compared with other specialt Ranking of care availability, continuity and comprehensiveness as compared to other characteristics Osgood Semantic Differential applied to Role of Primary Care Physician, Nurse Practitioner, Health Ranking of importance of HMO Personnel Maintenance Organization as in comparison with other health and non-health related professionals

Unobtrusive measures - For validity, the following measures of the course'sstudents will not be informed of impact:

b. c.

At least 50% of participating students will select HMO elective experiencein second year At least 50% of participants will spend at least lhriwk above required class hours,at Wilson Center The scope _and_degree of_detail of-courseprojects produced byll 0 elective students will voluntarily exceed that of projects produced by 80% of students choosing other task force options

Cour _= evaluation questionnaire

student ratings of:

Course and Instructors for the first year courseHin Conrnunity. Medicine, HMO eijbgroup will equal or exceed these ratings given by 80% of the course's other task forces .

.

THE SEMINARS

CURRICULUM OUTLINE

First Seminar - Organizat1n__of Group Practice 1.1

Entitlement 1.1.1 Expectations in the doctor/patient relationship 1.1.2 Private practice .1 No legal requirement to continue care Payment expectation not certain .2 Prepaid group practice - mechanism to firm up expectat ons on both sides of doctor/patient relationship

1.2

Prepaid Group Practice Organization 1.2.1 Diagram of Genesee:Valley Group Health Association (GVGRA) organization 1.2.2 Contractual relationships between insurer, consumer and providers .1 Balance of services with premium cost .2 High premium costs and the self-defeating spiral of 'rising costs .3 The medical group at risk Risk forces efficiency .4 Internal mechanisms for care delivery .5 Insurer's functions (capital, advertising) .6 Entitlement ("contracted benefits", representation in .7 plan operation) 1.2.3 Distribution of premium income 1.2.4 Critical enrollment level

1.3

Medical Foundation Plan 1.3.1 Diagram of foundation plan 1.3.2 Characteristics .1 Similar to traditional free enterprise insurer's benefits extended to office care .2 1.3.3 No controls on costs such as hospitalization 1.3.4 Limitations on free market. controls 1.3.5 Illness-skewed population and cost overruns 1.3.6 Risk

1.4

Rochester Blue Cross/Blue Shield 1.4.1 Membership (85% of population) essentially hospitalization 1.4.2 Basic coverage 1.4.3 Governing board - industry representatives 1.4.4 Industry - Premiums, hospi'al costs 1.4.5 Blue Shield Founded by health providers .1 Governed primarily by surgeons .2 Repayment and specialty interest .3

151

1.4

Rochester Blue Cross/Blue'Shield (Con'd) 1.4.6 Major medical supplements 1.4.7 Blue Cross/Blue Shield and local governance

1.5

Peer review 1.5.1 Necessary to control qual ty 1.5.2 Allows decentralized control

1.6

Summary 1.6.1 U.S. health care - 8% of GNP Tax dollars - 50% . 1 2. Consumer and government objections 1.6.2, Efficient health care organization as an answer .

Second Seminar

Financin

of Grou. PracticE

Economy of scale allowing self-perpetuation

2.1

Goal:

2.2

Organization phases 2.2.1 Preoperational 2.2.2 Deficit 2.2.3 Operational

2.3

Evolution of MIGHA 2.3.1 Rochester Blue Cross/Blue Shield versus excess hospitalization Factors encouraging hospital construction .1 Hospitals and increasing health-care costs . 2 Bases for comparison (beds/1000 populationi .3 hospital day utilization rate) 2.3.2 Rochester Blue Cross/Blue Shield and group health alternatives

2.4

Preoperational phase 2,4.1 Community study co= tree 2.4.2 Preoperational plann ng

2.5

Deficit phase 2.5.1 Boundaries: First patient to self-perpetuation 2.5.2 Cash reserves necessary 2.5.3 RMO and the health-care community 2.5.4 Controlling hospital day utilization Savings to Blue Cross/BlueShield .1 .2 Limiting referrals Pressures for hospitalization in private practice ..3 2.5.5 Costs .1 Facilities .2 BaSic Service.Croup .3 Administration Advertising 04

152

2.6

Operational phase 2.6.1 Definition: Member fees = Expenses 2.6.2 Critical mass: 30,000 population 2.6.3 A cross section of population necessary

2.7

GVGHA and alternative plans 2.7.1 OVGHA a true HMO 2.7.2 Neighborhood health centers (NHC),dependent on federal subsidy 2.7.3 Medical foUndation - economically unsound

2.8

HMO attrition 2.8.1 Inadequate funding 2.8.2 Lack of administrative systems

Third Seminar - Facilities Deyelopment 3;1

Planning Group Health Ambulatory Care Facilities 3.1.1 Predictions from population statistics 3.1.2 Maximum population for one center: 30-40,000 3.1.3 Accessibility 3.1.4 Adaptability to unpredicted needs 3.1.5 Services mandated by law

3.2

Satellite Expansion 3.2.1 Regional dispersion 3.2.2 Primary care staff only 3.2.3 Capital accumulation difficult 3.2.4 Static HMO -1 Population growth -70vercrowding -7Decline in care 3.2.5 Efficiency increases up to 100,000 members 3.2.6 Projected local sites 3.2.7 Problems of medical records 3.2.8 Advance planning and construction avoids overcrowding 3.2.9 Problem: When stop expansion for profit taking? 3.2.10 Expansion increases impact on'hospitalization

Facilities costs - Wilson Center 3.3.1 Construction - $3.2 million - $50/square foot 90 examination rooms . 1 Modular design .2 Based on Kaiser Portland program . 3 Operation: Utilities, maintenance, rent 3.3.2 3.4

HMO and hospital cooperation 3.4.1 HMO can predict hospitalization rate From this the hospital can plan census and adjust capacity 3 .4.2

3.5

Costs of Rochester Health Plan alternatives, 1975-76 3.5.1 GVGHA - close to basic Blue Cross/Blue Shield 3.5.2 NHC - significantly more 3.5.3 Medical foundation - premium has doubled - skewed patient population 3.5.4 RisA. sharing - necessary component of HMO

3.6

Student Questions 3.6.1 Q: Role of Psychiatrists at GlIGHA? A: Consult and treat psychosomatic as well as frank psychiatric problems 3.6.2 Q: Urgent visit mechanism? A: Phone triage by nurse, physician reserved for seine day appointments 3.6.3 Q: Is GVGHA enrolling a younger population than overall Blue Cross/Blue Shield? Will costs rise when older population admitted? A: No, enrollment profile not different. No, 20-44 age bracket use significant number of OB beds. Fifty percent of last month's hospitalization OB. 3.6.4 Q: Pattern in failure to re-enroll? A: No, termination rate less than 1% 3.6.5 Q: Loss ratio? A: Amount used for benef ts compared with administrative costs - GVGHA loss ratio 94%, objective 96%

Fourth Seminar

Staffing for Com rehensive Health Services

_4.1- Student knowledge and attitudes-regarding health care givers 4.1.1 What is an optometrist? (Few students knew) Specialized in-depth training .1 Comparison with ophthalmologist, optician .2 Legal restrictions and professional collusion .3 result in underutilization 4.1.2 Restrictions and underutilization common among health professions .1 .Example - nutritionist, at GVGHA counsels and consults .2 .Example - nurse clinician +general ignorance among students regarding nursing) 4.1.3 Emphasis - physician ignorance of other care givers 4.2

Comprehensive health care (CHC) 4.2.1 Even the best systems have limitations list determine definition 4.2.2 Definition - local resoUrces and source of 4.2.3 Need to shift from medical care to health care Health insurance deals with "cure" problems .1 Most resources needed for "care" problems .2 C.H.C.Team - 50% medical, 50% other personnel (care based 4.2.4 4.2.5

on need,not prerogative) Benefits - monitoring of performance and varied inputs

1 54

4.3

4.4

4.5

GVGHA staff organization 4.3.1 Executive committee - represents 'all services, de-ermines staff policy 4.3.2 Physicians share control 4.3.3 RoleAetermination No job descriptions .1 Freedom to assume care roles .2 Regulation by personal responsibility and internal .3 accountability by as many people As possible 4.3.4 Flexible system - skills given be forced to work with, 4.3.5 Emphasis - physicians will soon not above, other health professionals Physician - Nurse Clinician teams 4.4.1 A colleaguial relationship of peer professionals and skills 4.4.2 Each provides unique knowledge male, uncontrolled hypertensive. 4.4.3 Team example - 55 year old medication, nurse clinician Physician considered raising end diet before more recommended working on home stress medication. psychosocial aspects of problems 4.4.4 Nurse Clinician diagnoses physician or nurse 4.4.5 First patient contact - either 4.4.6 Nurse clinician as counselor .1 Time less expensive than physician's One-third less patients for longer periods .2 routine problems (e.g. vaginitis, sore 4.4.7 Nurse clinician manages throat, family, planning) health team 4.4.8 The patient as part of the 80% routine physician tasks Nurse clinician capable of 4.4.9 Primary care definitive 4.5.1 Diagnoses seldom easy, clean or 4.5.2 Medical school preparation Emphasis on explanation of every sign and,symptom, .1 Unrealistic for primary care -can't explain everything .2 complete explanations 4.5.3 Clinical judgment replaces Nursing training for primary care .1 Long term observation and assessment of cr tical .2 factors-

4.5.4

4.5.5

H use officer dependency on technology .1 Overuse of lab tests High.cost substitute for anilytic,thinking .2 Primary care learned by dealing with people

155

1 --

4.6

Effect 4.6.1 4.6.2 4.6.3 4.6.4

of staff organization on ca e After hours call rate - 30% of other groups 30% of services from non-physicians Per client visits per year - 3.91 Substitution of non-physician services saves methhers money

4.7

Nursing 4.7.1 Types of nursing education - Midwife, LPN, RN(types), MNP, PNP 4.7.2 MNP and PNP - Nurse with physical assessment skills 4.7.3 Primary care nursing coordination of care for comprehensiveness and continuity 4.7.4 The legal definition and redefinition of nursing 4.7.5 The nurse's "right" to practice some skills now defined as "medical"

Fifth Seminar - Consumerism and Group Practice 5.1

Rise of consumerism 5.1.1 Traditional physician control of health care system 5.1.2 Lack of consumer involvement 5.1.3 Need for cost containment 5.1.4 Unification of consumer special interest groups 5.1.5 Possible physician/consumer relationships . 1 Cooperative synthesis Continued adversaries . 2

5.2

Consumerism as a corrective mechanism 5.2.1 Traditional situation - malpractice suit the only corrective feedback 5.2.2 Limitations of free market mechanisms "closed" practices .1 .2 M.D. shopping discouraged Problems of consumer edncation 5.3.1 Example - Yale-New Haven trained community workers to AnZorm members regarding health care and costs 5.3.2 Informing labor leaders 5.3.3 Question-of phySician responsibility 5.3.4 Reluctance of patients to question

5.4

The consumer's role in health care 5.4.1 Definition of needs, not means of delivery 5.4.2 Misapplication of pressure on delivery mechanicms 5.4.3 Delivery mechanisms the professional's responsibility 5.4.4 "The better the system, the fewer (more appropriate) appointments" GVGHA 2.8 physician visits/year, 1.1 non-physician visits/year; nationally 4.5

156

Malpractice 5.5.1 Lawyers view as quality control mechanism 5.5.2 Suit frequency and amount proportional to resources 5.5.3 The decline of auto liability and rise of malpractice as sources of lawyer income

Sixth Seminar - Clinical Proble

in the Primary Care Set ing

6.1

Diffe ential Diagnosis of Strep Throat (Pharyngitis) 6.1.1 Sign: observed, objective data 6.1.2 Symptom: subjective data, reported by patient 6.1.3 Example: typical signs and symptoms of strep throat 6.1.4 Aspects of fever: significance, sites 6.1.5 Array of possible diagnoses 6.1.6 Tests useful in differentiation: incl WBC 6.1.7 Other differential signs: liver, spleen, adenopathy

6.2

Problems of primary care diagnoses and treatment 6.2.1 Presenting symptoms outnumber signs 6.2.2 The quest for "objective" data: laboratory tests and surgery 6.2.3 Diagnosis and treatment on the basis of symptoms .1 Appropriate in ambulatory care . 2 Reliance on the body's healing processes 6.2.4 "Sequellae of intervention fequently more serious than most disease processes" . 1 Johns Hopkins study: 40% medications given in error . 2 Strep throat: penicillin may be more dangerous than natural disease process Symptomatic treatment: conservative, most conditions self-limiting

Seventh Seminar.- Marketing Group Health Insurance 7.1

Advertising 7.1.1 Mass media costs 7.1.2 Alternatives to mass media .1 Targeting on-site presentations to certain populations .2 Member recommendations to co-workers .3 Open house nights 7.1.3

"Service sells, not advertising" - Sloan Institute study: Peer information process most important in health care decisions

157

7.2

Physician inv lvement in marketing limited

7.3

Group health and industry 7.3.1 Many industries restrict on-site promotion 7.3.2 Efficient HMO offers Savings for employers 7.3.3 Allow's employersto offer a choice of benefits

7.4

NHC and GVGHA Two health care plans in competition 7.4.1 Simultaneous marketing confuses consumers 7.4.2 NHC and its advertising designed for inner city population no threat to suburban physicians 7.4.3 GWHA population a cross section of Monroe County 7.4.4 NHC . 1 High federal subsidy allows inefficiency .2 Population 5% prepaid - not or4anized for prepaid practice .3 A federation of independent centers . 4 Administrative costs - 45%, GVGHA's 9% 7.4.5 a federation nf independent centers . 1 Duplication of administration . 2 Each local community group pressed for complete services; therefore,redundancy of expensive secondary services (inappropriate consumer control) 7.4.6 GVGHA services located in one facility, NHC refers client to specialists outside organization

Eaghth Meeting - Patient Home Visits 3 .'1

(Preceptor

and three students)

Student #1 - Patient, Mr. M.S. Mr. M.S. is a 50-year-old caucasian male. Diagnosed approximately four months ago with cancer of the lower GI tract. Excision of the primary lesion and the lower portion of the rectum gave remission of symptoms for approximately two months. He was rehospitalized two weeks ago with extreme lower back pain radiating posteriorly down the legs. Preceptor feels the prognosis is poor. His pain is relieved only by closely regulated large doses of a mbrphine derivative in hospital. He seemed in relatively good spirits and comfortable with the hospital care. Each student asked questions about his symptoms.

.2

Student #2 - Patient, Mrs. M.S.

Mrs. M.B. is a 52-year-old black female diagnosed with hypertension and renal failure within the last month. She has started dialysis at Rochester General and now is dialyzed three times a week. Student interviewed the patient for approximately ten minutes, tracing the history of her problems over the last ten years. Preceptor palpated her ankles and asked several questions regarding her progress. Mrs. M.B. was concerned about taking a two week vacation to visit relativesin a southern city. Preceptor said he would call ahead and make arrangements with a hospital for continued dialysis i N

Student #3 - Patient, Mr. C.

8.3

.

Mr. C. is a 67-year-old white male with chronic atherosclerotic Ilart disease and a neurological deficit, probably due to atherosclerosis. He retired three or four years ago, after a number of minor heart attacks and is now confined to a wheelchair. Mr. C's neurological deficit effects his legs and speech. He also has diabetes. Within the last year his wife has suffered a minor heart attack which required that she be hospitalized while Mr. C. was placed in a nursing home. While at the riursing home for three of four weeks a therapist Preceptor is succeeded in reambulating him to 'some extent. The student possible. concerned that he continue to walk as much as condition and medication. asked several questions regarding Mr. C's

8.4

Assignment: Following visits with all patients, preceptor assigned students to study their chart and construct a'history of their illnesses.

8.5

Student Comments 8.5.1 Preceptor "..is evidence contradicting those who say that internal medicine and primary care are not challenging fields." The student amplified, saying that his parents and others 8.5.2 in his family expect hiWt(515ecome a specialist, and he has argued the value and challenge of primary care as a 8.5.3

Other students have also expressed increased understanding of the challenges offered by internal medicine and primary care.

Ninth Meeting - Primary Care Task Force Reports (Medical Center Recall Session) a

9.1 Metropolitan Hospital Group Practice 9.1.1 Patient contact mechanism Students make first contact by phone . 1 Interview times difficult to arrange . 2 .3 Patients suspicious of medical students' motives Student frustration - "Problems could have been avoided .4 by preceptor contact" 9.1.2 Contact with health care professionals (HCP) No continuous contact . 1 Wide range of different H.C.P.'s . 2 9.2

Urban Family Practice Group 9.2.1 Patient contact A patient assigned to each student . 1 Minimum of one home visit . 2 "Overall little patient contact" . 3 Elementary school mental health sere . 4 9.2.2

H.C.P. Contact

Inner-City Health Center 9.3.1 Patient contact - limited to observing one patient in the system. Will not be' astigned a patient. 9.3.2 H.C.P. Contact .1 Administrators .2 Community Services Pnblic health nurse - Difficult to arrange meeting

9

.

9 4

Residential Neighborhood Health Center 9.4.1 Patient cOntact - soon to be assigned 9.4.2 H.C.P. contact - continuous experience with a physician 9.4.3 A few small research projects begun

9.5

GVEHA 9.5.1

Patient contact - patients assigned to individuals. Many contacts already made. Preceptors involved. H.C.P. contact - Continuous.contact with physician preceptor plus interviews with range of H.C.P.'s .

9.5.2

Tenth_Se 'ner 1

Plannin

Student Clinical

_

esentations

Assignments Patient Problem

Student

Patient

1

Mr. M.S.

Ca colon, terminal

2

Mrs. M.D.

Renal failure

Mr. C.

Chronic acherosclerosis with neurologic complications

4

Mrs. E.W.

Ca breast, spinal met stases

5

Mr. F.U.

Minor CVA

Mx. H.

Post-second EVA, chronic emphysema Ten-month old, developm ntally retarded

7

8

9

D.F.

Eight-year old with nephrotic syndrome

10

A.S.

Four-year old, mild mental retardation

11

W.D.

Adolescent, Sydenham's Chorea

12

T.V.

Twenty-month old, spina bifida

160

10.2

10.3

Presentation format 10.2.1 Briefly present the clinical entity relevant to patient and family, 10.2.2 Summarize identifying data constellation including age and family the clinical problem/ including 10.2.3 Present a brief history of sequential onset, high points of course, present status personnel involved 10.2.4 Characterize the health care 10.2.5 Make prognosis 10.2.6 Length - 5 to 7 minutes Student comments visits. 10.3.1 Student #3 - patient's wife refuses further wishes, unavoidable" "Aware of situation, respect Preceptor: with patients they are more at ease 10.3.2 Many students stressed than at beginning of semester. Preceptor: "Has seen great increase in overt confidence" regarding taking more from patients 10.3.3 Concern was expressed than able to give. Students are benefitting patients by giving Preceptor: em attention expressed over feeling unprepared 10.3.4 Some minor frustration to interview and examine

Eleventh Se inar - Student Clinica Note :

Presentations of students 1, 2, and 3 not recorded due to (home visits) observer absence. Refer to eighth meeting for description of patients.

Twelfth Seminar 12.1

Presentation

Student Clinical Presentations.

is a one-year-old male born nine Student #7 - The patient, is diagnosed as developmentally weeks premature. His present condition due to frequent apnea during the retarded. This situation,is probably J.F.'s mother five weeks in which he was hospitalized postpartum. fifty times stopped brathing at least -estimates that he must have these occasions, the On at least two of in the hospital and at home. retardation wete first The symptoms of oxygen deprivation was severe. rapidly. He has since apparent when J.F.'s head growth accelerated deficit and performed poorly been diagnosed as having a motor skills It is the opinion of the pediatric on a Denver developmental test. brain damage. J.F. is neurologist called in on consult that there is Center. the Monroe Developmental now in a course of rehab training at His but is well now. J.F. contracted viral pneumonia two months ago became.pregnant with mother had a miscarriage one month before she the management of this patient. He J.F. The student eommented on his mother_ 'received a lot .felt it was generally good, that J.F. and The student visited the of emotional support from the-OIGHA PNP. Center, and once at Strong patient at home, four times at the Wilson neurologist.' Memorial, sitting in with the pediatric .

_2.2, Student #9 - The patient-is a six and one half year old boy, D.F. His condition, idiopathic nephritis, was diagnosed by the preceptor approximately one year ago. It is now reasonably well controlled by diet and drug therapy, but the patient now has a lowered resistance to disease. When he is ill, the protenuria recurs. At this point in time the illness has recurred, but the overall prognosis is reasonably.good for children. The preceptor noted that there was some correlation between parents with allergies and children with nephrotic syndrome. Both Patient and mother are compliant and conscientious. ,The'motherss medica) history is interesting. She has had many medical problems, Ob/Gyn problems, headaches, and eMotional problems. The student observed that there is very little communication between the mother and father. The mother seems inclined to hysterical revealing of her problems, as exemplified by the speed and detail with which she presented them to the student on her first intervieW. .In addition, her memory of sequences of events is poor. The student.commented that the Management of this case was good, and the prognosis reasonably good, i.e., 70% of children with this nondition do recover. The preceptor reviewed the diagnostic criteria wth the student and discussed what drugs were used in therapy, dosage and side effects. The preceptor complimented the student on observing that, "as usual, the illness involves more than organs - control-of the social environment is a greater challenge than the kidneys." 012.3

Student #4 - The patient, Mrs. E.W., is a 71 year old WOMan with recurrent metastases. Mrs. E.W. had a radical right mastectomy in 1968. A recurrence of metastases in 1970 was treated with cobalt therapy. Her long history of arthritis, in-the-spine makes it difficult to diagnose metastases-In October, 1973, she came to the preceptor. It was the first time she had had a regular internist. In November, 1973, metastases were found, and she was treated with radiotherapy. In February of 1974, she had acriohypophyseetomy. Thip may or may not have helped, but has relieved her pain. The edema in her right arm has worsened, so she is'now taking diuretics. These are not helping as much as they should, so there may be a tumor involved there. Mrs. E.W. is on several drugs including demarol, which she resists taking. She maintains detailed redords of all aspects of her problems, probably due to her training as a nurse. The student made only one visit with the patient, does not know the prognosis or other sources of support for her care. He did not comment on the management of the patient.

12.4

Student #5 - The patient is a 49 year old, white, male, Mr. FAL diagnosed with mild atherosclerosis, high cholesterol and triglyceride levels following an attack of angina pectoris while walking to work. Mr. F.U.'s first visit to the preceptor was his first physician visit in, ten years. He was treated with. vasodilators. The student noted that the patient was somewhat confused over his medication regiment, thinking that he need only take his medication when pain occurred, when really the preceptor had prescribed it on a regular basis. .

162

Thirteenth Seminar - Student Clinical Presenta *ons (5/19/75) .1

13.2

13.3

Student #11 - The patient is a fourteen year old female, W.D., who developed neurologic problems subsequent to several strep infections. The patient presented complaining of emotional lability, slurred speech, and nervousness. 'She exhibited signs of fidgeting, decline in fine motor'capabilities, depression; physical examination revealed a slight heart murmur. The preceptor provisionally diagnosed post streptococcal chorea. She was admitted to Strong for a cardiac She was consult regarding the possibility of rheumatic fever. finally diagnosed as having Sydenham's Chorea, popularly known as St. Vitus' Dance. The student made two home visits with the W.D.'s symptoms havevacillated. for several months; preceptor. therefore,one of the biggest problems in her management was the question of her going back to school. The preceptor and the parents decided that it was best that she be tutored at home. This was arranged with the school district. There is a possibility that W.D. may have mild heart damage, but her progress has been such that the preceptor expects she will be free of symptoms:by summer and should return to sbhool next year.

Student #10 - The patient is A.S., a four-year old male diagnosed His mental age is mild mental retardation of unknown etiology. His younger brother is also approximately two and one half*years. retarded and died at age twelve months of an unrelated cause. The retardation was diagnosed early. The child now attends a home care training program at the Rehabilitation Center, as well as a day care center near his home. The child currently has communication problems in that he can understand what people are saying to him, but is unable to return the communication. The student visited the. Rehab Center with the patient. He detailed the large number of specialists involved in the'care of a case like this, including a physical therapist, audiologist, specialist in activities of, daily living, and more. A.S.'s parents are highly educated. They take good care of him. However they want to terminate therapy and keep him in the nursery school where he is now. Although he is doing well, the health care professionals are uncertain as to whether or not he can handle.the environment as a sole The prognosis is uncertain, since his condition's source of therapy. etiology is unknown. Another student challenged the validity of the psychological evaluation. The presenting student defended it, explaining the subjective aspects of this evaluation were as important as the more objective tests. Student #12 - The patient is T.V., a 20 month old male who has spina His condition has resulted in incontinence, paralysis bifida. In addition, his social below the waist, and hydrocephalus.. situation is clilite unstable.. T.V.'s parents were unwed at the time of his birth, the father unemployed and apparently a petty criminal. T.V.'s delivery was difficult, probably due to a lack of prenatal He is slightly mentally retarded, but can feed himself. The care. student described spina bifida, its process, research, statistics of occurrence, complications, and treatment. He then described the social history in more detail. He described the large number of health care personnel involved, a very complex management problem.

163

STUDENT INTERVIEWS WITH GVGHA DEPARTMEN'T CHIEFS

L.0

Business Office 1.1

Objective: Systematic Recovery of Patient Expenditures

1.2

Patient management form 1.2.1 Based on Kaiser Permanente 1.2.2 A complEte record for each patient visit 1.2.3 Form information including billing type, services used, fee deviations

1.3

Insurer claim processing

1.4

Referral mechanism 1.4.1 Referrals costly 1.4.2 Director, Business Manager approval required,for reimbursement

1.5

Out-of-town claims paid

1.6

Member screening 1.6.1 Reserve right to refuse members ip 1.6.2 As yet no attempt to screen

1.7

Other activities 1.7.1 Reception and patient routing center 1.7.2 Membership information

1.8

Problems 1.6.1 The business office is point of contact between the group and the insurer. Thereforeit is often the site of inter-organizational conflicts .2 Development of computerized billing .3 Fee for service billing - diversity of third party sources- partial repayment-schedules

.0

3.0

Pharmacy 2.1

Patient education 2.1.1 Individual drug use profile 2.1.2 Counseling on doage and side e fects

2.2

Drug pricing 2.2.1 Necessity of being competitive_ C6st plus sliding fee mechanism 2.2.3 Substitution of generic drugs eliminates duplication, allows large lot, wholesale buying (physician waiver required by law)

2.3

Formulary - listing of drugs the medical group considers necessary for practice - eliminates unneceSsary inventory

2.4

Underutilization of pharmacists

2.5

Clinical pharmacy 2.5.1 Consultation with group physicians on pharmacological problems 2.5.2 Emphasis on clinical work bRyond the pharmacy 2.5.3 Training: more biochemistry, physiology and pharmacology than traditional "druggist" program (Doctor of Pharmacy) New degree new role, not 2.5.4 Pharm.D. yet widely accepted in medical centers.

Internal Medicine Section-7

31 Patient J.R., 79 year old, female, routine check 3.1.1 Chronic diabetes and hypertension 3.1.2 'Blood pressure elevated - failure to take medicine Preceptor suggested arrangements to help patient get medicine 3.2

Patient /k.S. 50 Year old, female, first visit' irritated by nervousness, 3.2.1 Recurrance of hiatal hernia roughage 3.2.2 Personal and family history -3.2.3 Drug histRry - patient asked for refill of old prescription - preceptor checked PDR, refilled but advised limited use. 'Preceptor advised scheduling for complete physical 3.2.4 diagnoStic tests, consultation with nutritionist and exercise

165

4.0

0

6.0

0

Optometrist 4 1

Patient E.H., 65 year old female'Complaining of blurred vision 4.1.1 Complete visual exam: ophthalmoscope, acuity, astigmatism 4.1.2 Assessment of family history, physical condition, past health 4.1.3 Tinnometer - glaucoma test. Showed possible pressure elevation. Patient asked to return in one week for second test. 4.1.4 Optometrist altered bifocal prescription

4.2

Patient C.W., 68 year old male complaining of excessive tearing 4.2.1 Complete visual examination and assessment 4.2.2 No abnormality found - slight change in prescription -and replacement of badly scratched lens.

4.3

Patient H.N., 17 year old male - urgent visit for apparent allergic reaction 4.3.1 Examination with slit lamp revealed no abnormality other than obvious irritation 4.3.2 Reaction had 'odcurred previously - optometrist agreed with patient diagnosis, prescribed ointment for symptomatic relief

Communications Center 5.1

Patient appointment system

5.2

Types of patient calls

5.3

Defining patient needs

5.4

Urgent:Visit triage by nurse

X-Ray 6.1

X-Ray record syste

6.2

Equipment - purposes, techniques, safety

6.3

Automatic processing.of films

6 4

Interview with radiologist (diagnosis of colon p lYp

- access and periodic retesting

Other Rotation's 7.1

Rotations in pediatrics,. Ob/Gyn, Urgent Visit Clinic, Laboratory Services and Medical Records were not observed. However, all rotations were attended by all students. r

166

RECOMMENDED READINGS 1.0

Organization of Group Practice in a 1.1 "Development of a Prepaid Group Practice Plan OM,10 Dr. Harold Gardner 24 month Period in a Metropolitan Community," (New York 1.2 "Health Maintenance: It Works," Shiela K. Johnson. Times Magazine). 1.3 "General Medical Care, identification and Analysis of Alternative Approaches" by Walsh McDermott, M.D.' 1.4 "A Medical Society-Sponsored Comprehensive Medical Care Plan," by Richara Sasidy and Carl E. Hopkins, Medical Care, Vol V, No 4, July-August, 1967. "PSRO and HMO - Some Dimensions of Quality " by Ernest Seward, GRAA, 1.5 October, 1974. 1.6 "Prepaid Group Practice and the Delivery of Ambulatory Care " 112H=Ea2land Journal, August, 1974. 1.7 "This is Prepaid Group Practice Medical Car " by J.A. Prussin, Medical Group Management Association, 1972. 1.8 "The Role of Prepaid Group Practice.in Relieving the Medical Care Crisis," Harvard Law Review, Vol 84, No 4, 1971. "The Organization of Medical Care," Ernest Seward, Scientific 1.9 American, New York, September, 1973. 1.10 "Recruitment of Physicians and Organization of the Medical Group." 1.11 "Prepaid Group Practice: Its Components and Their Interrelationships by Jeffrey A. Prussin.

2.0, Financing of Group Practice "Some Information Descriptive of a Successfu ly Operating HMO," 2.1 Department of HEW, by Etnest Seward, Janet Blank, and Henry HMO Service. 2.2 "Health Maintenance. Organization, Financing Problems," by Avram Yedida, peech presented at AAMC Southeastern Regional Workshop on HMO's, University of North Carolinat.Chapel Hill, Feb. 15, 1972. "Health Maintenance Organizations: Some Organizational and Financial .2. AL Models, by Jeffery A. Prussin 3.0

Facilities Development "Planning and Implementation of the dommunity Health Foundation of 3.1 Cleveland, Ohio," by Avram Xedida, U.S. Dept. of HEW, 1969. "A Viable Health Center for an HMO," by James L. DeLong, March 20, 1972. 3.2 3.3 "Factors to be 'Considered in HMO Site Selection" b- Jeffery A. Prussin, September, 1973.

4.0

Comprehensive Health Services 4.1 "Physician Assistants at Kaiser: Distinctive Patterns of Practice"by Paul Lairson, Jane Cassels Record and Julia James. Paper given at APHA annual meeting, Atlantic City, New Jersey, 11/14/72. 4.2 'Nurse Practitioners in Primary Care," by Walter 0. Spitzer. and Dorothy Kergin. CMA Journal, Vol 108 4/21/73.

5.0

Consumerism.in Group Practice 5.1 "Consumerism and Health Care," by Samuel Wolfe, Public Administration Review, September, 1971. 5.2 Consumer incentives for Health Care, edited by Selma Muihkini prodest Publisher, New York, 1974.

University o

CURRiCULUM MODULES:

Pennsykvania-

RATIONALE, OBJECTIVES, METHODS AND PREREQUISITES

Mod4le A.

Primary and Comprehensive Ca e

Module B.

The Health Care Team

Module C.

Consumer Participation

Module D.

Quality o7 Care

Module E.

Economics of HMOs

Module F.

Change and Innovation

16 0

A.

Module 1:

Prima

Care/Comprehensive Care

Rationale

With the rapid movement in the 1950's and 1960 s away from general practice to specialty practice, there has de-

veloped a corollary concern for the manner in which a patient makes his initial contact with a provider of care.

Primary

.

care encompasses the professional and related services administered by physicians (internist, family practitioner, obstetrician-gynecologist, or pediatrician) tioners

dentists

social workers

nurse practi-

and other health profes-

sionals in an ambulatory setting, with referral to specialists as necessary.

Comprehensive care invokes the concept of a

broad spectrum of health services, including physicians' services and hospitalization which may be required not only to maintain health but to diagnose and treat physical and psychosocial illness.

For the student contemplating the

choice of a specific career within medicine, the importance of this section lies in his opportunity to explore alternative modes of serving patients with a concern for the implications these choices carry for both the providers of health care and for the patient.

170

Objectives The student hho o6 puniaruy heath calm .c.n an HMO setting

Given an open-ended queistion on heath acute deLivvuj out Arnexiaa, the Atudent hhoutd be. abLe g the to htate the 6ottowing 6acto/th and devetopment o A HMO'h:

6 asked about the dttthu.&on o6 he

cam, the htudent hhould be. abLe. to in the. flange o6 pati.ent/MD dataibution.

Ovenspeciafization a 6aeton the student Zs asked to deoc.tthe. the. /wee. o6 the pno6it motive in shaping .tizaditionat

private practice, he zhould be abte to

do 40.

The. btudent hhoutd be. abte. to answe..4 questions on the. U.S. commit.ment to heath calm detiveny uhing compaizative mateAiat 6iLom otheit nationae Aystems.

The btudent 6houtd be. abtet de.Lnep/iima/uj the. 6oflawing elements:

A 6eaturze oi plummy caite.is that it AiAst point o6' entruj into the. heath yhtem L. e.. , pat contact medicine.

the

The ph,unWuj heath caite ptovideft. ass wneh

nezponsibitity 604 integAating patient'A heath cam..

Integuteb into patient's health opinions and peanb ol5 Azieimed

econd to whom 4peciati4t6

patient ia

czc2Utate. oy4tematLc cake Ot valzied pAobtemh POMR ah byastem to

Communieate6 the in6o4mation to the pa.tLent

Apptie4 ate inioAmation to the patient The phimaAy calte pnovidea id nehponSibLe 60A the continuity 06 the patLent'b compuhensive

heath cam oven arne.

asked to desoibe the 6eatutes o a compte-

e- studost-

hensivei ptipakif (mite, shoilid & .abte to- £. 06 the systein:

oL&xuLn

aspects

_

Conitehens-tv

Total wiz in heath and ciLsea

e

Heath mainte.nance seen 02 an

pottant £unction Methods used:

ecZion

P/Levention

dis ease

Peiriodia heath evatuattont Lab tests, 4cAeetung, apptoptiate intetventions

Heath

education

To involve pa.tLejvt 02 an active

Imoomate paAticip heatth cane pugum To 4_11 won patient o behaviom th wia maximize itiA health 4tatu4 Co-

/moo

atient'4 cane

tht0aghout A 1b-4y4tem oaonn4veL 00gtam

Ass wne tespons

OA p

heattit caiLe. need6 0t1

Speaatist

&else/ma/as when indLeated

On cat covmage 24 hams a day, 7 days a week

PA0vi4ion6 Lot titeatment in an ememency .64ting wheAetre& and wheneveA nec.e6saigy

172

A

es4ibility Phy,sicatly weLL

zeAved by

sotem

ed ion. p paation-

FtnanaczLty acce,s4ibte to aet 4 egm od poputation thtough uoitiou4 payment

ptopam PnouidetA who ate zemitive to the vatysociat needs od the patients, i.e. 4ociae acce&sibiaty

To the eon4lumeh

To the

pulie44ion

Peet teviek, p

4Lotci ireuLew

To govelmment agenates whete thete i4 Auppollt

OJL pA0gAnn16, accountabte dot

quantity, quatity od eau The 4tuden.t Ahmed be abte to tiot the types pitActitionet4 who deeive4 ptimam heaetk cake Farray pitactitionet

InteAn44

PedLatAi Obstetti_cian-gyneaotogiat

Mulue pAaetitionet

Mentat heath woAhet, e.g.

Aociat .woniwC. ot

psychiatnizt A4 a tesutt od k

act2vitie6

at an HMO, the. phoician

in tAAining Ahmed °tient ki4 cauelL pean4 taloa/az oppoirtunitie4 to do eompAehensive eaxe.

The 4tudent 4howed devetop a po4itive attitude towatd the pnovon od comptehenhive carte to patients

173

The 4tudent Ahoued uaLue tho teach compnehendive cate MOU oi HMO'expehienceThe-Atudent 4houtd Aegatd çL46t aoJvtaa.t medicine,

and the oppottunity to oovide continutng carte, a6 a Atimulating way to pnactice OppoAtunity iox genuine po4' in tilSe o6 patient

174

"11_

Prerequisites

The student should have been exposed to the introductory material in ID 103 before entering the sequence in the clinic.

If not, listening to the Hertz cassette is the

minimum requirement.

Important here will be references from the literature on comprehensive screening and on the concept of health maintenance as contrasted with crisis medicine. Learning Experi ences

The section concerned with,the factors underlying the development of HMO's will involve mainly didactic material. Methods for delivery of curriculum will include assigned bibliographic material foliaged by discussion of approximately one hour.

The staff resource person is DT

Klaus.

Other resources available include reading material and specific sections from the taped lectures by Dr. Hertz. Key topics to be covered in these activities must include: 1.

Patient-MD distribution

2.

Overspecialization

3.

Profit motive

4.

Comparison of our system with other national systems

Dr. Kobb has major responsibility for the students' understanding of the process by which the patient finds his entry into the system.

The activity here will be observation.

A student can work with a provider and note different ways

of entry into the system, such as the episodic visit and initial comprehensive examination.

Here the clerk should

be assigned to a provider for one day.

Near the end of the

day there will be some discussion of concepts to be elicited from the observation.

Special attention will be directed to the POMR as a means to facilitate general patient care.

Resources include

the booklet on POMR, the Hertz cassette, and discussion

with

the provider to'observe how Penn-Urb records are kept and how One activity will

the POMR lends itself to a team approach.

be to compare standard clinic records taken over from Graduate Hospital with POMR at

Penn-iJrb

Aspects of comprehensive care will be treated first through observation, followed by student participation in three complete comprehensive examinations.

The student will

start with the initial screening, move to the physical examination, and then observe discussion by the team of the formation of a treatment plan.

Scheduling should be so arranged

that different types of patients will be seen; for example, a younger patient

an older patient with multiple problems

in a situation requiring patient education, a pediatric case, etc.

Checklists of.points they are to observe will be developed

and students will be scheduled in a manner to allow them to F

follow a provider until the checklist is filled out.

Teaching the section on continuity of care will involve relatively little didactic material.

176

Here we will use dhe

device of having the student on call for 24 hour periods to answer incoming messages and work in consortwith a provider to develop appropriate responses.

It is hoped this will

serve to fulfill the goals of general familiarity with the system and specific differentiation of the kinds of calls received and the outcomes with the focus on continuity.

One

technique here might be a requirement to make and use a log. Sone time will also be spent in the Graduate Hospital emergency room.

The purpose here is to illustrate theobjective

in developing continuity of care of

psing

the emergency room

as infrequently as possible, only as a necessary backup. student will

The

in this context make rounds with a provider

carrying a sufficient case load in the hospital.

The unit on

continuity of care will require a review of the system of specialist referrals.

Such referrals are made a number of

times during the week, offering opportunities for student observation.

An exercise in the review of demographic data will serve as an introduction to the issue of accessibility of care.

Here the student will be actively involved in developing

information on where the patients live economic levels are, age factors

what their socio-

and other variables that

relate to and affect the access to varying levels of health care.

In the affective area, the student should also be sub-

mitted to situations that will sensitize him to the varying social needs of the patient.

As an introduction to account attend a consuner council meeting.

ility, the student will

He will then,be required

-

to audit several Charts to develop a clear understanding of-

how these precedures aredeveloped. A Check list will be developed as a mechanism to alert students BS to what they are looking for in the audits.

Finally' broader questions, suCh

as accountability to goverament agencies, will be covered in a didactic-manner.

178

B.

Module 2:

Roles and The Health Care Team: Responsibilities of Different Health Care Practitioners in a Primary Health Care Team

Rationale

With the advent of specialization, medicine has witnessed a phenomenon not unlike many enterprises that emerged throughout the industrial revolution.

As operations

in these complex enterprises have endeavored to respond to variouS needs of a mass urban society, differentiation of functions and roles has of medicine as well.

taken place.

This has been true

The manner in which these different

functions are integrated remains an important issue, since it has too often been left to the patient.

The development

of the health care team is one response to this issue, but

its successful opetion depends on the development of proper understanding of the importance of each of the various contributing roles to the health of the consumer.

Here the

student can explore, through direct observation, some of the problems and prospects of a team setting.

179

Wectives in the c2Enitive Domain The student shoutd be abte to disctiminate among the notes and nesponsibitities 06 heatth cane pkactitionens and showed be aro& to utilize the competencies 06 each

pnactitionea apoopniatety. The student shoutd be abte to de6ine the N Pnactitionet (NP) Vetineation o6 the expanded note o

the. n-

e

Aneas 0 6 competence

Independent and dependent wutLc Accountahitity Division 0 tioneAs

pon6LbLWy wLth ()then p

How the NuAse PAactitiOnet t heath pAo6essionalS Physician-NuAse Ftactitione&

LntedtatLon

NuASe P4actitionet as a memben. 06 a e.g., Nunse PAactitionen-Physician-So Licen6ed Pitacticat NUAAC

team, oithet,

How the Nunse PAactitionen inteAacts with pcttLe

Heatth education as an impontant pant 06 the Nunse Ptactitionees note Long tetm management 06 chlioniz ittness

Diagnosis and tneatment 0 uncompticated acute disease in accoAdance with pnotocots Famity oniented heatth carte based on a knowtedge 06 6ami2y dgnarnLc4, heath behavion SuppoAtive /tote counseting, ,zuntuAing and cattng

me impohtant shitts in upeAtoite 06 the NuAse PAactitionet

180

/70 0 -

The student 4houtd be ahU to deLoAibe how the wee o6 the NuAse PAactitioneA van/Les accoAding to the woAk Letting NUAZie oactice v setting

acconding to heath calm

Famity nuAse speciatist

caL, nWt6e.

The 4t(ident 4houtd be a/ate to de ,tne the So_

o

Pet6on who woAks 60L poLitive change within individuath and gitouo Mobilizes out6ide 4e4outc

Haps peAson diocoven own AesouAces The student showed be abte to utitize the Sociat WoAkeA appAopkiatety in a heatth calte setting with the knoweedge that the Sociae Wothea ha4 the 6oteowing competencies and oAientation

Psychotogical tuatment o6 sick peopte Emphasis on stAengths 4_ndalidual possesses, AatheA than on weakness ok iteness

Function6 to hap patient iiind coping stAategies 6on cuiment physicat and psy Logicat pubtems

incAeased awauness o ecotogy o6 patient, i.e., the patient as a whote peAson in turins og h44s Nychotogicat and 40ao-economic context FacititatoiL o

StARA4 on 2mpo4ta4e.e. o6 psychotogicat

which witt hap OA hindeA pat2ent'4 heath maintenance

Commitment to matti-ptoliessionwe, mati-speciatty team appnoach to heatth caAe senvices FacititatoA 0 4tati6 competence at meeting psycho-sociat needs oi the patient

Competence with individuat and 6amity o counseeing

ed

The student showed be abte to exptain the eatuAe4 the physician in an HMO setting soli the /tote o

He shoutd be abte to de&ie vaAious modets

Mattidisciptinam gAoup pAactice modet Family ptactitZonet modet The student shoutd be abte to demo tAate tha.t he undeAstands how an okganized system 06 health detivem impact4 upon medical. of:mace o the physician He shoutd be abte to exptain the ways in which tasks axe divided accoAding to the oineipte that each membex o the team ptovides to the patient the type oi heat& cake he i4 but ptepaiLed to detivet

When the student he shoutd choose cottegiatty

contiunted with a patient, wotk coo pi a' veLy and

The student shoutd choose to woAk with otheA 4pec2ati4t4 atound arnLy heatth ea/Le He shoutd make use o the easy aCCe46 to cotteaguRs 6ot discussion 06 tteatment sttategies and the devetopment o health

&me poticies BehavioAat exampte4

Management o, chuni.a disease, e.g., diabetes, the Nuue PxactitLonet edueat patient and manages tteatment Social 4envice component bAings 4pe.c. ptoiessionat expexUse which buadens undeutanding oi patient

The student shoutd be abte to Wt the methods thAough which the quoLttj o6 heatth cam_ can be monitoAed in an HMO Peet Aeview

Intennat audit

ExtetnaZ puiessionat Aeview

182

g

I 7z---*

The 4tudent shoutd be abte to Lest the Of1cMUfl g 6eatuae4 o6 wolthing az a phy4ician in an oaganized system

Futt time, sataAied p/we44LOnO1 Management aspects 0 6 paactice Wre ae4pon4 bitity jointty o6 administAatons who ake pant

o6 the puviden onganization New empha44:4 on heatth maintenance and pkevention a4 wett a4 cuae

DiSSeaent economic pke44ute4 in an HMO as com0 with a See- ot-4eavice paactice Commitment to 4ocketaZ sackiSice

oats witho

majon pea4onat

OppoitwiWA

OA teadthig and .Lnte.uwtovi with 4tudent4 in univeasity netated HMO's

The 4tudent shoutd demonstAate that he can dLscu6o the 6oLtowing p)Lobtems o6 medicat paactice in an HMO High tevet o6 ambiguity due to stilt evolving oaganization Oaganizationat. con4ttaint4

The 4tudent 4hould be abte to exptain and to demonstAate oppaopaiate u4e oi the competencie4 o diSSetent level paactitionek4 In Aetation to the 6ottowing a4pe.CL#5 o 6 heath caM.

Patient education

Histom tahieg and physicat examination Diagnosis

Tkeatment wd managemen t P4evention In &elation to ctLvvtoe. ch

patient poputation Age:

1

pediatkics, inteanal medicine,

3

oc vie

173

Sex:

Ob-gyn

Socio-economic 4tatu4 Pae4enting paobtem

P4ycho4ocia and phy4ic4t m Medicat emeagency (uagencylmeehani4m The 4tudent shoutd be abte to WI4WVL que4tion45 on the /tote 06 the home caae paogaam a4 an exampte 06 team paactice o6 compaehensive heath cake

Ve eLpton 06 the home cake paognam Emeaging intekest in continuity 06 patient cake a en hooitatization Economkc impticattonts 06 the home cake paogaam

Team appmach to the detiveay 06 heatth cake 4 e)vice4 in the home

Team compozition deteMvLed by the need4 the patient Unique 4etting iot the de 4eavice4

vvuj 06 heatth cake

Heath cate piovLdeJ adapting to the ecotogy 06 the 6amity, e.g., the patient in the home Aelting Patient eomptiance and icamity 4 -pott towaad Jin ptementing theaapeutic goat4 cauciae to the 4ucce44 06 the paogaam

Home cate NP a4sume4 /tote 06 educatoa to

patient and ha 6am1y about taeatment pean and goat!'

Majoa 4tke44 on having patie active /tote in taeatment ptan

Home calm NP deviza di4ehaage ptan, and o ten cooadinate4 oveaatt taeatment ptan vc.ence4 between Student zhoutd be abte to tiAt the d an integnated heath cake team and gaoup pkaetice (space 4ha)i2ng) in team6 06:

Continuity 4oA the patient Knowtedge lo4 and Contact wLth othet app topAi _e pAovideAs Methods avaitabte son. d

iveAing 6amay

oAiented heatth cau e Li

StandaAdized AecoAd keeping to pAoliessionat communication

InteAdependent pAo4e44iona2 /teLatLon4hip4

the

cottegia appAoach The student shoutd undeAstand the Aationaee behind the stAuctune and composition o4 the team Advantages

Disadvantages

Obect1ves in the Affective Domain As a successtiut outcome 04 the a46ective t aAnkng, the

physician in tAaining shoutd choose to woAh in a team wheneveA possibte.

The student shoutd demonstAate his p1ieekence OA an undeAstanding o4 team detiveAy (34 heatth caAe in the Ottowing way4: The student shoued descAibe team

oAk as an

ecient means to detivelL heatth cate He shoutd not avoid opetating az a te.ani because he 4inds it -LA time consuming OA cumbeAsome

The student 4hout4 demonsttate how he the 4atowing ptobtems as a membeA (34 woAking in the HMO setting, he showed aAticutate the Aeasons 4at his choice in each situation

woutd handee a team; when be abte to o4 cotteagues

Diagnosis

ett-baby

and con4 uLta.ton with paitent6

AboAtion Diabetes

Potentiat 4 ucLde

The physician Ln tAaining 4hauLd demonstAat

attitudes

towatds othet ievee oacationeAs that enhance eective team liunctioning

The student shoued choose to make use 06 the independent conttibution that NuAse Ptactitionen, SocaZ Wotket and Physician's Assistant ate capaiote o making to heath cate 06 patient

Must appneciate and atticueate that othet puctitioneAs ate not just extensions olise16, but that they bting new insights 6tom othet disaptines to beat on patient's ptobtems Examptes

Social Wotket ah.ee to diagnose and inteAvene

suceeziquily with mentae heath components that physician mLght not notice

Nutse Pnactitione4 s competence with nwLwüng and management 06 chtonicatty Let patients The physician in tAaining shoued demonsttate ttust that othet Levet paactitionem pet6otm thWL 6u1ctions competentey in the 60Lecwing ways= The student showed be abte to use in6oAnation 6tom histoty and physicat done by Physician's Assistant ot Nutse Ptactitionet as basis 60t diagnosis and tuatment, tathet than tedoing puccedutes

The student showed betieve that inOtmation and suppott on chi2dtealuIng given by Pediattic Nutse Ptactitionet has been adequate and acculzate

186

7

Preriis it The student will familiarize him/her self with xpanded nursing role through the following articles: 1.

Bates, Barbara.

"Doctor and nurse:

changing

roles and relationships." NewEngJ. of Med., 283:129-139 (July, 1970). 2.

Lewis, C. E. and Resnick, B. A.

"Nurse clinics

and progressive ambulatory patient care." New Eng. J. of Med., 277:1236 (Dec. 7, 1967).

3.

Lambertsen, Elinor C. PA."

"Not quite MD more than

J. of Amer. Hosp. Assoc.:

In addition

Hospital.

references will be made available on

principles of practice and on the primary care practitioner. The student will be expected to be familiar with the contents of "A Medical Student's Guide to Health Main enance Organizations" produced by Simon, et al. at Georgetown University School of Medicine. relevant here.

The Bernheim and Hertz reference is

Learnin

nces

As part of developing his awareness of the differences

among space sharing solo practice, and the Penn-Urb setting, the student will be asked to attend specifically to differences between space sharing as he observed it at the Hospital of the University of Pennsylvania and the collaborative practice he was introduced to at Penn-Urb.

The Penn-Urb

Medical Director will discuss these issues in a tutorial conference.

Other activities designed to demonstrate colla-

borative practice to the student will include participation in the comprehensive examination, work with the POMR, and

participatien in the workup of a mini contract following discussion of the data base and problem identification of a plan patient.

Participation in the record review will be

both for completeness and for management.

This will be

done both in pediatrics and adult medicine.

The student will be required to attend a multi-disciplinary planning session about problems of the family.

This

is included to illustrate how the social worker is invoked in a collaborative practice.

In similar fashion, the student

should spend one session per week with a certified nurse midwife teamed with an obstetrician.

These experiences will

be reinforced through a weekly discussion of collaborative practice based upon the collaborative aspects of health care observed by the student during his sessions with providers.

portunities will be made available to allow the student to expand and clarify his definition of the nurse

practitioner in terns of expanded role practice, dependent and independent functions, accountability, and interaction with other health providers.

Experiences will be structured to provide opportunity for -tudents to observe nurse/social worker, nurse/physician interactions within the context of the normal practice caseload.

It is anticipated that the student will observe

the pediatric nurse practitioner for two sessions, an adult

nurse practitioner for two sessions, and a certified nurse midwife for two sessions.

The student will select a nurse/

patient interaction from each session:

he will disucss the

interaction with the nurse practitioner, being prepared to articulate whether or not the nurse practitioner made a

unique contribution to the health care of the patient.

The

student and nurse practitioner will allot the final half hour of each session for this discussion.

The student will observe

physician and a pediatric comprehensive visit involving both a a pediatric nurse practitioner.

The student will observe the

and with other nurse pract tioner interaction with the patient providers.

Discussion will focus on the content of the visit,

assignment of tasks, family involvement in health care plans. A number of other observations and experiences will be designed to enhance the student's understanding of the

psychosocial discipline as an integral compolInt of primary/

comprehensive health care and his ability to make appropriate use of its services through collaboration, consultation, and referral.

Teaching will be carried out with case

conferences, seminars, individual supervision and informal discussions.

Consultation with the individual student for

the purpose of diagnostic evaluation, leading to recommendations for treatment

ith emphasis in selection of that

psychosocial therapy most suited for that particular individual.

The student will be assigned to a team through

which he will gain first-hand experiential learning in relation to cases being serviced by his team.

The Dental Component

As a part of developing the students' concept of a health care team, the existence of a dental component in an HMO offers a special learning opportunity.

The following

module was developed as a separate but related set of learning activities.

Rationale

This section of the curricuhnn derives, as do the others presented here, from the consensus that the area of greatest

deficiency in our health system is the organization of primary care.

Since this aspect of the health system em-

phasizes the management of common and chronic should serve as a link between the patient and ce specialized and technologically complex components care.

Oral health and disease is unmistakenly within the

19(

purview of primary health care and primary care providers must develop some competence in this area if we are to expe_ience any majo: imporvement in the oral health of the nation in the years ahead.

Ob ectives

The student 4houLd be capabte o6 pe

okming an out

xamination.

The student shoutd be aapab& o6 Aecognizing aft

tissue and tandmatbs in ht heath unateked state The student shoutd be capabte o6 Aecognizing the dq6ekence between what is noAmat, heathy tissue and that which pusents in atteked states 06 heatth The student shoutd be capabLe o6 diagnosing the pusence o6 the most common (mat diseases The student shoutd be eapabte so6 n.eeogvzing the signs and symptoms 06 dentat cakies in ,as vaaious stages

The student should be capabte 0 e.cognithtg the signs and symptoms oi peniodontat ck4 e.cz4 e in its vanious stages

The student should be capabte 0 aecognizin the signs and symptoms 06 matocctusion The student shoutd have andeAstanding 06 the b 06 tAeatment 60a the difficetent disease pucesses.

The student should be 6amitian with those syste pkobtems on diseases that diaectty a66ect dentat tAeatment The student shoutd be w veAsed in the pkecautionaay steps invotved in a.tme.n.t 06 the me.dcaL2g campkomised patients The student shoutd be capabte 06 cooadinating okat health cake with othea health needs 06 the patient The student shoutd have complete undeAstanding o6 tit

imptication o6 advanced dentat disease and why eakty aecognition

vitat.

The student shoulld be competent to caAAy out dentat ptevention pkogtams and assess patients' pugAess in °kat hygiene

I92

The student houtd be competent to communicate elgectivety with dentists about the joint managem 6 patients.

The student ishoued be co pete apptopaiatety tiox dentat caae

The student zhoued be competent to evatuate tuatment post opetatively and assume aesponsaitity lioteow up heatth maintenance

The student shoutd be wett veased in ba4ic denta teaminotogy

193

Prerequisites

The student should St

e following five references

prior to attending the seminar. 1.

Gerrie, Norman F. and Ferraro, Richard H. Organizing a program for dental care in a neighborhood health center. Public Health IltspEt., 83 (8), August 1968, p. 633.

2.

Schonfeld, Hyman K. Origin and growth of dental group practice and closed panels. New York State Dental Journal, 36 (2), February 1970, p. 77.

Dental expenditures, utilization, and prepayment. Blue Cross Reports, 1 (2), September-October, 1963. Nikias, Mata K. Prepaid dental care: Patterns of use and source of premium payment. American Journal of Public Health, 59 (7), July 1969, p. 1088. Nikias, Mata K. Social class and the use of dental care under prepayment. Medical Care, VI (5), September-October 1968, p. 3g1.

Learning Experiences

The objectives will be met by the following approaches: A.

Seminar.

This will involve a slide lecture pre-

sentation and follow up discussion. B.

References.

These will give students necessary

background information to better understand the seminar and for future use. C.

Clinical.

Time will be spent in the examinat

treatment of patients to allow students the opportunity to reinforce material presented in the seminar. D.

One two hour seminar will incorporate a clinical session for introductory material.

After that it will

be optional if the student desires to pursue the subject in greater depth.

194

C.

Module 3:

Active Consumer Participation in an Organized Health Care Setting

Rationa e

Recent years have witnessed a marked emphasis on consumeri

--the expectation and rights of the consumer to

full information about the services being purveyed.

In

contrast to other services, health care, if it is to be comprehensive, actually depends upon active consumer involvement in order to effect favorable outcomes.

The con-

sumer or patient must be an active member of the health care team if preventive health care is to be practiced--he cannot remain passive.

The consumer s compliance is imperative

and compliance is related directly to intelligent involvement.

Furthermore, if the health care system is to be re-

sponsive to the needs of the consumer, then the consumer

must be motivated, educated

and sophisticated enough to ma1
an intelligent assessment and statement of his needs.

i7C

Ob-ectivesivive Domain Given a question about the nights o4 pa.tLe nt in an. HMO

etting, the student shoutd be able to inctude the ttowing points:

Patient's night to heatth status

U in 0

'on abowt hJ

wn

Pravacy/congdentiatity In6oAmation about the nat uke and consequences pkoceedunes and intenventions Comp-taints and conceAns 06 patLe.n3

tLthth

by membens o6 mganization The student shoutd be abte to demonstnate his Linden-

standing 06 the impontance 06 actLve patient panticipation kn the heatth cane pitocess both by bekng abLe to

descnibe its imptications and by his behavion.

Student shoutd be abLe to tist the Ottowing 4eatune4 06 patient education: Patient shoutd be educated about impontance heatth maintenance, eatty detection and ptevention 04 ittness Patient shoutd have a ctean undeAstanding, thnough education by the heatth cane team, 06 how hi4 behavim impacts.upon his own heatth status incneased patient comp&oiice. with tneatment ptan 4:46 hoped to be an outcome 06 the heath carte team's commitment to heatth education and patient paAticipation

Student shoutd be abte to descAibe the ways in which consumetism impacts an onganized system 06 heatth cau Divides knowtedge and tesponsib pnovidat and patient

between

ommunication a/wand patient'S concenns 04 COMpttaMtA

Estabtishes impoAtance 06 diuct Monne& o

196

ShapeA

ype and timing c

vi'A..ae

itezde.ited

Student Ahoutd do patient education in ate possible encounteAs with patient Student zhowed demonz Wiie. that he kegakdz education as a high pkiokity when choices must be made about how to utilize Zimited time-with patients

ec 'yes in

Affec

e Domain

Student zhoutd undekztand that active pati

pation in heath cake pAocess is impoktant. has the

The student zhoued /maize that the patLe.r powek to inguence his own heatth pAocess

The student zhoad be abee to dezckibe ztkategiez by which he woad attempt to involve patient in own heath cake 's co The ztudent zhoued teakn to value pati bution in descAibing pkobtem and potential zaeutionz

The physickan in tAaining zhoued kegakd 4uet inpAmation to patient abo t health ztatuz and consequences O

inte4-

vention az ethicat obeigation.

The phyzi

&ma-

in ttaining zhoued kegakd patie

tion as an essential component 06 heath cake

Student zhowed ee.Z encouiLaged about possible positive outcomez litom time spent on patient education Student zhoued Zeakn to Aegakd Zack o co Ziance by patient az possible aituite to be convincing about vaidity a inteAvention udent zhoued want to wank in a setting wh 6action is taken seAio u1&J a oi

e patient

a meazuke 0

quaeity

Student

outd be zenzitive to patient az whote pe44on

/Lathe& than body to be wolthed on

Student Ahoutd appiteciate apowttunity cant/tact with patientz az human beingz

ex.tended

Prere uisites

Before attending the various experiences outlined in this section, a student should study the following references.

The student also should have mastered the content of the Patients Bill of Rights issued by the American Hospital Association 1

.

Redman, Barbara K. Patient education as a function of nursing practice. Nursim- Clinics of N rth America, 6 (4), Decent:ler 1971, p.

Toward consumer-oriented

de Tornyay,. Rheba.

health care. Tosteson, D. C. The ri-_t to know: PUblic education for health. Paper delivered at the plenary session of the AAMC Annual Meeting, Chicago, Illinois, NoveMher 13, 1974. 4.

Lewis, Edith P. The health care consumer: Compliant captive? .

5.

Gillum, Richard F. and Barsky, Arthur J. Diagnosis and management of patient noncompli Journal of the American Medical Association, 1 7 12 June 8

6.

Pomerleau, Ovide, Bass, Frederick, and Crown, Victor. Role of behavior modification in preventive medicine. New En land Journal of Medicine, 292:1277- l282 JI&12, 1975%

7.

Becker, Marshall H. and Maiman, Lois A. Socidbehavioral determinants of compliance with health and medical care recommendations.

Monaco, Rose Mary, Salfen, Linda, and Spratt, John S. The patient as an education participant in health care. 9.

Simonds Scott K. Current issues in atient education. New Yor : Core Communications in Health, Inc.

10.

Moffat, Samuel. Patient education: A new weapon against malpractice suits. Medical Alert Communications, 2 (6), June, 1975.

11.

Lesparre, MiChael.

The patient as health student. Hospials, Journal of the American Hospital Association, 44, March 16, 1970

Learning Experiences

Seven distinct experiences have been outlined for the student to achieve the objectives of this module.

These are

both observational and behavioral in terms of what they re-

quire of the student and as such should contribute to an active learning process.

The seven experiences are out ined here in the sequence

that would optimally itroduce the student to the curriculum content of this section. 1.

Participation in introduction of patients to the Penn-Urb system by the Patient Service Representa ive.

2.

Observation of first part of the comprehensive physical examination by Mary Dougherty who will describe haw she works with patients; why it is

important to tell patient exactly what is happening with each test and why; what difficulties are encountered in obtaining test results; how she relat s to other providers, etc. 3.

Observation of patient-provider encounter re patient education.

190

4.

Attendance at a behavior modification session conducted by Dr. Ovide Pomerleau with B etsy Roeback conducting a 20 minute didactic session beforehand.

5.

Attendance at a health education session where group members share a cc:maim disease.

Lew Wells will

conduct a didactic session beforehand on group interaction. 6.

Attendance at Penn-Urb Subscriber Council Meeting.

7.

Review Penn-Urb Public Relations files and news-

letters from PHP. Harvard Community Health Plan, and Columbia Health Plan, and draft news article for submission from Penn-Urb to PHP newsletter. The staff work gr up responsible for the design of this module elected to delineate the specific acpivities of each of the above experiences through a series of study questions. These questions as given here represent a detailed guide to focus the attention of both student and staff.

1.

2.

In what way are consumers presently introduced to a health care system? How should they be introduced?

What points should an introduction to a health care system include? How does a consumer choose a health care provider? What information should he/she have?

4.

In what ways does this experience encourage active consumer participation in the health care process?

..E7,..i_ence 2 ltiu I.

What are_the consumer's thoughts about or reactions to health screening and testing? Does he/she consider the process valuable, necessary, appropriate?

2.

In what way does the Health Care Assistant explain the experience and prepare the consUmer?

3.

What is the significance of this experience in regard to the consumer's introduction into the system?

4.

What is the role of ancillary personnel such as the Health Care Assistant in health care services; articulating for the consumer, provider, and the system; and promoting good relations?

Kxp!riffice 3 study questions 1.

What aspect of the interaction best illustrated the process of health teaChing on the part of the provider?

2.

What teaching techniques did the provider employ, e.g., verbal description, analogy, physical demonstration, use of printed materials and aids?

3.

How did the provider assess the patient s learning nee How iid the provider assess the patient's willingness, ability, and readiness to learn?

How did the provider convey expectations and assignment of responsibility to the patient in regard to learning? 6.

How did the provider assess that 1earig on the part of the patient had or had not occurred? Interviewing techniques employed? Other techniques employed like patient demons tration?

Criterion measures utilized? How determined? 7.

How did the provider determine and deal with obstacles to learning?

How did the provider document in the record that teaching and learning had occurred?

202

..H.Slience 1.

study

What is a brief working definl ion of behavior modification? What are possible applications of behavior modification to health care? In what ways is use of behavior modification therapy in health care compatible with the concept of the "activated consumer"?

4.

What behavior modification tethniques are outlined in this group session?

-.SIience5stt.lestions. 1.

What is the stated purpose of the gro

2.

What is the nature of the group, e.g., didactic, interactional?

3.

Does the group appear to be working in a consistent with its stated. purpose?

4.

In what ways are teaChing and learning illustrated within the group?

5.

What patterns of interaction may be observed within the group?

6.

What type of leadership may be observed in the group?

Experience 6 stuy questions 1.

2.

What is the stated purpose of the group? What is the nature of this group? What type of leadership exists--formally and informally? Who are the members of this group? motivation for joining?

What is their

How does this group articulate with PHP and with Penn-Urb? What is the nature of their franchise? What is the nature of their input re advisement and policy making? To whom is the group accountable? How does this group work--contributing and listening, synthesizing, arriving at consensus?

iq 3

-

Lerience7sttanies The primary requirement is for the student to write an article about some aspect of health care at Penn-Urb for submission to PHP Newsletter.

The purpose is to use this

medium for patient education.

Other optional experiences

include involvement in an interviewing and picture-taking session by news media in the PHP network, participating in an interview with reported regarding the student's Penn-Urb clerkship, or interviewing a PHP staff member regarding netvork attitudes and participation, and consumer participation and education.

Stimulus questions might include the following:

1.

Who is the PHP/Penn-Urb consumer demographically?

2.

Who are the targets of the different PR th

3.

What messages are intended to be conveyed?

4.

What different media are employed and for what

ts?

purposes? S.

How does an organization go about attracting and utilizing the media for its purposes and what are the professional/legal r;..strictions on advertisement

of physicians' services.

What input do consumers have in the use of media? 7.

In what ways is consumer education accomplished through the media?

Mbdule 4:

One Quality Health Ca e for All

Rationale

Today health care is a riØt rather than a privilege, and therefore it must be available to all persons at consistent quality. context

When health care is examined within the

of accessibility, continuity, comprehensiveness,

and accountability, It becomes clear that there are gross inequities which have their bases in socioeconomic, ethnic, and geographic factors.

Future providers and planners of

health care will need to be sensitive to these issues so that newly developing health care systems will overcome the inequities.

205

Objectives

Given a question about

e tpe. 06 medicat calm cut-

aentty avaitabEe to pati nts in the U.S., the student shoutd inctude the 60a0Wing paint45:

Taaditionat patteus 06 cane 60a middle 6on-senvice, ptivate pnactice physician

:

Fee-

Types 06 pnactLce thaough which cane -a detiveaed Genenat paactitionet who focal:6 whote 6amity

Famity heatth needs met sepaaatety by independent speciatists Emphasis on episodic carte, ahe than on pnevention and modi6ication o6 heatth teZa.ted behavioa

Financiat incentives wank against pneventive medicine

Patient edacatLon Lcw 02 aity Taaditionat pattenns o

calie. 60a pooa

Setting in which caM 416 paovided Haelpitat ainic a typieae setting 6o/L cane

No constant peasonat paovidea with whom one can identi6y in ctinic settings Patient education not pnovided 6ort aoutine heath cane issues Thiad pcirt

method o

paiflne6 fhaough pubtic 6 einbunsement

Student's shouLd be abte to descnibe the di6 en_ e

betveen Penn-Unb and ttaditionae modetA 6ot ate ceases Attempt to make method 06 payment independent 06 4tyte, qaatity 06 ealte

Paobtemo invaeved in attempting to °igen unqoAm4 high qUatity cane, despite the di66etent payment methods used in a pnimany cane untex that has _unsement many 6oAm6 06

Assumption that oe-p

ent woad allow compte-

hensive cake to be 066eked to att pati.ents

Penn-UAb'estabtished with atm oi pkoviding high quatity cake ackoss socio-economic Spectkum Ecatogy oti the consumek seen as impoktamt component o6 high quatity health cake

ditionat patteAms o6 medical cake had too much kagmentation 06-cake to allow much knowtedge 06 the ecology, including dynamics 06 the 6amily

jet

Prerequisites

The student should preview the videotape in which Dr. Hertz conducts interviews with "Ghetto", "Bryn Mawr'

d "Penn-Urb" types of patients vis a vis their health care.

Student should also have read the Health-Pac article

and the article by Bodenheimer in the September 3, 1970 issue of Inquiry III entitled "Patterns of American Ambulatory Care."

Learninz Experiences The broad goals of this module require the student to define components of "Quality" care, look at traditional patterns of care for middle class and poor in terms of their absolute and relative quality, and look at Penn-U health care.

The criteria for assessment will be the

degree of quality and extent to which there is one quality of health care for middle class and poor patients.

The student

will be required to make a comparison of Penn-Urb health care to the patient's previous health care

to identify ways

in which Penn-Urb is still a two-class system, to point out the problems in overcoming a two-class system, and to suggest means for achieving a one-class system in Penn-Urb.

The opportunity for an analysis of Penn-Urb's quality health care will be offered through interviews with sub-

scriber and clinic patients regarding their health care experience at Penn-Urb compared to their previous health care riences:

An interview form should cover elements of

",qua ity":

accessibility, accountability, con inui Following the interviews, the student

comprehensiveness.

will meet with staff to discuss impressions of the interviews.

Each student should interview at least two patients

who will have been screened by providers. A checklist for the interviews includes the following: Accessibility:

1.

Appointments

2.

24-hour availability Use of referrals

4.

Continuity:

1.

Geographic accessibility

Primary provider who coordinates all activities vs. primary team relationship to sub-specialities

Comprehensiveness:

1.

Education--explanation of prdblems, cf. Rx, preventive care and education

2.

Understanding/integration of psycho-social factors All medical/mental health needs met; not fragmented

Relationship of health center to community 5.

Acco

ility:

Periodic foll

1.

Consumer input--formal (grievance procedure, decision in hiring/firing, policy changed) and informal (feedback to provider)

2.

Community out-reach

Peer review/chart audit

A sugg,sted pattern of questions follows that used in the Hertz videotape of the three patient types.

Those

questions were: 1.

Where do you live

2.

Where do you get medical care? For example, do you go to a private physician, health center, hospital? How about if you had a problem with allergy? with a skin rash? a feeling of serious depression or amdety? or needed a general checkup? If you need to go to a "specialist" (e.g., a surgeon), who pulls it all together? who follows up?

Main source of income?

How do you get to your physician, health cen er or hospital? Transportation, parking, wheelchairs Office hours:

do you miss work?

What happens if you are ill on weekends or at night? Can your physician (other provider) explain thin to you well? Is there time? Is there a barrier between you? Have you been satisfied with your health care? If you had a suggestion or a complaint how would you handle it? Would your physician care?

E.

Module 5:

Economics of

Rationale

The economics of health care is an important topic for study because financing affects the delivery"of health care and shapes the type of practice in which students will be involved, the quality of care that will be offered each patient, and ultimately will reflect back on the general quality of life in the socie

211

Objectives ...

The student showed be al:Lee to exptain teL64ue4 teLilted to e66iciency in the 6inanang o

Wealth cam.

plom the 6ateolgin9 petspectives: Consumet:

Methods by which the cons

6o/7_ heath 'cane'

Canal/Lunt paymen.t---anotJv.

Lten

househad budget an acce Assumes medicat ca4e to catty without insutance

abLe AXA

Patticutatty applicabte 6ot smaLL potadic expenditutes (occassionat episode, occassionat ptescaiption)

aepaymentcomsume& pays into an inswzance 6und ActuaAially 6igmed on the aisk 06 incidence 06 ttelte44

Spteads the base o6 payment

Plioliazionat Pnovidet:

handting (36 money

How the puvidet teceives payment 6ot cate

Fee-604-senvice payment-6ot each sexvice oovided

Incentive to ooduce mou UntlA 06 4PAViCe Fot each tAansaction the consumeA has chaice 06

oovidet Capitationpayment pe& individuat 6o/r. medically detetmined numbet o6speciged seavices 60x Apeci ied tength o6 time Ptovidet 4haA2.6 the /ask o6 Jne44/U.tA2'ZatLOfl o6 setvices with consumet

Incentive to keep the individuat heathy, L. e., not utilizing setvice

212

d6cAAJJe the va,tLou4 models

The Atudent showed be able

6 &inane/Eng 04 cake iW Ameuca. ConcunAent:

6ee- on,:sekvice

e most,common method

06 payment OA. pAimam cake PAepayment: Blue CADSA

6ee-liot-4envice 44 the u6uat comm Blue Shield appkoach

eapJtctt2on Ls the Health McunJenanae PAepayment. Okganization apptoach

Pkovidek has the 4,nanciai incentive to keep patient heathy and to have the patient utilize the most co4t-e44ective mode 04 deliVeky

Has Led to Loalek hooitat utilization 40/r. HMO's

Ge.nexaJJj, highek utilization 04 ptimaky cake Aenvieu and neaten_ utilizatLon a pkeventive Aekvicea

Lo 'n6etiot, and att No evidence that heath tattth heath some evidence that bettek achieved Pkovidet can budg

kesoutces and utilize

e66icient manageat technique4 The student should be able to exptain how &Lnancing a66ecto equity 04 medical cake. Peuonae medical, carte Ae4ouAces ake ailocated by the makket mechani6m in Ametica Pkobtem 04 catastkophic cost 04 pito-longed

Pkoblem 04 fazing cotIt 04 kegutax tkeatment inhib ing some consume/Is 4kom keceiving cane

Solution eithek a non-mathet allocation 04 Aesounce6, i.e., a planning model, at making the base 04 payment moke equitabte, i.e., nediatitibuting pukchas-

ingcapabitity Since the HMO is not a chakitable ac.tv evekyone must be enkolled by paying a Jo/minium

The HMO 4.6. cost eective, though, whicit appeats.to 6unding:agencies,:such-as, Medicaid

and Medicau Atso, can hetp biting heatth tesou4ce4 to unde4-4ekved communities by putliding a

Aationat stkuctuite 04 oactice The student shoutd unde4stand the iiinanciat devetopment o

the HMO. Ptanning stage:

e HMO

easibte?

Vo the necessam 4esau4ce4 exist (physicians, hospitats, capitat, management, consume4s) Ok ..121 theu a good puspect that they can be putted togethe4

ReZative 4nexpens ve, but need entuptenewtiat tatent Devetopment stage:

Dete4mining and

pulLütg tAe ite4ou4c

og

etting up covo4ate stauctuAe to

.iniptement ptans

Con4t4ucting Oh 4enovating necessaluj

84inging togethe4 necessam puvideAs Genmatty Aequktes Imptementation stage:

mittion in 64c nt end

taunehing the HMO

Stanting to puvide ca4e Need 04 "twin a4Dund 4unds" to suppoAt HMO in paiod untd enuttment catches up to minimum Levet oi expenditune which was necessam to oli6e4 seAvice

Tit/Eating expansion:

in entattment

OuAc

Prerequisites The student will be conversant with the material in the following references prior to participating in tutorial conferences and seminars. 1.

Saward, Ernest W. The relevance of the KaiserPermante experiende to the health services of the 707-17 (SeptU.S. Bulletin NY Acad. Med. 46: eMber

2.

MacColl,William A. Gofmedical care. 'Was Al

actide and ire on:

ai

_ress, 1966.

Donabedian Avis. An evaluation of prepaid group practice. Inquiry, VI (3), pp. 3-28. 4

Saward, Ernest W., et aL Documentation'of twenty years of operation and growth of a prepaid group practice plan. Medical Care, VI (3), pp. 231-44 (May-June 1968).

Learning_E

riences

Since the material on the economics of HMO's is largely cognitive, we have undertaRen to develop autotutorial materials for this area.

A cassette recording of the

Perloff ID 103 presentation has been made.

This is now

transcribed and edited and will be retaped in order to inter-

sperse self-administered items testing the understanding of basic principles.

The student will be expected to achieve nastery of these materials prior to involvement in tutorial disucssions with the Penn-Urb economist/administrator.

F.

Sociologic Considerations

Mbdule 6:

Rationale The iproblems involved in delivering quality health

care to the United States population today aie complex. Appropriate resolution of these problems will derive not alone from the biomedical sciences but must involve the social sciences as well if a healthy population is to be the objective.

This is particularly relevant to the physician

in-training who may be contemplating a professional career in an HMD.

Here preventive medicine as well as episodic

care depends on an environnental and contextual understanding of the population being cared for.

The concepts

skills,

methodologies, and theories of the social sciences provide the physician with a broader knowledge base for managing the social, psychological, historical dimensions of health care.

political and economic

In addition, to move the present

massive ongoing structure of health care delivery in socially relevant directions, the physician of tomorrug should know something of the strategies of planned change and dissemination of innovation.

01_31ssitjvcs

Peanned.:Change 0V

The dtadent dhomed undeAstand the phenomena oti panned

change in peAsonatity and zociae system.

The student showed know the degation oi panned change o.t d

The student zhowed undetstand the motiVation peAzonotity ot a zociae system to change

panned

The dtudent dhoutd undeAstand the phased o change

The dtudent howed widetwid the pn.oae Pb nLLLence and the mechanism undettytng each dtage o6-ehan e

The student Ahmed undeitistand the itote o

the change

gPit

The dtudent dhowed be 6amifia4 with methOdz oi chang_in,9 individuats and zyztemz

Innovation ...

The student showed

ndet4taitd the phenomena o

nova-

tion az it netatez to heatth sotem The dtudent zhoued know the degnition o The student zhowed

undmstand the

innovation

phased o6 innovation

Student4 dhoutd undeutand the attAibuted oi an innovation

&Wentz zhowed &mdvtotand the tqpe.

a

Lnnova.tLon

Studentz should undenztand the Chal=telaAtiC4 o eaftly adoptuts

Q01

MoliessionaLization The student 4kould have a wolzhing knoweedge'o6 the' essentiat etements which de4ite. a pkoliession.

The student shoued be ahte to

de4cbe*Jted(e,Lenae

among pnolcessionalization atatudes among pAivate

oactice physicians, hospitat based speciatiAts, and HMO physicians, with kespect to the 6atftwing dimensions: The student shoutd andeAstand the Eul_qeksQLpL_Eoliessionatization

The student shoued be tioniei which if/60,a the pAoliession

with the contir.olz

The student should be avaAe o6 the teeations oti medicine with othet heath opiessions

The student showed know about ooliessionat as ocia tions and cotteague netations

anizations ...

The student showed know The eteme

TheAtudent should undeAstand the

mganization.

:t'on4kp betNeen

the individuae and the orLganizatton. ...

The student showed be 6amiiiat with the 4ttLLau.ke an o4ganization.

...

The student showed know about oiganAzctLona2 goaes

...

The .student showed undeAstand how pOwVi opeAates 4n an o4ganization.

The student showed unde.and how aonict6 oc an otganization.

The student Ahmed undeAstand The. envLonrnetvt in

which an oAganization

The student 4hod and e

and inteto

anizationat

tetations.

The student shoutd be abU to appZy these genetat concepts to the context o4 speai

a heatth eau

oAganizations.

ReseaAch in Heatth Cate Detivety SettinE The
o4 behaviotat science AeseaAch in heath eau detivem _etting6

The ztudent 4hcu2d unduatand teseaAch

e liunzttanh

The student shoued undeAstand the stAuctuut components o4 a teseaAch puject The student shoutd undeJustand how ite4ea4ch 414 conducted in the zetting

Prere uisites

For students with no sociology background, read Inkeles:

What is Sociolo

Other r- uired reading will include:

Profession of Medicine (selected

1.

Friedson, E. chapters)

2.

Trela, James and O'Toole, Richard. Roles for Sociolojists in Service Organizations.

Cther supplementary readings will be available on request in the student's area of interest:

These include:

Analyzing social settings

3.

Lofland, John.

4.

Rogers and Shoemaker.

5.

Georgeopolos, Basil. health institutions.

6.

Riley, M. W. and Nelson, E.

7.

Franklin and Osborne. insights.

Communication of innovation.

Organization research on

Sociological

Research metho

Emery and Trist. The casal texture of o tional environments. 9.

Issues and

aniza-

Case studies on organizational issues developed at Penn-Urb.

Learning experiences Case studies analyzing various aspects of health organizations will serve as the major vehicle by which these sociological concepts will be taught and applied.

Each of

the five topical areas will be dealt with as it applies to the cases being consi

The material will form a basis for small group discussions and individual conferences.

Specific issues of in-

terest to a student or to the group will be further explored through group participation in focused interviews with the providers who were active in the events being analyzed in the case studies.

Emphasis will be placed on meeting an

individual student's needs and interests as they relate to social science and research in the health setting.

Students

spending extended periods at Penn Urb can be introduced to the technique of participant observation.

24-

ResourCe Paper No. 5

PROPOSED CLERKSHIP FOR THIRD-YEAR MEDICAL STUDENTS:

RATIONALE, OBJECTIVES, METHODS AND PRERLUISITES *

From Appendix J of the University of Washington Final Report, Project to Develop Curriculum For Physician Training in HMOs

cl 9

INS1RUCTION11 GOALS AND OBJECTIVES

I.

CLINICAL GOAL

INSTRUCTIONAL METHODS

F.VALUATION.METHODS

OVERALL:

Primary Care

:The student will gain knowledge of and skill in dealing

1.

Participation in patient care under faculty super-

with the common health problems encountered in providing

vision, with patients pre-selected for their

primary medical care.

instructional value.

2.

Seminar discussions requiring students to research, present, and discuss-pertinent information.

3.

Assigned readings,

SUI;GOAL

Given N new Patient/physician encounters, the student will

The student will develop skills and knowledge in

satisfy the preceptor as to

clinical data gathering with ambulatory patients with particular reference to common problems.

his ahility to:

In

deing this, he will be able to:

SKILL

Objective

Take a brief history of the

1.

See Uverall Methods,

1

present illness.

Objective 2:

Perform a screening physical examination.

Tike

a

satisfactory patient

h'story,

2.

The preceptor will:

2.

Demonstrate effective use of health care team,

Porform an adequate screening physical exam.

and provide explanation of sound practices and 9bjeotive_.3:

Utilize health care team personnel

potential problems,

,

3.

Iliteract with health care 'team"

to acquire and record in a timely

pc.rsonnel in gathering and re .

manner, informatiOn regarding the

ccrding patient data,

patient.

etaluations will be based on

Preceptor

directobservation or review of video tapes and will utilize the "Interview Evaluation Checklist."

JOJIINUto

UUAL) AAU UDLILIIVLJ

I.

CLI.1;1CAL GOAL

11111i'Ve.

Primary Care (Cont'd)

YAGOAL

Acquire skills in patient thterviewing.

The

student will be able to:

SKILL

Obeeeeive ):

Establish and maintain.rapport with

1.

Given M patient/physician ercoun-

The precepts will:

ters, Ihe student will satiefy

Choose appropriate patients for the student to

the patient.

the erecOteir that he can effect-

interview, building from simple to complex, and ively apply the indicated irtere

ObjeOve 2:

provide examples of common interviewing problems.

Encourage and allow the patient to

personal skills in dealing teith

describe problems in his own terms, the.paeient.

Objective 3,

Ask "open-ended

questions perti-

2.

Precepeer evaluating

will be based on direct observe-

Observe and critique the students' interviewing

tiens or review of video tapes of techniques.

ecot to the expressed or suspected

encouneere. problems. 3.

Ohjective 4:

Provide clear feedback to the student regarding

Demonstrate an ability to utilize

his/her interviewing behaviors, effects on others

interviewing principles as described

and overall communication Skills.

in 'Skills of the Medical Interview." 4,

DeEtieej:

Demonstrate techniqug which 2re based on current scientific knowledge and which work for you.

Write a patient profile based on a

Gieen a taped patient interview (this may be from a previoufly

taped patient interview, 5,

Discuss openly with students the pros and Ms Of

roared interview seiected for

various approaches in dealing with patients,

Oveluation purposes or may Ile se-

considering the characteristics of the patient

lected from any other source),

and the physician.

The student will write an appro .

priate patient profile.

SUBGOAL

The student will develop skills and knowledge in clinical problem definition, with primary emphasis on ambulatory

patients suffering from came problems.

In doing this he

will be able to:

The preceptor will:

KNO4EBSE

Objective 1:

Demonstrate his awareness of which are the ten enst common problems.

1.

Discuss with the student pertinent facts, concep and ideae which are current and relevant to your practice.

e

1.

Liit from memory eight of the ten inot common medical problems.

,

1;11 3 'VII)

I

1):Ikil

1

IlhI:I MAL ril.111MS

I VI

1,1EflIUDS

!

I.

CLINICAL GOAL

Primary Cern (Cont'd)

(These problems were identified

2.

Acquaint the student with available resources

-

after looking at data fror the

consultants and literature . pertinent to comon

Royal College of General Prac-

problems.

titioners in England, and review of family physicians' practices

Point out clinical examples of these problems and

in the State of Washingtonl)

their natural course during the course of patient care;

c,b1E1.,.

State correctly the natural 2. 4.

course for each of these pro-

Given three from among the ten most

Demonstrate techniques in diagnosis, treatment and common medical problems, correctly prevention.

blems.

describe their natural course. .

Objective 3:

State correctly the diagnostie

5.

Give students feedback on your assessments of their

3,

knowledge and skills in context of clinical practice.

and therapeutic techniques

common medical problems, correctly de-

commonly applied for prevention and treatment of these problems.

Given three from among the ten most

scribe the commonly applied diagnostic 6,

Adequately evaluate the student's knowledge and and therapeutic techniques for their skills at the end of the course. prevention and treatment,

SKILL

Objective I:

Select appropriate data and

,

See Overall Method 1.

.

justify his selection of histor-

Given a patient-physician encounter selected by the preceptor and in.

ical, physical, and laboratory

The preceptor will:

volvinq one of the tenroost coon

data in terms of common high.

probability diseases and cost

disease entities, the student will se-

Explain the appropriate criteria for sound data

lect appropriate histeriCal, physical,

collection. effectiveness.

and lab data and satisfactorily justify 3.

ODAL

his selection to the preceptor.

Demonstrate effective data collection with several

patients, and explain the rationale for the judgemen

s

made:

The student will develop knowledge and skill in clinical pronlem solving with ambulatory patients with particular reference to pgion problems:

In

doing this, he will be able tor-The preceptor will: Objective 1.

Review initial inforration

Ask students questions designed to elicit logical

gathered about the patient and

thought in solving problems:

make cost-effective decisions as to which laboratory tests to

will select appropriate lab tests in

Follow a problem-solving sequence in preSenting

lections to the preceptor,

cases during conferences.

Develop an appropriate differ.

ential diagnosis from the effi-

Given a set of patient data, the student

reasonable sequence, and jUstify se. 2.

select in which logical order.

Objective 2:

1.

Explain the rationale for your judgements to students in the course of clinical work;

2, ) Given d comprehensi.ve set of patient

data selected by the preceptor,

deve-

ciently ielected data.

lop an appropriate differential diagnols and justify to the preceptor,

913'

Primary Care (Ccrit'd)

CLI11CACODAL

ilgqiie 3: Make appropriate decisions re.

4.

garding:

a)

Ask the student to explain his/her logic, de-

3.

preceptor, make the indicated de .

quality of th2 judgment.

cisions and justify them to the preceptor.

hospitalization or continued "outpatient' treatment.

Given k patientS seleCted by the

cisions, and rationale; and then critique the

5,

Review the student's records on histories, physical

exams, laboratory data and on-going management; and b)

discuss the quality of the student's judgments,

Referral or continued Management; 6,

c)

Discuss the pros and cons regarding hospital vs. out-patient management of problems, and why.

Nature of follow-up, whether by phone, return appointment, delayed callback, or use of

7.

recommend consultation, and why,

other personnel.

d)

Intervals for follow-up.

e)

Referral to appropriate

Discuss instances in which it is advisable tO

8.

Discuss and assist with the appropriate use of referrals to other medical disciplines vs. continued management.

specific agencies, 9,

follow-up using the phone and other personnel,

SUCGOAL

The student will acquire knowledge of, and skill

10. Evaluate and givo feedbackqo students regarding their clinical judgment and problem solving

in, the use of the telephone in delivering health care,

Discuss the appropriate interval and mode of

abilities.

The student will be able to:

Objective 1:

The preceptor will:

Explain the principles of tele.

.

doles of telephone management of patients,

phone management of patients.

Objective 2:

Orally, or in writing, explain the key prin-

(Objectives 11 4 and 7) Discuss Nith the student

Given the appropriate patient chart and an

application of the key princi-

the conceptual and theoretical bases, the limita.

audiolape of a telephonic physician/patient

ples of telephone management of

tions and effectiveness, and the psychological

encounter

patients by self and others,

ramifications of telephone management (1) tele-

cation) of telephone management strategy.

Evaluate the effectiveness of

1.

identify application(and misappli..-

phone consultation (4) and telephone referral (7). 3

kttiLl: Employ the key principles of tele . phone managment of patients when interacting over the telephone with patients.

.

(Objectives 2, 5 and 8)

Allow the student to

observe and critique the preceptor's telephone management, consultation and referral according

Given a patient telephonic inquiry and the patient's chart.

The student will deal with

the patient to the preceptor'i satisfaction (this may be audio taped fOr use in 12 above)

to key principles and effectiveness, Orally or in writing, Obitctive 4

Explain the

explain the key princip.'

principles of effec .

tive telephone consultation,

lAb olfol.elephone consultation

(Objectives 3, 6 and 9)

"Provide the student with

opportunities to utilize telephone management, consultation, and referral principles,

4

of patient

j t

CLINICAL COAL

Objective:

ti::1

1 b

lat

i IUOS

CFI I V-2

Primary Care (Cont'd)

Evaluate effectiveness of the

5

Given the appropriate patient chart and

application of telephone consul .

an audio tape of a telephonic physician/

tation principles by self and

consultea encounter, identify application

others,

(and misapplication) of telephone consul. tation,

Obiective 6:

Employ key telephone consultation

6,

principles,

Given a patient problem requiring telephone consultatinn, the student will re. quest consultation via telephone under

direct supervision of the preceptor (audio tapes of this consult may be uSed in above,)

ptjective 7:

E plain the principles of effective

7.

telephone patient referral.

Orally or in writing, explain the key principles of effective ,elephone patient re 'erre

Objective 8:

Evaluate effectiveness of the

8,

I

Given th appropriate patient chart and

application of telephone patient

an audio tape of a telephonic physician/

referral principles by self and

patient encounter, identify application

others.

(and misapplication) of telephone menag.. ment strategy!

Objective 9.:

Employ kettelephone patient referral principles,

9.

Given a patient telephone inquiry and the patient's chart, the student will make an effectiva referral to the preceptor's satisfaction.

5U8GOAL

Given a :ollection of unorganized patient data provided by the preceptor, the student

The student will develop skill in the maintenance

will organize and present the relevant

of clinical records which aid in problem solving

information to the preceptor's satisfaction

and provide continuity, dent will be able to

pbJectivg t:

In doing this, the stu-

in such a manner that it will be: The preceptor will:

:

Organize patient data so as to be

1

Orient the student to the patient record keeping 1,

able to commoicete it to other

Clear and comprehensible to other health

system in the office, care personnel.

health care personnel.

L32

I.

k:E.

CLINICAL

Primary Care (Cont'd)

L .

::-Abjective _

.

'

Organize data so as to assist in

2.

Discuss the pros and cons of hiS medical record:.

formulating diagnostic and thera-

keeping.system in the context Of hiS style,of

peutic plans

practice.

2. 'theful in developing3riatMilt, plans:

Given !I patient -physician.encounters

Observd orparticipatedin.by.the .studentlhe student.will prePare. PatientivsUmmarieS acceptable to

the prrceptnrising.each

of:the.

following methods: .Oblectlye 3.:

3.

Use dictating equipment

Review the student's records and discuss the clarity .

Dictating eqUipunt .

and organization of data which assists in formulating

in recording patient data.

diagnostic and therapeutic plans, Objective 4:

Use the telephone in re-

4. 4.

cording patient data,

Telephone

Explain his rationale for diagnostic and therapeutic plans and the format he uses in recording this data.

5.

Assist the student in the appropriate use of the telephone as a means to obtain clinical data and make medical decisions.

SUEGOAL

The s:ucent will develop skill in prospective analysis of the health of his patients.

This

will include acquring an understanding of the principles of preventive care, cost benefits,

and the,added motivation for such carejn a prepaid system.

The student will be able to:

..Jw.

Orally (or in writing):

Chjective I.:

Explain the principles of pre-

1.

Discuss health risks and medical interventions when-

1.

as applied to fee-for-service and

ever applicable during care presentations/conferences.

ventive care as applied in the

HMO settings.,

HMO and fee-for-service settings,

Objective_2:

Explain the cost-benefits of preventive care in a prepaid system.

Explain principles of preventive care

2.

Ask the student to outline health risks in association with patient care in the office and hospital, and supplement student's knowledge by pointing out important risks.

2.

:

.

explain the cost-benefits of preventive'

Care in a prepaid System.

.

'"1.1.1,11.03141W1,-

CLINICALGOAL

Primary Care (Cunt

2j!qii3:

0,7

)

W

451

d)

_

List N measures which

3,

will Tend to reduce the

,

Oistuss methods of reducing risks identified during

3,- List N measures which Will tend

case presentations.

to reice the N most economic

:

N most economic health health tare riiks. care risks:

2bitc_t:12:

Analyze his actual experiences at Group Health Cooperative

4,

Help the student think through and use methods to

4,

effectively reduce health risks, in the context of

.

and identify specific preven-

Based on experiences in GrOupilealth

identify anfgive the ratiOnalejor

patient care.

the N major preVentive care practice

tive care practices he en-

at the facility;

gaged in.

Objective 5:

Identify and describe major

5.

health risks each patient

Where possible, involve the student in planning and

5.

(Given a Patient'profile or chart)

delivering prematute care.

Describe the N major healthlisks

encountered,

cOnfrOnting tie patient,

SNEGOAL

Develop a sensitivity to the psycho-social

iin.

pact of a disease on a patient and his family, and understanding of the physician's respon-

.

sibility, and treatment approaches for dealing with the impact.

:

The student will be able to:

-KNO',.ILEDGE

Orally (or in writing):

Discuss with the student the Identify a 'significant' human inter.. ... .

effects of key humane inter-

.

.action which ean infringe on a,patient.

.

actions on health.

Explain

SuChlhat itaffects his healthltd

.

which and how human interact. - offers a rationale for the effect..

ions in the patient's immediate environment are important to be aware.of in dealing with 'his health problems.

Objective 2:

Explain the psycho-social im-

The preceptor will:

1.

Expose the student through case histories, ongoing

2, What are the N major psycho-social im.

pact of the tkmost common di .

patients and seleOted readings to the psycholocial

pacts (any selected common disease)

seases on thi patient and his

concomitants of various common disease entitities.

immediate social environment.

1

upon the patient Ad his immediate social environment?

236

Primary Care (Cont'd)

Pak GOAL

,

3.

discusslhe currely accepted social ethic Explain the physician's respon7 sibility and.approaches for dealing with psycho-sotial imPact of disease.

when nealing with the:pSycho-skiar..

regarding the physician's respsibility an4o7paches' to dealing With the

sease; Jurther the

What'isihe:PhYSidinl'OesOdnsibilty 7.'

impact CI!

Osychc-socialconcommitents of di-

disease?

'

preceptorshould orient the,Student

tolhe variettbf intra;and intekouse resources for

(any selezted conno disease)?,

helping the patient with the psycholocialconammitants.

SKILL

Objective I: Niue e findings available'for' a patient and assess the psycho-

Familiarize the student with Critical

signs

socialAistress both disease specific and more generally through:case-histOrieS ind selected biblibgraphic re-

sodal impact of his disease on the patient himself and his

1.( Ginn a,particalar

psycho.

chart or sixnaly

of finf:ingS) Fral the data.provided

whaf,eVidoce_coou find that'thiS: disea0',process is hadng an, kpact_,

ferrals

on the p.tient's

social ervirount 7,

iasetiate social envirorrent.

Ob.jective2: Rtcommend and justify treat-

4. Model and discuts

the,cognitive'process utiliied in

.2.1Given a particular chart or-patient, sumndry), Frr the data provided:

,

the.decisionlaking process:regarding:the approment for the above decisions,

a) recatend intervention

priate treatment,

fOr alliv-.,

.40004sycha-socialimPact,, of'.this'ditease on.the patient

ard his eriVircrent.

b).Ciftr a.hrief

rationalejory ur;

,

reuxent.tlons.

Objective 3:

Oatermine and describe the

.......ur.gency of the problem to

the patient, his family,

S. DiscusS.with the studentAhe urgency

.ditptiveness andsi

of special prOblems and model appropriate handlings.

3. (Giver.a,particUlar.chart surrory),

the data provii!ed.:

evalOateje level of)rgency.

a)

Tie patfent

b)

Tle family

c) Te =unity

Understand the major differences between a

muity health care facility (such AS an iiNO hospital

) and a University affiliated

teaching settinq.

to:

The student will be able

The

piychAbcial elexent represents fer.

and his community,

GOAL

or patient L

,.,; 'I, I

-

..";ii'y I,

I,

C17;n4W0Wri;' 401

-

ft: ,

"4 1-r

'OLINICAL COAL

Pr'imary:,Care (Contid)

The precep tor _ will .

,

,

Objective 1:

List the 1:ey differences

1.

Didactically introduce the student to the policies,

in policies, procedures,

procedures, goals and practices of the,community

goals, 311(1 practices be-

health care facility

.

tween'a coamunity hoS-

paramteril'.

or differeitesjetwo'0 a

aq. N m.

IOnimuniiiand)leaChing'.hOspital,..:.

pita] and a teaching .hospital.

9,11intull:

Describe the differences

21

Through selected bibliographic'references anddidacti

DescribilliCdifferencesjn:patient.'._

in patient population, both

communication introduce the student to demographic

population, both inlerms.

in:terms of economic status

elements noted in objective 21

and distribution of medical

probleMS'i,between a:coMmunitOnd.a

problems, between a community

teaching hopital.

hospital and a teaching hospita].

keq11: Describe the implications of

lre tht

DiscosS with the student the differential concepts

What

increased emphasis OA primary

of primary care in the two settings and, the'impli-

emphasis on primary care in,a ccainunity

care in a corunity health

cations for health care.

health care facility (as compared to a

care facility ( 8 compared toi university affiliated setting) on physician delivered care,

39

Orally. (or ..in,writing) answer the question:

.3.

university

implications of increased'

ffiliated seffing) on phy-

'lician delivery care:

AL bOAS

YJLVjflJ

IhsTRJTioNALtE

-ANO OlidECTIVE:s

CLINICAL GOAL yntinuity,of Care

The student will gain knowledge and skill in providing comprehensive, continuous health are on a longitudinal basis.

.

GOAL

Understand and practice the principles Of continuity of care, particularily

'within

a closed medical community,

The

student will beible to:

The preceptor will:

XNNLEOg

Objective l:

Define continuity of care,

1.

Define the terms:

Elaborate for/with the student the operational

definition of continuity of care, longitudinal

longitudinal treatment, epi .

Continuity of Care

treatment, episodic treatment! and closed

sodic treatment and closed

Longitudinal treatment medical connunity,

medical community.

_

_

Episodic.treatmant _

s

,

Closed mdical commuiity

Gbj

tive 2:

Differentiate betwe n longi-

21

Deserlbe_th2 ?I most important

During the course of planning long-term health

diffeiences bitweeniongitudinal

carefor HMO *dors, clari,fy elements which differentiate this planning from that

tudinal and episodic health

and episodic health care.delivery.,

care delivery, which relates only to episodic,

ObjectiO

.

Identify the N major elements of

Explain the major elements Of continuity of care,

3.

A)

Identify the basic characteristics of

continuity ofhealth care and exclosed medical community manifest at yOur

'plain.how they impact upon health

HNO:facility, B)

care oelivery,

During the course of health care delivery, identify functions, patterns and trends, et which are changed by or a result Of the community being,closed.

4,

Objtailt_i:

Describe a closed medical community and its implf .

cations to medical practic.,

What are the implications:to health care of a closed medical community?

lorrati Ld'ilkil;

1

-UNCIAL GOAL

Pligcliyiki.

Continuity of Care (Cont'd)

Discuss the differences and

5

How doeS longgerM:health care de-':

similarities in delivery

livery.differ between open fee7for-

of long-term health care

-service,ard.clpseOrepai0edical. comunitiesT...

within a closed prepaid conniunity and open fee-form

service comunity.

tah_eaiVe6:

Evaluate student.delivered

6.

Evaluation of the student.delivered Identify the.precepter whose

care to the extent that

care,.

principles of practice in

continuity of,care processes'within

a clesed medical community

a closed

edical community were'.

and continuity of care were properly applied.

SKILL

itieLtiyll:

Demonstrate at a level appro-

Select patients whose medical progress over time

priate to his training, de-

can be reasonably predicted and permit the student

livery of health care on a

to manage their treatment withbinimUm'S4PerVition

longitudinal basis in a

over the period of the clerkship.

closed medical community.

1

given N patients' charts selected

prior -to Ihe clerkship, and reiponSilii 1 i tyfoiplanning- and:de;'

livering required health care (within.

theJimit of the student's level)

during,thc clerkshi4the student. will satisfy the preceptor with respect to.his

A) -EvalUate prior therapy 8)

Develop a treatment plan

C)

Interact with the patient

D)

Manage the appropriate therapyi i.e. deliver, the care

P

'

clkiar;s

PRACTICE ORGANIZATION AND MANAGEMENT GOAL (Cont'd) 11,

Frovide lopport 8nd counseling pertinent to interpersonal relationships!

12,

Serve as an effective role Wel in his relations with office and hospi.

WI personnel, peers, students and others,

13,

Serve as a role model in his life style by providing time for both professional and personal respon. sibilities and interests,

H! Share his rationale for priorities and decisions

in

working out equi .

table professional and personal life

commitnnts,

Riscuss openly with the student the needs of medical practice, the commun . ity,

and self which must be considered

iA establishing realistic plans for professional and personal life!

16! Riscuss the student's future career Plans in terms of his/her personal ind professional attributes,

2 7

4

INSTRUCTIONAL

INCIIIIIONAL GOALS ANO.OBJECIIYES

II.

PRACTICE ORGANIZATION AND MANAGEMENT GOAL

IDDS

"ro

(Cont'd)

GOAL

Understand the principles of cost effectiveness in health care delivery including the differences typically found in a prepaid system.

Orally (or in writing): The student will be able to:

kectivej:

Explain the principles

1.

Instruct the student in the principles

of cost-effectiveness in

of cost-effective medicine as applied

health care delivery.

in an HMO setting and in fee-for-ser-

I.

What are the principleS of "costeffective" health tare delivery? L

vice practice.

Objectiv 2:

Describe and explain the

2.

Where you feel vnur cost-effective_ from conventional

differences in the appli-

practice differs

cation of-cost effect-

practice, explain how your pattern

iveness principles in health

differs,

2.

How does the application of"costeffective" practice principleS differ in an HMO setting from the

applicadon in fee-for-service practice?

care delivery within a pre. Why you make the differing manage--

Who benefits?

,

paid system.

meg decisions ,HoW de they benef'1? - How tpe patient benefits - How the group benefits

Oljectivc 3:

Evaluate the care pattern

3. Where the student has delivered care,

delivered for a particular

show where his care pattern cOuldbe

disease and patient, and

more cost-effective and reinforce

determine if the delivery

positively cost-effective management

was cost-effective.

choice using the question-in #2 above.

.Giveo a patient to manage,

3. A. 1.

aply cost-effective

.

cililes to the treatment plan.

2. hey choice of patient mina . ge,aept on the basis,of cost-

effectiveness principles. B: Giveo a patient work-up and summary of care delivered

1.

Idkritify where cost-effective

measures nave been correctly applied.

2.

Identify cost-effective measures which could/should have been used.

3,

Give a rationale for your choices.

.1

248

14S:4CIIONAL COALS ARO OBACTIVES

INSTRUCTIONAL MOWS

111 COMITY GOAL

Tne student will gain knowledge of and skill in dealing with and using community resources which relate to health. The student will be able to:

Objective 1:

Describe the major health hazards

The preceptor will:

1,

in the community.

Orient the student to major community health

1.

Identify N major health hazards in the community,

hazards during the early part ef the clerkship. 2,

Objec ive

A.

Describe the present role

Describe the appropriate role of the HMO physician with respect to

2.

of the HMO physician with

Point out to the student evidence of com-

respect to these hazards,

munity health hazards when individual these hazards.

patients are affected by them. B. 3.

Is this role appropriate and

Serve as a role model through his action effective?

Justify your

toward the reduction of such hazards:, response. 4.

L.2ivtl:

Discuss contrasting roles taken by various 3.

Identify essential supporting

physicians in the community, evidencing

agencits and professionals in

the interplay between community needs and

the community and their functions

the physician's personal styles, talents

as they relate to health care,

and attidudes,

(fhe student may select a given community health care support agency or nne may be specifically

5.

assigned).

Describe the role of

the,

agencyln the com-

Acquaint the student with the use of direc-

mnity and the means by which an

tnries for service, medical and non-medical,

PO physician can gain access far

in the comnity.

augmenting the health care delivered

:

to HMO members. 6,

Point out agencies he uses in patient care and the processes by which he engages their

Work with community agencies and

4.

With A selected patient(s) who

services.

professionals in augmenting health care delivered by the HMO.

can binefit from community health 7.

Ask the student questions in the care of

services, the student will serve

patients which elicit ideas regarding which

as the H10 and patient's liaison

agencies might provide useful services in

and facilitate delivery of the healtl

specific areas.

care for the patient to the SatiS; faction of the preceptor.

8,

Acquaint the student with key people in the community and their contributions.

9,

Facilitate student contacts with these persons, especially when an issue relates to patient care or specific student project.

10. Facilitate student involvement in community where action is being taken on behalf of health hazards.

T1EAL IT1103 01:JUTHES

nJA ;rJOA15

n CV:MCC IA kno4ledgo of and experience The student will acluire with 4 pro-paid health care

delivery system to .

facilitate a more informed career

choice decision,

Underatand the function, theory, structure, ind legal and

organizational

economic aspects of

Wn's and differentiate these

from fee.for.

service system,

The student will be able to!

InlE5E !Iran art the ornaniza.

Obiletive 1:

1,

Explain tho oreanizational _

structure; logal, economic, and

All objectives should 14110

tation, with_appropriate

didactic prosen .

tienal structure,

audiovisual support,

econtlic Ind Adlinistili

either in largo or small group:,

tiv

administrative principlos 4nd

NInC171!' eld

,function; of Inn?

function: of HrOlsi

iny b2.cvalv.tld *: .

A.

SYn't answv tinns

D, 'Objective luestions

2,

05loct1ve 2:

prmin.

tiV11 StrtletUMI 1r310

Explain the organizational

00101k and ad7inistrative

structve, legal, economic, and administrative principles

'Alt aro the

princinles and functions. .

and

of fee.fer.nervice s'iltems?

functions of the fee.for.service

This lay be ovaluetee by: systems, A,

Short answer gum. tions

Pi .ObJective

A

luostions

.

INSTUTIO1AL COALS AMU OJECTIVES

INSTRUCTIONAL-METHOOS...

.1 V.

HMO EXPERIENCE COAL (cont'd) Obiective_3:

;

3.

Contrast the organizational struc-

.

Phat are-the.differeuces',

in organizational structur6:

ture, legal, ecOnomic, and admin .

eBali economic and "adMin-

istrative principles and function of the HMO vs, the fee-for-service

istrative principles and func-

systems.

:ions of .the HMO's vs.Ithe fee-

fur-service systems? This may be evaluated by:

Objective 4:

Explain the advantages and dis-

4.

A.

Short answer questions

B.

Objective questions

C.

Essay questions

Uhat are the advantages and

advantages to the consumer of pre-

disadvantages to the consumer

paid medical service and medical

of.prepoid medical service and

insurance.

medical insurance? This may be evaluated by:

Objective 5;

Compare the advantages and disad-

5.

.

.

A.

Short answer questions

B.

Objective questions

Contrast the advantages and dis-

vantages to the consumer of pre7

advantages to the consumer of

paid medical service vs. medical

prepaid medical service.vs.

insurance.

medical insurance. This,may be evaluated by:

Obiective 6:

Explain the patient/physician

Observe the patient/physician encounter in an HMO

relationship in an HMO and a

Encounter patients in an HMO.

fee-for.service setting

6,

A.

Short answer questions

B.

Objective questions

C.

Essay questions

_

Vhat is the patient/phytician relationship in an IIMO end

a fee-for-service system? This may be evaluated by: A.

Short answer questions

B.

Objective questions

C.

Essay questions

D,

Providing the-stUdent

.

the opportunity to efl .

counter.patients in the HMO setting and observe these encounters.

,

13TRUOML (11ALli 10 oBJIC111/1.5

IV.

HMO EXPERiENCE GOAL (cont'd.) Objective 1: COntrast the patient/physician

7.

Nhat are the differences in the patient/physician relation .

relationship in the HMO vs, a fee-

ship in the HMO vs. a fet-for.

for.service setting.

service setdigi Mis may be evaluated by:

Objective_B:

Explain the advantages and Os-

8.

Observe physicians.operatinTin a consumer.run organization.

operating in a consumer-run

run organization,

B. C.

Essay questions

What are the advantages and .

of operating in a consumerrun organization?

organization.

Objective 9:

Short answer questions

Objective questions

disadvantages to the physician

Deliver health care in a consumer.

advantages,to the physician of

A.

This m3y be evaluated by:.

9

the student

Explain the procedures necessary

Provide a simulated experience where

to establish an HMO in a medium-

goes through the procedures of establishing an

sized metropolitan area in NhiCh

HMO in a medium-sized metropolitan area.

A.

Short answer questions

El.

Objective questions

C.

Essay questions

Whet procedures are necessary 7.o establish an 10 in a medium sized metropolitan area in.which such a facility does

such a facility does not presently not presently exist? exist.

This.may be evaluated by; A.

Short answer questions

B.

Objective questions

C,

Successful crpletion of

a simulated Nerience of establishing an

Oblilptiyo 10.

Evaluate the adequacy of a

proposal to establish an HMO

10,

Evaluate the proposal prepared in tha simulated

O.

What constitutes an adequate proposal for the establish-

eXperience above and explain the evaluation.

ment of an HMO?

and justify the evaluation,

This may be evaluated 5y: A.

Short answ questions

B.

Objective questions

C.

Essay questions

D.

Successful completion of evaluation and justification of same of proposal prepared for simulated experience,

4

4

25

F..010

nST;UCINIL COALS PilU OBJECTIVES

IV.

"MX16.'4111.06

INSUCHUNAL METHODS

WO EXPFRIENCE 60AL (cont'd,)

Objective 11:

ggsty_e_12:

11,

How does ? consumer join an

Explain the process by which

Provide a Simulated experience which allows

a consumer joins an HMO,

the student to go through the process of joining

HMO7

an HMO.

This may be evaluated by:

Explain the advantages and dis-

Observe the consumer receiving care in a prepaid

advantages to the consumer of pre-

medical service facility,

paid medical service and fee-for.

prepaid medical service facility.

A.

Short answer questionS,

B.

Objective questions

N, What are the avantiges and disadvantages to the consumer

Deliver care in a

of prepeid medical service and fee-for-service?

service care.

This may be evaluated by:

itaclivid3:

Contrast the advantages and dis-

Provide a simulated experience which allows the

advantages to the consumer of pre-

student to be a consumer in a prepaid service

pRid medical service vs, fee-for-

facility.

13,

A.

Objective questions

B.

Short answer questions

C.

Essay questions

,

What are the differences to the consumer of prepaid med7 ical service vs, fee-for .

service care?

service care.

This may be evaluated by:

Objective 1.4:

Explain the role and responsibili-

Observe the physician practicing ifl an HMO.

ties of the physician in an HMO

Deliver health care in an HMO.

14.

A.

Obctive questions

B.

Sn:q answer questions

C.

Essay questions

What is the role and reSPons$:: ilities of the physician in an

HQ setting and in a fee-for-'

setting and in a fee-for-service

service group practice setting?:i.-..-

group practice setting.

This may be evaluated by:

Vective_li:

Contrast the role and responsibili-

15,

A.

Objective questions

B,

Short answer questions

C.

Essay questions

What are the differences in the role and responsibiiitie

ties of the physician in an HI setting and in a fee-for-service

of the physician in an HMO setting and in a fee-for-

.

group practice setting.

service group practice setting? , This may_be evaluated by: A.

Objective questions

B.

Short answer ques

C.

Essay questions

4,

f

Iv.

ith!A.C.',:(1114L5410'...OPRTCTIVriS,

liWAI 1,9 Mil°

HISTHU.

HMO EXPEUENCE GOAL (cont'd.)

, n

Objecttve _16:

Explain the behavior and atti tides

Observe behavior and attltudes of members

concerning seeking health care of

seeking health care in an HMO.

16

What are the behaviors ;and, attitudes of:meiohers.:seeking heal th ca

patients enrolled in HMO's.

ly an VD?

This may be, evaluated by: Objective' questions: B.

Short. answel' questions

C.

Essay questions-

GOAL

Develop knowledge of the skills in those prac-

tical futures and medical praCtices which are characteristic of an HMOI using Group Health Cooperative at Puget Sound as the focus,

SOGOAL

Understand the di fferences between HMO' s and

fee-for-service settings in the use of the telephone in delivering health care.

The student 14111 be able to:

Objective 1:

Di frerentiate between the

techniques used in telephone

What ( re the differences bet-

Observe telephone management of patients in

ween techniques used. in

.a prepaid 'setting.

management of patients: in fee-for

Practice telephone management of patients, in.a

service and prepaid settings.

prepaid setting.

,r.

telephone mapagement of'patients, .

in feetfor-service.and prePaid'settings? This may. be evalvat2o

Objective questions a.

5hot answer gvestions

C.. EsiayAuestions 0,

Observing studflts applying technique .4f. tel e.

phone management of .pet !

ients in the prepaid. .setting.

Rill 1

10AL GAS MU: OBJECTIVES

INSTRUL'I-IONAL METHODS

IV:. HMO EXPEMENCE GOAL (cont)

Objective 2:

Differentiate between use of

Observe telephone consultations in a prepaid

What are the differences

telephone consultation in fee-

Setting.

between use of telephone

for-service and prepaid settings.

a prepaid setting.

.

Perform telephone COnSultations in

consultation'irfee4orservices and prepaid settings?

This may be evaltoledby:; A.

'Objective questions

8,

Short answer. question

C, ,Essay.questions --11.--.0bserving students per.

forming d telephone' consultation in a pre. paid setting,

Mective 3:

Differentiate between telephone

Observe telephone patient referrals in a prepaid

patient referral in fee-for-.

setting.

service and prepaid settings.

0 prepaid setting.

Perform telephOne patient referral in

3

What are the diffrrences between telephone patient referrals in a fee-for .

service and'pripaid setting? This may be evaluated by: A.

Oojective questions

B.

Short answer questions

C.

Essay questions

D.

Observing studmt pee.

.

forming 'a teleOene'

patient referral in a prepaid setting.

,SIGOAL 1-13

Understand the purpose, organizational structure, and function of the walk.in ellergency

service offered at Croup Health Cooperative.

id

A

'

:

Iv

INSTH

-1:

tTIOHAL GOALS1110AXTIVEB

,

4

_

'rag ,EssE

IV.

HM0 EXPIRIENCE GOAL (cnnt'dj

The student will be able to:

Objective 1:

For the walk-in emergency service

1.

By didactic presentation,

explain the purpose,

organization and function of the walk-in emer-

offered at Group Health Coop.

AnsWer' the following ti ther: in writing 'or .orally to 'the satiSfaction .of the pre.'.'

gency clinics.

erative, explain the:

ceptor:

purpose -

1.

Organizational structure

2.

Provide opportunities for the student to observe

What is the: . purpose

.

the clinic in operation and: - function

organizational structure -

elicit questions from student regarding function

.

the clinic . respond to elicited or spontaneous

3.

studen

of the emergency walk.in

questions Provide the opportunity for the student to

function within the walk-in emergency clinic to the level of his training.

pBODAL 17c Understand the skills and problems involved in the management of the WHO health care team in both preventive and therapeutic

roles,

The student will be able to:

Wine the role and responObjective 1:

Define the role and the res. ponsibilities of all prOfess-

Didactic presentation of: responsibilities of various the roles and

sibilities.of the follodiPg health care team members ,as

members of the health.care team, e.g., lona], para-professiOnal, and non-professional members of the

they are used in 'the WO the physician, physician assistant, nurse practitioner, nurse (both registered and

Group Health health care team. practical), nursing aid, social workers,

setting: -

(Select as many team members as desired).

ward clerks', etc.

. management

principles such as deleriation of

Alternate:

,

.

.*,

Provide severe] role des=:

duties, oral and written reoorting patterns, criptiens as found in ,the'

role and responsibility definitions, etc. active - conflict resolution strategies such as

specific ii:10 setting ex.'

perienced by the student

listening, usounding board', confrontation,

and require identificationnon-directive, etc. of the teal memller.

- Other multiple chice item$

5

416i

IhSTRU:TIMAL GOALS AND OBJECTIVES

IV,

HMO EXPER:.ENCE 'GOAL (cont'd,)

Objective 2:

Describe and explain the rationale

2.

foreach team member' s posi-

When.managing and utilizing the health Care'team,

2,...Describe:th(tirganizational

- model desired managerial-behavior

tion in the organizational hier-

-.:..tire',,,of:the..Bilaheal.tk.cdre team

"Oehrief" student oft both.what you did and

archy of Group Health Cooperative,

the rationale

..and,live..a.,.-one.sentenceIrationale

fori the placement of eaCh.::(or

T

- ask student to identify managerial strategies

Objective_1: :Describe the major principles of ,

,,

sel ectleMber( s

you apply and ask for a possible rationale

Utilizing and managing a health

struc

{,

,

3. Dascri be,' the

major pr.thti ples

Hake available opportunities for student to

for the 'Elianaginent, of the. health

care teaflincluding nurSes, social

practice management of the health care team.and

care team.'

workers, et. II.):

then ask student to:

.

.

Objective 4:

Identify the

ji .most common

inter4ersonal problems which can develop in a health care team,

- identify specific managerial strategies used

Identify ,P1

. provide a rationale for having selected the

mrsonal preblems which effect

strategy

y

most concon inter.

the health .care team.

evaluate'its effectiveness ,

Oblectiva.5:

Explain how the

N_most common

interpersonal:management prOb.

,

For the following common mana: Irial problems (select .as many

,

lems in vhealth care team can

4$ desired):

be prevented and rectified.

whit preventive measures may-:1;!: be taken?, - ,:what Interventions can be

Objective 6A:

Evaluate a health care team de .

livering patient care and ident-

.

Having observed a health care

ify interpersonal management

faction of the precepter the

problems experienced by the team,

student should; A.

B:

.'

ean in.oneration, to the satis-.

.

Evaluate the patient.tare

Recommend ways and give a ration-

delivered and identify .2

ale to rectify identified inter-

interpersonal ranagementi.

personal management problems'With.

problems, experienced by

in a health care team,

the team.

,

B.

Recomend ways and give a

.

rationale to rectifilden.. tified interpersonal mana gement problems within a.: health care team.

4

EXPOENCE GOAL.(cont'd,)

Demonstrate positive attitudes toward HMO's a$ systems for health care delivery, as future employ.

.ment settings, tnd as training settings, after ..rexposure tO HNO training,

!.3an

AFFECTIVE

Objecti e

,

Following training in an

KO, the student will respondequally or more favorably (compared to pretraining responses) to ques-

lo special instructional strategies are:reqUire(1:

.

Instruction Islorbe'accordinglo:contentlrescribed objectives written for the content:a.m.::

AttitUdinal:..inventories,1 coorse

through the .student

e'ial-

uation process.

tionnaire items assessing

attitudes toward HI's as health tare delivery sys. tems and as possible futur employment settings,

-Studentcourseevaluations Objective 2: _

For courses taught at several

ferlultisile'course0o sites, some of whichAre HMO :beJleveloped:throughlhe settings, student mean ratings on cour:e evaluation ques .

i.tUden(oyal..jatIon,proces 'ancrto.-nef.used...in elr,tites

tionnaires for those stu-

dents trained at as.will

wherein

the. Curricular Cora-

Ponent.js taught

Itqes to

equal or exceed the mean ratbe tordeSigned-as .,to allow

ings of those trained else .

forItatigiCal antlysiS, where on such dimensions as course satisfaction, usefulness, and satisfaction with instructor/predeptor.

4e"

INSTHUE.rlOWIL COZAD UOIT1VES

EVALUATION,MfTHO

IN TRUCT1ONAL METHODS

.2.W...4,

IV.

HMO EXPEIENCE GOAL

7

Objective

(eontid.)

For courses taught only at HMO's, students will, rate

the courses equally or more favorably than'comparable courses on such dimensions as importance, satitfaction, and instructor competence.

27

3

COre evaluation, items_relating to .StudentS '

evol 0 ons

Of courses will be com.pared statistically to'Selected.-

courses of similar content.

7

Resource Paper No. 6

CLINICAL OBJECTIVES'FOR

A PRIMARY CARE RESIDENCY IN INTERNAL MEDICINE *

1.

Interview Objectives

2.

Urology Objectives

3.

Otorhinolaryngology Objec ives

4.

Ophthalmology Objectives

5.

Orthopedic Objective!

6.

General Surgery Objectives

7.

Nutrition Objectives

8.

Dermatology Objectives

9.

Obstetrics/Gynecology Objectives

9A.

Bibliography - Obstetrics/Gynecology Objectives

From the Harvard UniVersity Final Report, December 1975 Project to,Develop Curriculum for Physician Training in HMOs

ABBREVIATIONS

AOTIM:

Areas other than int

TPWBA:

The physidian will be,able

GAMS=

Given a series of statemen

STWAT:

. Select those which are true

al medicine

I.

1.

INTERVIEW OBJECTIVES

MBA to: a.

b.

autline the basic steps and the substeps of conducting a medical interview. State the role or non-verbal cues in the medical interview and physical ishar

examination. c.

Use non-directive questions in the medical interview, as judged by a senior medical observor.

d.

State ihe seven general questions that must be asked regarding any symp

e.

Adequately elicit historical information about the present illness,

past medical history, family and social history, and the review of systems, as judged by a senior medical observor. 2.

Given a common presenting symptom, TRIBA to ask the pertinent applicable questions.

3.

TPWRA, as judged by a senior medical observor, a.

Systematically examine a patient.

b.

Systematically examine major body regions/systems, appropriately applying the methods of inspection, palpation, percussion and auscultation.

c.

Demonstrate the ability of applying historical information in performing a more specific physical examination.

d.

Verbally present a case succintly and

e.

Generate a problem-oriented record.

f.

Use the commonly accepted classifications of disea es Heart classification).

.g. the New York

UROLOGY UBJEC Draft #2

(d1";of. ;Wont ile :IndloMy and runctiOn of the genitourinary system.

PWBA

STWAl.

TPWBA to a,

Ohi tin in adequa e history re f'errahle to lhe

1/ system as part or the

general revicw or systems. h.

SysternaUcally examine

the Gb system; the adequacy of which is to

j'mlged by a senior medical observor. TPWGA to: a.

Adequately perlorrn a urinalysis.

b.

Recognize common abnormalities of the urine sediment. Adequately collect, examine lnd properly culture urine specimens

suspected of being infected with either bacteria or mycobacteria. (;ASOS about the rollowing

TPWRA to STW.T:

a.

Prot

b.

Speciric grm vily/osmolalily or urine.

c.

Urinary electrolytes. i

ine tlearance.

HUN/creatirilnie ratios. F.

Intravenous and reYrograde pyelography.

g.

Cystoscopy.

h.

Renal arterio:, aphy. Gystometrograins.

S.

GASOS about li

urologic disease 6.

erer ed pain and gstrointestintil symptomatology of TPWHA to STWAT.

TPWicA to:

a.

Describe common

b.

Outline the appropriate evaluation and treatment of' irritative urologic symptoms in adults.

itative genitourinary symptoms and to list their cause(s).

Alw common obstructive genitourinary symptons and their cause. d.

Outline lije appropriate evaluation of obstrt tive genitourinary symptons in adults.

7.

Given a patient with the following symptoms or Cindings, TPWBA to list the common causes and/or outline the appropriate diagnostic steps; a.

Hematuria.

b.

Persistent pyuria in men/women.

C.

Incontinence.

d.

Pneumoturia.

e.

Acute scrotal pain.

f.

Urinary retention.

g.

Urethral discharge in men.

h.

Pen._ chancre or wart.

1.

Hemospermia. _

MBA to describe the clinical Features and t eatment of: a.

Acute bacterial prostatitis.

b.

Chronic bacterial prostatitis.

c.

Congestive prostatitis.

d.

Benign prostatic hypertrophy.

TPWHA to list t'le indications for elective pros atectomy.

GASOS dealing with the diagnosis and management of the following conditions, TPWRA to STWAT: a.

Acute and chronic urina

b.

Gonorrhea and lues.

c.

Orchitis/epididymitis.

infection.

Ildrocele/va icocele.

Renal/ureteral/bladder stones. Infertility. g.

Impotency.

h.

Torsion of the appendix testis.

276

11.

MBA to deseribo the pa hophysiology of

lithiasis with regard to the

rolo of: a.

Stasis.

Jion.

b.

n

c.

Immobiliza

d.

Bypercalcemia.

e.

Hyperuricemia.

GASOS about the management of suspected trauma-to the genitourinary system, TPWBA to STWAT. 13.

14.

CASOS about the following, TPWBA to STWAT: a.

The clinical courses of carcinoma of the prostate.

b.

The therapy of carcinoma of the prostate.

CASOS about the diagnosis and management or neoplasms of the kidneys, bladder and testes, TPWBA to STWAT.

15.

GASOS about the medical complications of urologic surgery, TPWBA to STWAT.

16.

GASOS about vasectomy, TPWBA to STWAT.

17,

TPWBA to suspect or recognize each of the conditions listed below. for each item, the physician will also be able to ou line the appropriate therapy: a.

Testicular swelling.

b.

Epididymal swelling. Renal carbuncle. Perinephric abscess.

e.

Prostatic abscess.

f.

Obstruction associated with renal failure or infection.

g.

Paraphimosis.

h..' Torsion of the spermatic cord.

77

OTORHINDLARITGOLOGY OBJECTIVES Draft #3

1.

Given an unlabelled diagram of the outer, middle-and inner ear, as well as the tympanic membrane, TPWRA to label the indi- ted structures.

2.

TPWBA to obtain ar adequate history referable to the ear as part of the general review of systems. WhA to:

Systematically examine the auricle, auditory canal and typanic membrane. Recognize perforati ns of the tympanic membrane.c.

Distinguish between marginal --d central perforations of the tympanic membrane.

d.

Describe the complications which may be seen ith either a central or marginal drum perforation.

e.

Accurately record the results of this examination; the adequacy to be judged by a senior medical observor.

TPWHA to: a.

Select for clinical use a tuning Fork with an appropria_e frequency.

b.

Properly use head mirrors of differing sizes.

c.

Properly use an ear speculum.

d.

Properly use an otoscope including a pneumatic otoscope.

e.

Properly use a cerL _ n spoon.

List the indications and contraindications for ir igation of the ear.

g.

Irrigate the ear.

Remove foreign bodies from the auditory canal and be able to describe,.

Which of the-e must be referred for therapy. 5.

TPWBA to: a.

Describe the principle of the Weber

Rinne and Schwabach tests and be

able to describe the expected findings in each test in conductive and sensorineural hearing loss.

4,78

b.

List the common causes of conductive and perceptive hearing.

e.

CASOS about hearing loss secondary to external e r causes, middle ear causes and cochlear, 8th nerve or central causes, TPW8A to STWAT.

d,

GASOS about the effects of hormones

drugs, noise and aging on hearing,

TPWBA to STWAT.

TPWBA to list the common causes of tinnitus and otalgia.

For each cause

listed, TPWBA to outline the appropriate therapeutic steps. 7.

TPWBA to: a.

Define vertigo.

b.

List the common meanings of the term 'dizziness' as used by patients.

c.

List a series of questions which serve to distinguish between 'dizziness' and vertigo. (1)

TPWBA to list the common peripheral and central causes of vertigo.

(2)

TPWBA to list the characteristi-7 of centrally caused. vertigo.

(3)

TPWBA to list the characteristics of peripherally caused vertigo.

(4)

As part of the assessment of the patient with vertigo, TPWBA to: (a)

Measure the blood pressure in both arms as well as measuring the blood pressure in both the supine and standing positions. Listen for bruitS in the neck and upper chest; look for arrhythmias.

Examine the fundus for the pre (d)

nce of papilledema.

Assess hearing u i.

ii.

a masking maneuver the Weber and Rinne tests.

Assess cerebellar function by: i.

ii.

testing coordination testing balance using gait and Romberg testing,

Assess nystagmus by: examining for the presence of spontaneous nystagmus.

279

inducing nystagmus via:

optekinetic testing positional testi tig (Ny1en-Llariiny maneuver)

caloric t sting. (g

Describe snd elicit c _nisi nerve signs, brainstern signs and

contrslateral corticospinal tract signs. (Ii)

Order the appropriate tests if an acoustic neurOrna is suspected.

GASOS about the following causes of vertigo, TPWBA to STWAT: aric vertigo. (1

8.

TPWIIA to a.

Otitic vet1go (including perilabyrinthi

s

(c)

Hyperventilation-provoked positional vertigo.

(d)

hematologic and endocrine associated vertigo.

:

List those factors which may contribute to.the development of otitis externs (0.E.)

9.

10.

b.

Describe the signs and symptoms of O.E.

c.

List the types of organisms that may cause 0.1:.

d.

Describe the di fierences between 0.L. and otitis media (0

e.

Describe the principles of therapy in 0.1:.

TPWI3A to: a.

Describe the signs and symptons of acute O.M.

b.

Describe the therapy or acute U.N.

c.

Outline the complications of acute 0.M.

TPWBA to=

c ibe the signs and symptons of serous O.M. and the factors that may lead to its development. b.

List the diagnostic considerations in serous 0.M. in the aduat presenting for the first time with unilateral disease.

11.

TPWBA to: Ldg18

(t/10

- V -

Recognize and refer patients with chronic otitis media. b.

12.

List the complications of chronic O.M.

GASOS about the diagnostic significance of various types of discharge from the ear, TPWBA to STWAT.

13.

14.

GASOS about viral and bacterial labyrinthitis, TPWBA to STWAT. a.

TPWBA to describe the fistula test and its significance.

b.

GASOS about diffuse and circumscribed bacterial labyrinthitis, TPWBA to STWAT.

e.

CASOS about the treatment of labyrinthitis, TPWBA to STWAT.

CASOS about the pathologic process, signs and symptoms, and treatment of Meniere s disease a.

TPWBA to STWAT.

TPWBA to define recruitment.

15.

CASOS about the clinical findings in acoustic neuroma, TPWBA to STWAT.

16.

GASOS about the anatomy and fun tion of the nose, oropharynx, and larynx, TPWBA to STWAT.

17.

TPWBA to obtain an adequate history referable to the nose, oropharyrix, and larynx as part of the general review of systems.

18.

TPWBA to systematically examine the nose, oropharynx, and larynx and to accurately record the results of this examination.

The adequacy of this

examination and record to be j dged by a senior medical observor. 19.

TPWBA to: a.

Use nasal speculum.

b.

Use silver nitrate sticks.

c.

Place an anterior nasal pack.

d.

Check foreosinophilia in nasal secretion.

e.

Check for glucose in pat ents with rhinorrhea.

f.

Use laryngeal mir. o

g.

Use straight and curved bladed laryngoscope.

h.

Insert an endotracheal tube.

Obtain transtracheal specimen for smear and culture.

Perron!! nasotracheal suction. k.

20.

Per Form esophageal intubation.

TPWBA to outline the diagnostic steps and management of patients with: a.

Epistaxis.

b.

Nasal congestion; nasal obstruction; nasal polyps.

C.

Nyposmia, cacosmia, parosmia.

d.

Hurning of the tongue and mouth.

e.

Anterior neck pain.

C.

Sore throat.

g.

Hoarseness.

h.

Salivary gland pain ind enlargement. Globus.

21.

TIMM to list the causes of stridor and for each cause state the appropriate treatment.

GASOS about common normal and abnormal physical findings or the oropharyn

neck, MBA to STWAT. 23.

Given a series of cultu P data from the nose/pharynx, TPWBA to state the appropriate action.

24.

GASOS about white or pigmented lesions of the oral cavity, MBA to STWAT. TPWBA to outline the therapeutic steps in the management of: a.

[Jiver respiratory infections.

b.

Post nasal drip.

e.

Allergi_ va °motor rhinitis.

d.

Aphthous stomatitis. Oral thrush.

Pharyngitis including monopharyngitis. Peritonsillar cellulitis/abscess. h.

Paratitis. Sialadeniti-

(including submaxillary gland).

2

and

j.

Laryngitis.

Sinusitis (including sphenoid sinusitis.

TPWBA also to list the

complications of sinusitis. 26.

TPWBA to recognize and treat: a.

cricoarytenoid arthritis.

b.

Acute epiglottis.

c.

Angioedema.

d.

Cafe coronary

GASOS about tumors of the oropharynx and larynx 28.

TPWBA to STWAT.

GASOS about the use of nasal sprays and decongestants, TPWBA to STWAT.

4

OPIITUALMOLOCY OWL:MINES Draft 44

Given the Collowing unlabeled diagrams, TPWBA to label the indicated structures

2.

a.

Sagittal cross-section of the eye.

b.

The eyelids and lacrimal glands.

TIMM to: a.

Obtain an adequate history referable to the eye as part of the general review of systems.

b.

Accurately record the results of the eye history and examination.

The

adequacy o' this record and examination to be judged by a senior medical observor. 3.

TPWRA to: a.

Correctly locate opacities or lesions located in the cornea, lens, vitreous or fundus.

b.

List the systematically examine the structures to be examined during fundoscopy.

c.

GASOS or fundoscopic pictures about normal and abnormal findings of the disc, retinal blood vessels, general fundus background and macula, TPWBA to identify the true statements or recognize the condition presented.

TPWBA to: a.

Determine visual acuity using either the standard or pocket Snellen chart.

b.

To check gross visual acuity via pinhole sight.

c.

Examine visual fields by gross confrontation.

d.

Test for color vision.

e.

Use a Schiotz tonometer and list the indications and contraindications for its use.

f.

Use a slit lamp for examination of the anterior chamber. 1)

Bse oblique illumination for detection of corneal abrasion.

84

g.

Remove loreign bodies

h.

Apply an eye patch.

1.

Use sterile fluorescein strips for examination of the cornea.

j.

Do schirmer test.

k.

Obtain specimens from the conjunctiva for smear and culture.

om the lids or bulbar conjunctiva.

Given a patient who complains of a red eye, TPWBA to list and recognize those characteristics which distinguish these conditions: Conjunctivitis. Iritis.

Acute glaucoma. d.

Corneal infection or trauma.

For each condition, TPWBA to outline the appropriate therapeutic steps. For each sign or symptom listed below, TPWBA to: a.

List the common causes of each sign symptom

b.

State the appropriate followup questions.

c.

Outline the needed diagnostic studies.

d.

Indicate which conditions require referral to an ophthalmologist.

e.

Outline a treatment plan for the remaining conditions: (1)

Subnormal visual acuity.

(2)

Pain or discomfort of the eye.

(3)

Change of appearance of lids, orbit or eye.

(4)

Diplopia.

(5)

Discharge from the eye.

(6):

Increase or decrease of eye secretions.

7.

GASOS about the effects of aging on the eye, TPWBA to STWAT.

8.

TPWBA to: a.

GASOS about common abnormalities of the eyelids or o

The bhysician will also be able to indicate which of titc

STWAT.

onditions

require referral to an ophthalmologist and be able to outline the treatment fór the remaining conditions.

civen a pal i tn1 suspected of hay ing a corneal foreign body or abrasion,

TM IA

I o :

(1)

Measure visual acuity as the initial step.

(2)

Outline the diagnostic steps to be used.

3) (4)

Describe the treatment.

Recognize the early corneal infection and immediately re er patient to an ophthalmologist.

c.

TPWBA to provide emergency treatment of alkali and acid induced conjunctivitis/keratitis.

d.

TPWRA to outline the emergency treatment of corneal or scleral laceration.

TPWRA to recognize the following conditions and take the appropriate action: a.

Rerpetic keratitis.

b.

Corneal ulcers (especially due to pseudomonas

C.

Orbital cellulitis.

Central retinal artery occlusion.

10.

11.

e.

Chronic glaucoma (acute and chronic

f.

Vitreous hemorrhage.

g.

Sympathetic ophthalmia.

h.

Unilateral exophthalmous of recent origin.

see obj.

TPWliA to recognize and grade the fundoscopic al a.

Arteriosclerosis.

b.

Increased blood press

c.

Diabetes.

ormalities of:

including malignant high

blood pressure).

CASOS or pictures referring to the ocular manifestations of systemic diseases,

the physician will be able to select those which are true or correctly identify the pictures. 12.

TFWBA to:

List the commonly used mydriatics and their side effec State when a pupil should or shotild not be dilated.

Estimate the depth of the anterior chamber by oblique illumination.

86

13.

CASOS about the Collowing, TPWBA to STWAT-

14.

a.

Cycloplegics

b.

Drug therapy of glaucoma, especially interaction with other drugs.

TPWBA to: a.

List the i dications and contraindications for the use of topical ocular steroids.

b.

15.

16.

List the complications that may occur with the use of ocular steroids.

CASOS about the following, TPWBA to STWAT: a.

The use of topical ocular anesthetics.

b.

Diagnostic dye solution,

c.

Lubricating agents.

GASOS about commonly used topical ocular antibiotic preparations, 'MBA' to STWAT.

NERO-OPHTHALMOLOGY OBJECTIVES 17.

GASOS about the optic nerve and visual pathway, TPWBA to STWAT.

18.

GASOS involving the optic nerve or tra t, MBA to describe the resulting visual field deficit.

19.

TAGA to recognlze optic neuritis. a.

GASOS about the etiology, clinical findings and treatment of orti neuritis, TPWBA to STWAT.

20.

TPWBA to recognize papilledema and list the common causes ther of.

21.

TPWBA to recognize optic atrophy and list the common causes th

22.

CASOS about the following pupillary abnormalities

23.

a.

Argyll Robertson

b.

Tonic

c.

Horner's syndrome.

d.

Anisocoria.

e.

Intracranial hemorrhage

TPWBA to STWAT:-

thalamic, cortical, cerebellum, pons

GASOS about gaze palsies, TPWBA to STWAT. (frontal, occipital,lesions

287

brainstem

a.

24.

TEMA to recognize oculogyric crisis.

TPWBA to clinically recognize paralysis of:

oculomotor, trochlear or abducens

nerve.

a.

GASOS about the causes of pa alysis of the oculomotor, and abducens nerves, TPWBA to STWAT.

25.

TPWBA to list three types of nystagmus which may be normally elicited. a.

26.

CASOS about pathologic nystagmus, TPWBA to STWAT.

TPWBA to define amaurosis fugax. a.

GASOS about the etiology and treatment of those condt_ions lssociated with amaurosis fugax, TPWBA to STWAT.

27.

TPWBA to recognize subhyaloid hemorrhage and sta-e the significance of their findings.

GASOS about the phae- atos s, TPWBA to STWAT. 29.

GASOS about toxic nutritional amblyopias, TPWBA to STWAT.

30.

GASOS about the ophthalmologic findings in -'graine and related headaches, TPWBA to STWAT.

(blurred vision. scintillating scotomata, homonymous hemianopsia

ORTHOPEDIC O1J ECTIVES Draft #5

1.

Given a patient with a musculoskeletal disorder, TPWBA to elicit an

appropriate history and perform a systematic physical examination. 2.

TPWBA to: a.

Measure and record joint motion using the American Academy of Orthopedic Surgeon's criteria.

b.

State the normal range _f joint motion of spine, shoulders, elbows, wrists, MCP's, hips, knees, and ankles.

c. 3.

Identify weakness in a major muscle group.

CASOS about the following, TPWBA to STWAT: a.

The normaLand pathologic anatomy,of the vertebral column and large joint.

b.

Normal synovial fluid.

c.

The synovial fluid in inflammatory, infectious, degenerative and traumatic conditions.

d.

The natural history of a healing fracture

bone, ligament, and tendon

injury. e.

The factors influencing the healing processes of bone, ligaments, and tendons.

4.

Given a list of major peripheral nerves, TPWBA to describe the associated sensory and motor distribution.

5.

Given a series of major spinal nerve roots, TPWBA to describe the associated dermatome. TPWDA to: a.

Aspirate knees and bursae.

b.

Apply finger, writs, elbow, ankle, and cockup splints.

c.

Apply a sling to the upper extremity and/or sling swarth.

d.

Inject bursae and tendons, exclusive of-hip.

e.

Collect. properly and analyze joint iluid appropriately using gross and

microscopic techniques. f.

Int-rpret bone films of the extremities for fractures, localized demineralization, subperiosteal resorption, cortical erosion, cysts, osteophytes, and normal distribution of sesamoids, common ana omic variants, epiphyses (especially epiphyseal fracture).

7.

8.

9.

g.

Identify common radiologic anatomic variants.

h.

Identify epiphyseal fractures.

i.

Stabilize

1.

Perfo n a digital nerve block.

T

(

ictures to permit safe transport.

BA to:

a.

Diagnose and treat ligamentous and muscular st- ins of the low back.

b.

Describe and elicit findings in L3-4, L4-5, L5-Sl disc syndromes.

c.

State when acute disc herniation represents a surgical emergency.

d.

List the causes for low back pain other than muscle strain and disc disease.

TPWBA to: a.

Clinically distinguish bursitis from althritis.

b.

Recognize olec- non and prepatellar bursitis.

nar each condition listed below, TPWBA to take the appropriate measures as defined.

MAJOR_HEADINGS

Neck, Shoulder, &Jaw Torticollis Cervical root syndrome Cervical disc

Thoracic outlet syndrome Subacromial bursitis Bicipital tenosynovitis_

Diagnose Only (treatment may not be needed)

Diagnose Treat

I

Diagnose

BEAM NG

Diagnose On y (treatment may not be needed)

Diagnose/Treat

Diagnose/Refer

frozen shoulder

Cuff/supra spinatus tears Biceps brachii rupture Shoulder dislocation-anterior Shoulder dislocation posterior Acromio & sternoclavicular dislocation Snapping jaw Dislocation jaw Elbow, Wrist, & Band

Dupuytren's contract

X

'early) Ganglion

Felon (Whitlow) including herpetic infection Paronychia

Traumatic wrist injury Sprain & dislocation, PIP, DTP's

--_____-

X (if not easily reduced)

Subluxatio:

dislocation thumb an6 MCP's

Carpal tunnel syndrome

X

Calcific degenerative and inflammatory disorders of the wrist

Tenosynovitis, suppurative Trigger finger

de Quervain's tenosynovitis

ror recurrence)

Trluma Ic tenosynovitis

X

1

5 7

1AJOj.

UK/WINGS

Diagnose Ony

Diagnose Treat

Diagnose

(treatment may not be needed)

Mallet finger, Boutonniere deformity, profundus tear Tendon lacerations Olecranon bursitis

Tennis elbow (epicondylitis Stiff elbow Ulnar nerve contusion Forearm contusion :Spine, Thorax

Pectus carinatum Pectus excavarum

Tietze's syndrome

X

Costocartilage separctus

X

Fractured ribs

X

Acute lumbo-sac a- strain Scoliosis

y(if severe

X

Low b ck syndrome

X

Hip

Aseptic ne

osis

Trochanteric deep and superficial) bursitis Fractures of the hip

Slipped capital femoral epiphysis Knee

Derangement of medical lateral menisci

CI

X

lEADINCS

Diagnose Only (treatment may not be needed)

i

Diagno

Diagnose/Refer

Injury or collateral cruciate ligaments

X (if instability present) X

Referred pain syndrome involving the knee

Quadriceps/patellar ligament rupture Chondromalacia Osteochondritis dessicans Subluxing, dislocating patella Bursitis around knee Popliteal cyst

Ankle

X (if symptomatic or enlarged)

root

Flat feet

Sprain ankle Cavus feet

X(possibly

Metatarsalgia

Plantar neuroma Peroneal spastic

foot

March fractu e Hallux valgus

Hallux rigidus Hammer toe

X (if severe symptoms) X -4-4( (if

severe symptoms)

Achilles tenosynovitis Achilles bursitis Plantar fasciiti-

I VS

MA,1111(

Diagnose Duly

ling

/Treat

Din nose/I

(trealment

may noi be -ded)

P1intar wart

X-- --

Plantar keratosis

_

Achilles rupture Plantaris ruptures

10.

gastrocnemius

MBA to: Defirie osteoporosis. b.

List the causes or generalized osteoporosis.

c.

GASOS about the clinical features and management o1 osteoporosis, TPWRA to STWAT,

d.

11.

Diagnose and mtnage osteopo _tic vertebral collapse.

GASOS about the clinical findings,

complications and treatment of Pag

disease, TPWBA to STWAT. 12.

TPWBA to: a.

Define osteomalacia.

b.

List the causes or osteomalacia as well as the -_en al principles of treatm nt.

13.

GASOS about the pathophysiology, clinical symptoms, -and treatment -f fat embolism, TPWBA to STWAT.

6.

1

GENERAL SURGERY OB fCTIVES Draft 42

General 1.

GASOS about the natural history of wound healing a.

TPWBA to STWAT.

GASOS about the adverse effects of various local a d systemic factors on wound healing, TPWBA to STWAT.

2.

GASOS about antiseptic principles (including topical antiseptics, wound cleansing, prophylactic antibiotics and bowel preparation), TPWBA to STWAT. a.

The physician will demonstrate adequate antiseptic technique in the management of a skin wound, the adequacy judged by a senior medical obse-

3.

or.

GASOS about wound infections and the infections associated with localized pathology (e.g. cholecystitis, diverticulitis, skin infection etc) including regional and systemic differences in Flora, TPWBA to STWAT. a.

TPWTA to outline a rational approach to the treatment of infection associated with G.I., G.U. and Gyn pathology.

4.

GASOS about the natural history of thermal, electrical and chemical burns, TPWBA to STWAT.

S.

II.

GASOS about the indications and use of tetanus prophylaxis, TPWBA to STWAT.

Techniques:

The physician will demonstrate technical competency, as judged

by a-senior.surgical observor, in the following areas: 1.

Incision and drainage.of a skin abscess, including the application of wicks to enhance drainage.

2.

a.

Techniques Of wound culture.

b.

Sele tion of appropriate methods of culture.

Suturing of lacerations of the skin, excluding certain lesions of the face (especially around the mouth and eyes) and situations in which tendons, nerves and arteries are involved.

11

IA to desc-ibe those injuries which

at risk to heal with

a cosmelically deleterious scar and hence need specialized treatment from the outset

(e g.

ions about . 1 he month and eyes, flap and

1

sIellate lesions, etc. ). b.

TPWIIA to recogn ze wounds 1hat may be associated witl tendon injury.

Application of dres ings that are protective and secure. 4.

The selection, use, and potential complications of local anesthetics. a.

5.

TPW8A to administer a digital block.

Hxcision biopsy of skin lesions, not on tbe iaLe, and less than 1 cm in diameter.

TPWIIA to effect hemostasis in such cases.

TPWHA to describe an ad b.

1

ate preparation for a sigmoidoscopy.

The physician will demonstrate proficiency in tl- examination and the desc iption or normal and abnormal findings as judged by a senior medical observor.

c.

TPWRA to list the indications for biopsy through the sigmoidoscope, the techniqbes for biopsy, the steps iii handling materials, and the post biopsy precautions to be taken.

In.

Management 1.

TPWHA to state the principles involved in and techniques required in the management of: a.

Skin infections:

b.

'felons and paronychia (including herpet c whitlow).

c.

Ingrown toenail.

d.

Filonidal cyst abscess.

e.

Human and animal bites.

F.

cellulitis, furuncle, abscesses.

Management of clean and dirty, new and old sk n wounds. (1)

GASOS about the use of antibiotics in the management of skin wounds, TPWI1A to STWAT.

296

ision of papillomata, sebaceous cysts and other benign skin

g.

lesio s. h.

lirst degree and second degree burns of the skin, involving less

than V of the body surface.

TPWBA to describe the principles of

clinical staging of a burn. 1.

Hemorrhoids.

Stasis dermatitis. k.

Splinters and small cut, foreign body.

1.

fish hooks.

m.

Puncture wounds.

COLLABORATIVE MANAGEMENT Many,of the conditions cited in the following sections involve collaborative medical management.

Since the conditions generally present to, or are detected

by the primary physician, an interface must be defined.

Another very important

objective for the primary physician in this collaboration is summarized in this very important objective:

given a list of the 10 most commonly performed

surgical procedures. TPWBA to outline the physiologic consequences of the operation and the recovery phases postoperatively, including complications (early and late). I.

Breast Masses 1.

The physician will demonstrate a systema -ie approach to breast examination as judged by a senior surgical observor.

2.

GASOS about the efficacy and applications of the findings from

mammography (including thermography and xeroradiography), TPWBA to STWAT. a.

TPWBA to de

ibe the appropriate action to be taken

ased on the

results of mammography.

GASOS about screening for breast cancer (including high risk groups, self examination, periodic examination, mammographic techniques) to STWAT.

TPWBA

4.

Given a patieni with a breast mass

discovered on physical examination

or mammography , TPWHA to outline: a.

A differenti,1 diagnosis based on a,e, sex, size, and the presence of other features (pain, inflammatory indices, cyclicity, bloody discharge, etc.).

TPWDA to perform a needle aspiration of isolated breast lesions. c.

TINHA to select those patients who are cancer suspects and should have surrical biopsy.

TPWHA to outline the appropriate follow-up procedure for p. -ie ts with breast abscess, cystic hyperplasia, intraductal papilloma and fibroadenomata. 5.

GASOS about the presenting features, differential diagnosis and appropriate

treatment of PagetTs disease of the breast, MBA to STWAT, II.

Thyroid Disorders 1.

The physician will demonstrate an adequate syst-matic examination of the thyr_ d gland and associated lymph nodes, as judged by a senior observor.

Given a patient with one or more thyroid nodules or goiter. TPWBA to

list those epidemiologic, physical exam, historic and laboratory features which favor each of the following diagnoses:

3.

a.

Adenomatous goiter.

b.

Thyroid cancer.

c.

Medullary thYroid cancer.

d.

Thyroiditis - acute, chronic.

For each of the conditions cited in "2", TPWBA to list the appropriate management steps.

4.

III.

Thyroid function tests, pharmacology, Graves Disease:

see medical objective

Esophagus 1.

Given a series ofpatients with dysphagia or regurgitation, MBA to list

the epidemiologic, historic, physical and radiographic features which fay

Achalas]

2,

.

b.

DifThse spasm.

c.

Benign stricture.

d.

Tumors.

e.

Diverticula.

Given a se les of radiographs illustrating the above conditions, TPWBA to correctly identify them.

each of the conditions sited in "1", MBA to list the appropriate management steps. 4.

Esophagoscopy-Motility studie

5.

OASOS about the anatomic and physiologic relationships in hiatus hernia,

see medical objectives

TPWBA to STWAT. a.

GASOS about the clinical and x-ray features of hiatus hernia, TPWBA to STWAT.

h

TPWBA to outline the steps in managemen- of hiatus hernia, including indications for surgery.

c.

TPWBA to list the major complications of hiatus hernia along with their clinical features.

6.

TPWBA to list the presenting features and diagnostic steps in Mallory-Weiss and Boerhaave's syndrome.

IV.

Stomach and Duodenum 1.

GASOS about gastric acid secretion including endogenous stimuli and

exogenous stimuli (including test drugs), TPWBA to STWAT. 2.

TPWBA to list the indications for gastric secretory testing.

3.

TPWBA to list the steps in gastric secretory testing, pass a nasgastric tube, and collect samples for analysis.

299

4.

Given several sets of data from gastric secretory testing, TPWBA to correctly interpret them.

5.

TPWRA to-list the epidemiologic, historic, physical exwil, laboratory and radiographic features of peptic ulcers (duodenal and gastric), malignant gastric ulcers, acute and chronic gastritis.

6.

Given a series of radiographs illustrating the disorders listed in "5", TPWBA to correctly identify them.

7.

Given a patient with a gastric ulcer, TPWBA to list those features which distinguish benign from malignant. a.

TPWBA to describe the role o

each of the following in evaluation of

gastric ulcer: (1)

secretory testing

(2)

cytologic study of washings.

3

endoscopy (with biopsy)

4

radiography

(5) b.

A therapeutic trial for healing.

TPWBA to outline the indications for and elements of a therapeu ic trial for healing of -

8.

tric ulcer.

Given a patient with a duod --al ulcur, TPWRA to ouliiue an effective therapeutic program.

9.

for benign gastric and duodenal ul e s, TPWBA to list the indications

for eurgen. a.

TPWBA to describe the physiologic objectives for the various operative procedures for ulcer, as well as their indi-ltionsp success rates, and relative risk (short and long term).

10.

11.

for benign gastric and duodenal ulcers, TPWBA to list the major complications PWBA to list the major historic, clinical radiographic and laboratory tests which suggest'Zollinger-Ellison syndrome.

liP

L.

1PWBA 10 lisl 1. he major feat res of the followi tg post-gastrectomy

Lyndromes, 19 well Ns management steps: a.

Dumping syndrome.

h.

Nutritional disturbances (1)

megaloblastic anemia

(2)

iron deficiency

3)

(4)

steatorrhea

c.

Diarrhea

d.

Marginal ulcer.

13. V.

calcium deficiency

See also section on Acute Abdomen and 0.1. Hemorrhage.

Small Intestine 1.

Obstruction - see section on bowel obstruction.

2.

RE - see medicine

3.

Carcinoid Syndrome - see medicine

4.

GASOS about the incidence, nature, and presenting fe tures of small bowel

tumors, MBA to STWAT. 5.

Appendicitis.

6.

CASOS about the clinical features of occlusive and non-occlusive vascular

disease of the bowel, MBA to STWAT. VI.

Colon 1.

Ulcerative colitis - see medicine

2.

Diverticulosis a.

CASOS about the physiologic basis of diverticulum formation in the colon, TPWBA to STWAT.

b.

GASOS about the effects of diet on the formation of diverticulae, and diet therapy in the treatment of diverticulitis, TPWBA to STWAT.

c.

GASOS about the presenting symptons of diverticuli, TPWBA to STWAT.

301

d.

TPWIA 1 o ou1line ibe steps

Iii 140 medi

1 1)k(11igemurI1. or acute

divcrtie.

3.

TPWliA lo describe the indic tions ror surgery in diverticulitis

Radiation Proctitis a.

TPWBA to list the settings in which radiation proctitis occurs

the

effects of radiation On the rectum, and the steps in-the management of radiation proctitis.4.

Villous Adenoma a.

CASOS about the epidemiology of, the presenting symptons and,syndromesof, the diagnosis and management of vinous adenonia, -TPW A.to STWAT.

5.

Cancer or the Colon a.

CASOS about the epidemiology of and location of colonic cancers,TPWRA to STWAT.

b.

CASOS about the efficacy of stool examinations for occult.blood,.

routine rectal examinations, routine proctoscopic examination and serologic studies in the early detection of canoe- of the colon, TPWSA to STWAT. c.

GASOS about presenting symptons of colonic cancer and especially

,

the relation of symptons to location of the tumor, TPWBAto STWAT.TPWBA to outline the di;- nost

steps in a lesion suspected of being:

carcinoma of the colon. 6.

Polyps a.

CASOS about the epidemiologic, location and morphology of colonic polyps, TPWBA to STWAT.

b.

GASOS about the presenting symptons in colonic polyps, TPWBA to STWAT.

c.

GASOS about the malignant potential,of colonic polyps, TPWBA to STWAT.

d.

TPWBA to list the steps in management (indications for s (1)

polyps less than 25 cm fi.om the anus

(2)

polypselsewhere in the colon.

302

gery) -f:

e.

CASOS about the genetics, presenting symptoms, and management of Familial oolvnosis, TPWBA to STWAT.

7

Hemorrhoids

MBA to describe the process of hemorrhoid formation and the struci

a.

e-

involved.

TPWBA to des ribe the diet management of a patient Stool soTtness

ith hemorrhoids.

see medicine

TPWRA to describe the topical therapy of hemorrhoids and its indications.

CASOS about the indications for injection therapy and resection of hemorrhoids, TPWBA to STWAT. TPWBA to describe an acute external hemorrhoidal thrombosis, and will

be able to describe the steps in management. TPWBA to do an external hemorrhoidal dwombectomy. Anal Fissure, Fistula, and Papillitis a.

GASOS about the presenting symptoms, physical findings, and medical management of anal fissures, Fistula and papillitis, TPWBA to STWAT.

b.

TPWBA to list conditions which may present as fissures or fistulae in ano.

VII.

VIII.

IX.

Liv 1.

Portal hypertension, varices, asci es.

2.

Jaundice "medicine vs. surgery".

Gall bladder and ducts. 1.

Oral and IV Cholangiography.

2,

Gallstones.

3.

Cholecystitis, cholangitis.

Pancreas 1.

Acute pancreatitis

2.

Chronic pancreatitis.

3.

Cysts.

see medicine)

4. X.

XI.

XII.

XIII.

XIv.

Tumors (carcinoma) ]or endocrine

see medicinel.

Spleen i.

Rupture.

2.

Splenectomy for hematologic disease.

Hernias Veins 1.

Thrombosis

2

Varicose Veins

3.

Varicose ulcers

Arteries 1.

Dissection of aorta

2.

Aneurysms.

Lungs 1.

Bronchoscopy

2.

Tracheostomy Pneumothorax

XV.

4.

Caminoula lung

S.

Work-43 of coir_ les on.

6.

Scalene biopsy.

Acute Abdomen 1.

TPWHA to obtain an accurate historical data base from a patient with an Acute abdomen, including the desc iption of pain, relevant GU and Gyn history, past GI history, vomiting etc., as judged by a senior medical observor.

2.

Given a series of de_criptions of pain patterns, TPWRA to describe the likely underlying ,Nachanisms.

3.

TPWBA to satisfactorily examine an abdomen including the palpation of organs, percussion, detection of pe itoneal signs, and auscultation of bowel sounds. a.

'MBA to accurately describe these findings as judged by a senior observor

304.

4.

GASOS about the following laboratory tests and their association various acute abdominal-emergericies, TPWBA to STWAT: a

Het.

b.

WBc. Differential Urinalysis.

d.

KUB and Upright.

e.

Amylase

f.

Wood light exam of the urine.

Given a series of KUB's from patients with acute abdomens, TPWBA to

accurately identify disturbed patterns and match these patterns to likely etiologies.

Given the following list of common causes of the acute abdomen, TPWBA to describe the characteristic findings to be expected in each item of data base: Causes

Perforated

Data Base Item.

peptic ulcer

Pain pattern

Acute cholecystitis

Past clinical history-

Acute pancreatitis

age, sex

Acute appendicitis

vomiting

Acute diverticulitis

bowels

Acute gynecologic disease

menstrual his ory

(ruptured ovarian cyst,

physical exam

ruptured ectopic prenancy)

KUB, upright

Acute small & large b wel obstruction

Urinalysis

Acute renal or ureteral colic

Hemogram

Amylase

"XVI.

Upper Gastrointestinal hemorrhage 1.

TPWBA to list the common causes of upper CI hemorrhage in rank order of relative frequency.

30o

R7I For each of the common causes described in XVI-1, TPWBA to state-the

features of history and physical examination that favor that diagnosis. 3.

for each of the diagnostic studied listed, TPNBA to desc ibe its role in the diagnosis a.

Gastric intubation.

b.

BSP

c.

NB3 level

d.

Barium fluoroscopy

e.

Esophago-gastroscopy

f.

-Selective angiography

g. 4.

Ipper Ci bleeding.

Balloon tamponade

Assessment of blood loss a.

TPWBA to describe the use of the following signs in assessing the volume of blood loss. (l)

skin color

(2)

pulse

(31

BP recumbent and upright

(4)

CVP

(5)

urine o tput

(6)

stool volume and appearance.

5.--The physician will construct a skeleton chart indicating the parameters to be followed in managing the bleeding pati nt, and the desired frequency ....

6.

of observation.

GASOS about the objectives of trans fusion th- upy, and p ramete

in XVI-5

that effect the rate of transfusion, TPWBA to STWAT. 7.

GASOS about the application techniques and e_ plications of the following methods used in the control of CI hemorrhage, TPWBA to STWAT. a.

Balloon tamponade.

b.

Saline lavage

c.

Antacid therapy

d.

Pitressin infusion

GASOS about the role of the following factors in intervention, TPWBA to STWAT, a.

Patient's age

b.

Patient's diagnosis Rate of blood loss and magnitude of blood loss

Availability of compatible blood. e.

Other illness. First bleed vs. re-bleed.

XVII.

Lower Gastrointestinal Hemorrhage

he decision for surgical

NUTRITION OBJECTIVES Draft #1

GASOS about the digestion, absorption, and intermediary metaholism of-p carbohydrate and fat, TPWBA to STWAT.

GASOS about basic adult nutritional requirements

TPWBA to STWAT.

TPWBA to elicit a screening nutritional history. GASOS about the physical findings in states of altered nut ition, TPWBA to SNAT.

TPWBA to describe the major types of secondary or conditioned malnutrition and outline the principles of therapy for each. 6.

7

Given a list of drugs that may induce nutrient deficiencies, TPWBA: a.

To describe the mechanisms involved, and

b.

Describe the clinical effects that may result.

TPWBA to describe the limitations of short term intravenous feedings in providing total nutri ional suppo TPWBA to:

9.

10.

a.

List the indications for total parenteral nutritional suppo

b.

Correctly order hyperalimentation solutions.

c.

Describe and manage the complications/side effects of hyperalimentation.

GASOS about hypervitaminosis A and D, TPWBA to STWAT. GASOS about the effects of malnutrition on infection and wound healing, TPWBA to STWAT.

11.

GASOS about diseases caused by deficiencies of individual nutrients and vitamins, TPWRA to STWAT.

12.

OASOS about macroelement and trace element deficiencies and excesses, TPWBAto STWAT, and be able to describe the steps in the management of each condition.

13.

GASOS about tube feedings, TPWBA to.STWAT.'

14.

TPWBA to provide dietary counseling in the management of: _

Diabetes mellitus

.

Hypercholesterolemia and hyperlipoproteinemia. C.

Renal failure.

d.

Hepatic failure.

Congestive heart failure. f.

obesity.

DERMATOLOGY owirrivEs Ora

1.

5

TPWRA to: a.

Elicit a history and perform a systemic examination in patients who

present with skin problem

.

The adequacy of this examination to be

judged by a senior medical observer. b.

Recognize benign lesions which do not require trea ment found d

rig

the routine physical examination or the skin. e.

Describe the principle types or skin lesions morphologically and patho

physiologically, and be able to dist nguish primary From secondary (excoriat on) patterns. d.

Describe skin lesions in terms of: (1)

shape

(2)

arrangement

3) 2.

distribution

TPWBA to: a.

Use in examination of the skin a magnifying glass, glass slide (dia copy) and cross illumination.

b.

State the use of the drakfield examination,

c.

Collect, prepare and examine scrapings from suspected fungal lesions.

d.

Use and interpret findings from Wood's light examination.

e.

Adequately sample lesions for bacterial and fungal cultures.

f.

Biopsy skin with a punch biopsy.

g.

Namine smears cytologically from lesions suspected of being: (1)

herpes simplex/varicella/oster

(2). bullous eruptions. b.

Stake the application and indications of pa ch testing in the work-up of contact dermatitis.

10

R7G 1.

Staie the lises or iiltrtviolel light

he able fo advise

n dema ologie therapy and to

in their proper use.

j.

Curet skin lesions.

k.

Use electrosurgical units as well as cryotherapy.

TPWBA to state the

differential diagnosis and steps in the assessment and

treatment of the following conditions: a.

Dry skin, acquired icthyosis vulgaris. Burns

including sun reaction.

Urt lear -ia

(1)

CASOS about the pathophysiology

(2)

TPWBA to list the common causes of urticaria. (a)

of urtiearia, TPWBA to STWAT.

for each cause listed, TPWBA to:. ) state the elements of history and labo a ory exam which

support that diagnos state the appropriate therapeutic steps. Pruritis (1)

CASOS about the pathophysiology of pruritis, TPWBA to STWAT.

(2)

The physician will list those systemic illnesses which may present with pruritis.

(3)

from a list or common dermato es, TPWBA to select those in which

pruritis is commonly present and those which are obligate ttitcherst1. (4)

TPWBA to outline the appropriate therapeutic steps in the ma- ,gement of pruritis.

e.

Byperhidrosis

1.

tlyper., Ifypopigmentat ion

g.

Alopecia (1)

CASOS about the normal physiology of hair growth and effects of various physiologic events on this growth, TPWBA to STWAT.

011

-477

(2 )

TPWRA to describe the clinical maniFestations and significance of:

male pattern baldness, baldness associated with cutaneous infection and other skin diseases, alopecia areata, trichotillomania, female pattern baldness, scarring and non-scarring alopecia.

TPWBA to describe, for the above named conditions, the appropriate herapeutic steps. h.

Hirsutism vs. Virilism

1.

Stomatitis

Commonly encountered nail changes

TINBA to identify the following disorders from a mixed graphic presentation or patient population, and willie able to outline a diagnostic and treatment

plan consistent with those described in the Manual o' Hematologic Thera eutics. a.

Disorders of epidermal prolifer (1)

psoriasis

(2)

pityriasis rosea

ion

seborrheic dermati is b.

Sebaceous, eccrine, apocririe glands (1)

acne vulgaris

miliaria hid- d (4) c.

d.

suppur;itivri

acne rosacea

liullous disorders (1)

E. multiforme

(2)

Herpetiformis

(3)

Pemphigoid

Eczematous dermat_ (1)

allergic contact

(2)

atopic

(3)

mummular eczema

12

(4)

dyshidrotic eczema

(5)

stasis dermatitis

6) e.

lichen simplex chronicus

Primary disorders of skin and mucosa 1) (2)

f.

aphthous ulcers granuloma annulare

Disorders due to physical and chemical agents. 1)

thermal burns

sunburn phototoxic and photoallergic reactions frostbite g.

h.

Disorders due to microbial agen s (1)

impetigo, ecthyma

(2)

folliculitis - carbuncle - cellulitis - erysipelas

(3)

erythrasma

(4'

candidiasis

(5)

fungal infection (dermatophytic, sporatric, etc.)

(6)

T. versicolor

(7)

IL simplex

(8)

IL zoster

(9)

molluscum contagiosum

(10)

verrucae c. accuminatum

(Ill

rocky mountain spotted fever

Diseases due to arthopods (1)

mites - scabies

(2)

lice

3) j.

insect bites

Corns and calluses

CASCS about the pathophysiology and clinical characteristics of malignant

pigmented skin lesions, TPWBA to STWAT. a.

Given a brown or black pigmented skin lesion, TPWBA to recognize those

characteristics of color, shape, and topography which may indicate malignant change. b.

Given a brown or black pigmented skin lesion, TPWBA to refer for treatment those pigmented lesions suspected or being malignant.

c.

GASOS about the clinical epidemiology of pre-cancerous skin lesions, TPWBA to STWAT. (1)

CASOS about the clini opathologic cor elations in pre-cancerous

skin lesions and early squamous cell carcinoma, TPWBA to STWAT. Given a series of photographs and case material demonstrating skin lesio

which may be malignant, TPWBA to select those which

should be referred br biopsy. CASOS about clinicopathologic correla ions in b, al cell carcinoma, TPWRA to STWAT. 6.

TPWRA to diagnose and manage those treatable diseases which cause acute Febrile illnesses associated with a rash. a.

TPWBA to identify from graphic material and/ the boflowing dermatologic manifestations o

'ient presentations s,ystemic infection, or

will be lble to describe the necessary diagtIstic steps required to

differentiate among diseases having similar skin lesions: (1\

Rocky Mountain spotted fever (differenti,

diagnosis to include

meningococcemia and measles). Viral exanthems (macules, papules, vesicles, pustules or petechiae)

with the differential diagnosis to include the following categories: (a)

Petechiae:

meningococcemia, bacte 'al endocarditis,

rickettsioses, drug eruptions, any severe sepsis, many enteric viruses, hematologic disorders.

Macules:

typhoid lever, scarlet fever, drug eruption,

infectious hepatitis (c)

Papules:

infectious mononucleosis, rubella.

syphilis, drug eruption, rubeola rubella, many

enteric viruses. (d)

Vesicles or pustules:

staphylococcemia, gonococcemia,

rickettsialpox, drug eruption, zoster, varicella, herpes simplex

vaccinia, many enteric viruses.

Using the categories in (2) on the previous page, characteristic

morphology and distribution of lesions and epidemiologic data obtained from the patient or patient's family, TPWBA to select

tho e statements which correctly identify: Hand-foot-mouth Disease

)

(4) 7.

(h)

Herpes simplex

(c)

Herpes zoster

(d)

Varicella

Molluscum contagiosum

TPWBA to list the most common morphologic patterns that may be seen in drug eruptions.

a.

(exantham, urtiearia, eczematous lesions, photosensitivity reaction, purpuric)

Given a list of commonly used drugs, TPWBA to describe the common type(s) of drug eruption(s) that each may produce.

b.

TPWBA to recognize and state the significance of the following lesions: (1)

splinter hemorrhages of nails, osler's nodes, janeway

_

lesions,

tender subcutaneous nodules, cutaneous infarcts, nodose lesions.

ecthyma gangrenosa scarlitiniform eruptions in patien s with pharyngitis. (4) c.

palpable purpura

TPWBA to clinically distinguish a purpuric lesion from telangiectatic lesions.

TPWIA to recogui.

Ind stale the signi 1:icunce o

the following

types or pt puric lesions: (a)

petechiae on mucosal membranes

(b)

purulent purpuri purpura Fulminans

(d)

palpable purpura

(e)

psychogenic purpura

(f)

eyelid purpura (facial/upper torso)

(g)

perifollicula

purpura

progressive pigmentary purpura (i) d.

pinch purpura

Given a list of skin lesions thal may be associated with malignant disease.

TPWHA to describe each lesion and state the associated tumor(s). e.

TPWBA to describe and recognize the skin manifestations of rheumatic fever.

f.

TPWIA to list those disorders associated with: (1)

focal cutaneous hyper and hypopigmentation

(2)

generalized cutaneous hyper and hypopigmenta ion palmar erythema

(4)

telangiectasia

(5)

yellow skin

(61

erythema multiform

(7)

intermittent flushing of the skin

(8)

Raynaid's phenomenon acrocyanosis

(9)

clubbing and ridging of nails

(10)

cutaneous angiomatosis

(11)

calcification/ossification of the skin and subcutaneous tissues.

(12)

oral lesions

(13)

skin ulcer

(14)

xanthoma

nt

ror each category of treatment drugs listed below, TPWBA to list: a.

indication and contraindications

b.

the most effective agents

c.

d.

-their relative cost

their chief side effec s acne preparations antihistamines

anti-infective agents (4)

anti-inflammatory agents

(5)

antiperspirants

(6)

antipruritic agents

(7)

cleansing agents

(8)

cosmetics and covering agents

(9)

depillatories and removal of excessive hair

(10)

dermatologic topical preparations and vehicles

(11)

insect repellents

(12)

keratolytic and destructive agents; prepara-

tions far psoriasis, seborrheic dermatitis and other scaling eruptions. (13)

pigmenting and depigmenting agents, sunscreens

(14)

wet dressings, baths and astringents

9

TETR

Ill/NM:01MM' Olid I: 'I VIN Dra t`t

1.

#5

TPWRA to elicit an accurate obstet ic and gynecologic history as judged by a senior medical ohservor.

2.

MBA to perform and accurately describe a pelvic examination including inspection of external genitalia, speculum exam of the vagina and cervix, bimanual baginal examination or the uterus and ad exa and rectovaginal exam, on normal and abnormal adult patients

the adequacy of this examination to

be judged by a senior medical observor.

TPWIA to distinguish normal from

abnormal findings. 3.

MIA to: a.

Collect, prepare

examine and interpret a vaginal wet prep

ncluding

Swartz-Lamkin stain) and KOH prep. (1) b.

clue cells.

Prepare and interpret a cervical gram sta n. (1)

c.

TPWBA to recognize trich. vaginalis, yeast

TPWBA to recognize gram negative intracellular diplococci and polys.

Collect adequately and handle (planting on appropriate media when necessary cervical, vaginal, and rectal specimens for bacteriologic and fungal culture.

d.

Adequately collect vaginal pool scrapings, endocervical swabs, and cervical scrapings, prepare slides from such material and fix appropriately for cytologic examination.

He/she will be able to take appropriate

action based on cytologic evaluation. e.

Describe the indications for cervical pool scrapings and vaginal pool swab

f.

Accurately perform and interpret a cervical mucus arborization test.

g.

In truct the patient in performing a basal body temperature chart. (1)

h.

CASOS about the BHT chart

TPWBA to STWAT.

Instruct patients in the collection of specimens for HCC (pregnancy

tests.

(11

CASOS about the temporal

Features; sensitivity, and specificity

of pregn_:cy (HCC) tests, including B sub-unit assay, TPWBA to STWAT. 4.

TPWHA to collect- an adequate subjective and objective data base and outline

a logical approach to.the diagnosis and management ._..... of the:following .

situations:

(the level of analysis and hence point of referral will generally

be limited by the physician's technical skills -- see 3.) Missed period (suspected pregnancy) PunctiOnal menstrual disorder (secondary) including amenorrhea, excessive or irregular menstruation, and hypomenorrhea. Primary dysmenorrhea. d.

Secondary dy ne orrhea.

e.

Premenstrual tension.

f.

Vaginal discharge.

g

Infertility.

h.

Galactorrhea.

1.

Perineal pruritis.

j.

Dysp

k.

Post-menopausal bleeding.

1.

Lump in the breast.

m.

Stress incontinence.

n.

DES exposure,

eunia.

Venereal warts Mastodynia. q.

White lesions of the vulva.

For each of the Following disorders, MIA to ou line a diagnostic and treatment plan. a

Gonorrhea and syphilis.

Acute and chronic pelvic inflammato

disease.

Bartholin's cyst.

Vaginitis (acute, chronic, atrophic)

3 19

6.

GASOS ah-ut the physiology, diagnosis and management of the menopause, TPWBA to STWAT.

7.

MINN to take a sexual history that will be adequate to: a.

Detelmine dissatisfaction

b;- --Given diasatisfaction, will allow the appropriate referral (1)

be ma .e to:

marriage counselor psychotherapist

_3

sex therapist

GASOS about the application and limitations of various methods of cont

ception, MBA to STWAT.

He/She will be able to outline a teaching program

For patients, ability to prescribe, and the stages in followup for the following methods:

the pill, condom, diaphragm, IUD,

rhythm, coitus interruptus, 9.

Given a series

c _am, foam, jellies

sterilization, and the morning after pill.

r _ommon "minor" pill complications, MBA to outline a

rational approach to manipulation of various types of BCP's.

10.

11.

a.

Pill composition

b.

Side-enects of estrogen and progesterone predominance.

Given a list of drugs caumonly used in pregnancy, TPWA to select: a.

Those which are toxic.to the fetus.

b.

Those which are toxic to the mother.

The physician will demonstrate an understanding of the major physiologic alterations of pregnancy and the interactions between common acute and chronic medical conditions and pregnancy:'.

12.

The physician, GASOS about the presentation of ectopic pregnancy, will _be able to STWAT.

13.

GASOS about the clinical presentation of ovarian and uterine malignancies, TPWRA to STWAT.

14.

GASOS about the clinical presentation of ovarian cysts, TPWDA to STWAT.

15.

GASOS about therapeutic abortion procedures

follow-up, TAM to STWAT. .

30

evaluation, risk assessment, and

H1I3LIOGRPI1Y 9a.

Obstetrics/Gynecology Objectives MAJOR REFERENCES

Calderone, M.S. Manual of Emily Planning and Contraceptive Practive. Baltimore: Williams & Wilkins, 1970.

Danforth, D.N., ed. Obstetrics and Gynecology. New York: Harper & Row, 1971. Green, T.H. Gynecology. Principles of Clinical Practice. Boston: Little Brown, 1971. l
Gynecology. Principles and Practice. Chicago: Year Book Medical Publishers, 1971.

2nd ed.

Novak, V.R., Jones, G.S. and Jones, B.W. Nov-kys Textbook of Gynecology. Raltimore: Williams & Wilkins, 1975. Reid and Barton, eds. Philadelphia:

Controversy in Obstetrics and Gynecology. Saunders, 1969.

Reid and Christian, eds. Controversy in Obstetrics and Gynecology II. Philadelphia: W.B. Sapnders, 1974. Speroff,

Glass, R., and Kase, N. Clinical Gynecologic Endocrinology and Infertility. Baltimore: Williams & Wilkins, 1973.

REFERENCES Obj.

#:

1. 2.

3.

LISTED ACCORDING TO THE OBJECTIVE WHICH RELATES TO THE REFERENCE Introdu ion". In Kistner, pp. 1-16. a.

Lewis, G.C.: Office gynecology. 5: 129-138, 1972.

b.

"Introduction".

a.

In Green, pp. 19-20.

c.

In Green, pp. 20-21.

d.

In Kistner, pp. 141-144.

Amer.

I mily Physician

In Kistner, pp. 1-16.

In Novak, p. 804 Fish, C.R

Cervical intraepithelial neoplasia: rationale or investigation and management. Medical Clinics 58:743-753, 1974.

In Novak, pp. 763-766.

In Green, pp. 17-18.

Obj.

f.

_In Green, pp. 21-23.

g.

"Step by Step through the infertility workup." Patient Care, March, 1975. (Describes how to do this).

h.

_In Green, pp. 28-29.

Urine pregnancy test. 4.

b.

_-odical Letter 17:6-7

1975.

Smith, R.A., Litwack, O.: Endocrine aspects of menstrual irregularity. Medical Clinics 58_:869-876, 1974. Shane,

Reck

.M., Naftolin, F., and Newmark, S.: Gynecologic endocrine emergencies. JAMA 231:393-395, 1975. (Primarily focuses on approach to dysfunctional uterine bleeding). W., et.al.: Abnormal gyn bleeding. Patient Care. Oct. 15, 1973, pp. 20-60. (Systematic Approach to diagnosis and treatment).

"Amenorrhea". In Speroff, pp.71-84. (Outlines specific protocol in dealing with this problem).

Qysfunctional uterine bleeding". In SperOff, pp. 85-99. (Outlines specific approach).

"Secondary amenorrhea and primary amenorrhea". Patient Care. Oct. 15, 1972, pp. 64-84. (What questions to ask the patient).

"The value and limitations of endocrine assays specifically for obstetric and gynecologic conditions". Reid and Christian, pp. 725-750.

in

In Novak, pp. 721-726. d.

Tn Novak, pp. 721-726.

e.

"Evaluation and preferred management of premenstrual tension pelvic congestive syndrome". In Reid and Christian, pp. 751-782. "Premenstrual symptoms".

Brit. Med. d.

Banner, E.A.: Vaginitis.

Medical Clini s 58:759-768-,_1974.

Ma ch 24, 1973, pp.689-90.

Selloff, J.S., et.al.: When vaginitis keeps coming back". Patient Care Sept. 15, 1974, pp. 44-77. In Kistner, pp. 79-89. Viasis:

Office manageMent of cervical lesions Amer. Family Physician 9:119-121, 1974. (Emphasis on diagnosis and treatment of cervicitis).

Obj. #

4.

g.

"Investigation of the infertile couple". "Mhle infertility".

In

peroff, pp. 172-189.

In Speroff, pp. 204-213.

Step by step through the infertility workup". Patient Care Mar. 1, 1975, pp. 52-89. (How to take a history, do an appropriate physical exam and what laboratory tests to order. Bibliography on use of hormone levels and hormone treatment). Vande Wiele, R.L.: Treatment of infertility due to ovulatory failure. Hosp. Practice. Oct. 1972, pp. 119-126. h.

"Normal and abnormal lactation".

i.

In Kistner, pp. 38-51.

j.

In Danforth, p. 166 (Discusses psychogen c vs. organic etiology).

k.

In Green, pp. 430-431. (30Z have carcinoma and a DO is necessary in every case as part of diagnostic work-up).

1.

Schwar z

In Speroff, pp. 100-111.

G.P: Evaluation of the patient with a breast tumor. Surg. Clinics of No. Amer. 53:717-734, 1973.

"Management of benign lesions related to the diagnosis of early breast cancer". In Reid and Christian, pp. 465-514. (The view of three specialists). "Priorities in managing breast problems". Patient Care. April 1, 1975, pp. 20- (How to procded if patient presents with lump, pain or discharge; includes pictorial essay on breast exam.) Leis, N.D.: Clinical diagnosis of breast cancer. Med. 14:231-239, 1975.

J. Reprod.

Abramson, D.J.: A clinical evaluation of aspiration of cysts of the breast. Surg:, Gyn., & Obs. 139:53137, 1974. "Mammography".

Medical Letter 17:65-7, 1975.

Egan, R.L.: Mammography, xeroradiography and thermography.Cl n. Obs.Gyn. 18:197-209, 1975.

5.

m.

Isaacs, J.H.: Stress incontinence: a plan for systematic evaluation. Postgrad. Med. 54:102-5, 1973.

a.

Fiumara, N.J.: Diagnosis and treatment of gonorrhea. Cl. 56:1105-14, 1972. 11

Ba

hilis: a synopsis". U.S. Dept. HEW, 1960; monography on all clinical aspects).

Med.

(Comprehens ve

ett-O'Connor, E.: Current status of the treatment of syphilis. West J. Med. 122:7-11, 1975:.

Holmes, K.K.: Screening and the detection of gonorrhea. West J. Med. 123:367-71, 1975. (Who to screen

In Novak, p. 395, (includes differential diagnosis, IBD as etiology, 'cooling down pelvic inflammation') Patient Care. Dec. 1, 1974, pp. 90-99. (Covers differential diagnosis, specific organisms, flow chart In Green, pp. 166-167. In Green, pp. 171-172.

Jorgensen, E.D.:

White lesions of the vulva.

Medical

Clinics 58_:755-8, 1974. 6.

Easterling, W.E.: Managing the menopause. 7:137-142, 1973.

Amer. Emily Physic_ n

In Green, pp. 425-32. (Emphasizes psychologic etiology of many symptoms and advocates limited role for estrogen therapy.

"Estrogens and menopause".

Medical Letter 15:6-7, 1973.

Kerr, M.D. and Vaughn, C.: Psychohormonal treatment during the menopause. Amer. Family Physician 11:99-103, 1975. (Who needs hormones, who needs counseling, how to follow serial vaginal smears.) Greenblat

R.B., ed. The menopausal Syndrome. N.Y.: Medcom, 1974. (Covers basic science, medical and psychological aspects).

"The yxes and cons of estrogen therapy for gynecologic c In Reid and Christian, pp. 783-810. 7.

Human Sexuality. AMA, 1972. (Summary of basic aspects of sexual development and issues emphasizing role of physician. Sample history form is helpful).

Masters and Johnson. Boston:

Masters and Johnson Boston: 8.

ditions".

Human Sexual Response. Little Brown, 1966. Human Sexual Inadequacy. Little Brown 1970.

"Topical and Systemic Contraceptives". "Cu-7, a copper containing IUD".

Medical Letter 1_6:37-9, 1974.

Medical I tter 17:26-7, 1975.

"Choosing the best mode-of contraception". Patient Care 8:19-101, April 1, 1974. (Extensive sections'on the pill, IUD, vasectomy).

Methods of conception control: a programmed instruction course. N.J.: Ortho Pharmaceuticals, 1972. How to prescribe various modes).

Uricchio and Williams, eds. Natural Family Planning, Washington D.C.: Human Life Foundation, 1973. Discusses how to use thythm method, focusing on use of BBT, clinical symptoms, and observation of cervical mucus as ways to predict ovulation. Calderone.

(Extensive coverage on all forms of birth control from medical and practical points of view

In Green, pp. 439-40. In Calderone, pp. 351-67. (A detailed chapter with many pictures explaining how to). 9.

Nelson, J.H.: Clinical evaluation of side effects of current oral contraceptives. J. Reprod. Med. 6:43-8, 1971.

ones, D. and Halbert and choices.

D.:

Oral bontraceptives: clinical problems Amer. Family Physician 12:115-123, 1975.

Decker, et. al. When oral contraceptives talk back. Patient Care Oct. 1, 1975, pp. 104-21. (Summarizes side-effects and approach to selection of appropriate pill. Good bibliography of medical complications, i.e. clots, stroke, myocardial infarction.)

In Danforth, pp. 427-30. (Comprehensive li "Drugs in pregnancy"

').

Medical Letter 14:94-96

1972.

"Which drugs for the pregnant patient". Patient Care 8_:54-67, March 1, 1974 (suggests proper drugs for specific problemS, i.e. urinary tract infection, hypertension). Sabath, L.D.: Antibiotics in obstetric practice. In Charles and Finland, eds. Obsteiric and Perinatal Infections. Philadelphia: 11.

Lea & Febiger, 1973.

pp. 563-624.

For physiology - any of the standard texts. "Medical gynecology".

Med. Cl. No. America 58: July 1974.

Burrow and Ferris: Medical Complications During Pregnancy. Philadelphia: W.B. Saunders, 1975. (Comprehensive, new text.) Barnes, C.C.: Medical Disorders in Obstetric Practice. Oxford: Blackwell Pub., 1974. 12.

In Novak, p. 566. "Management of Suspected ertopic i.--cgnancy". Barton, eds., pp. 1-20.

In Reid and

13.

Deck

D.C.

Ovarian cancer and the internist. 58:769-77, 1974.

Medical Clini s

Burk, J.R., et.al. Inadequacy of papanicolaou smears in the detection of endometrial cancer. New Engl. J. Med. 291:191-2, 1974. In Green.

ADDITIONAL REFERENCES Hirsutism:

Karp, L.P. and Herrman, W.L. Diagnosis and treatment of hirsutisrn in women. Obs-Cyn 41:283-94, 1973. Sexual

velopment:

Bryan, C.T. Normal and abnormal sexual maturation. Amer. Family Physician 9:123-35, 1974. (How to evaluate and workup disorders).

Resource Paper No. 8

HMO CURRICULUM DEVELOPMENT:

SOME RELEVANT INSTRUCTIONAL RESOURCES

by

Arthur L. Elstein

and

Jack L. Maatsch

ILMO Curriculum Development:

Some Relevant Instructional Resources

Arthur S. Elstein a d Jack L. Maatsch Michigan State University

ABSTRACT The use of Health Maintenance Organi-zations (IE4OS) and o her

ambulatory care settings for undergraduate medical-education poses a challenge, since an educational .experience should not -disru

the...

care-giving mission of .the organization.. A numbe :techniques a

avaIlable that can help students improve their clinical

skills outside the practice setting so as to facilitate effec ive and efficient use of the clinical _xperience. These include:

use

of simula ed or actual patients to train students-in history taking

and communication skills; a variety of simulation equipment for training in different portions of the physical examination; clinical algorithms, flowcharts, comp

based or paper-and-pencil clse simulations,

and high-fidelity simulation games, all for sequential problem solving.

fl s._ru tion in complex,

The techniques are briefly descrihed,.

and,po Able uses In -1 the medical school and. IIMO are SUggOS ed. references.

31

1

HMO Curriculum Development:

Some Re evant Instructional,Resources

Arthur S. Elstein and Jack L. Maatsch ichigan State University

lth Mai tenance Organizations (HMO) are gradually becoming a more

common oranizattonai format in the American health care system. -Accordingly, ion is being focused on mechanisMs for 1- -vid ng m dical students with: cl. rkship cxperJLncL in the-11140 to acquaint the next generation.of 'physicians

with prepaid group care and to assist in recruiting staff for the new organizations

Renewed interest in primary care has also emphasize&the desirability o fering primary care experiences to the medical student; ,the HMO has been identified

as one possible learning environment for this experience.

However, ambulatory care settings, whether prepaid or fee-for-service enter-

prises, challLne undergradu -0 medical education in some ways not at issue with inpatient care.

Patients In an HMO nre not available and .idle for large

blocks of time during which they nre relatively free for a leisurely approach to n problem. his en

The medical student muSt learn to

than hn- previously been the c

-O._

-apidly earl ier in

:Furthermore, the economic soundness

of the HMO is p- dicated upon p 'vision of prompt.lnd efficient service. Strntegies developed for coping with teaching costs on inpatient services do not appear to be directly :ippt(cnbl.e since there is no third-party payer to provide

an ever-increasing day rate.

For these reasons, HMO managers and directors are

:appropriately concerned to provide educational experiences, especially in primary c,

that are efficient, cost effective, and do not disrupt

care-giv ng

inn of d- organization.

How can medical students be helped to fit in

this hew learning

environment early in their traininh and without an unreasonable-expenditure: of ti e and effort Of HMO staff?

This-paper. will outline .

number of-

available instructional techniques that cat-- help medical- students- (and' resid nts) :practice and improve their clinical skills-outside the HMO

set ing so that their useEulness within th- setting can be maximized. Sack of these technique- is :presently employed in several medicalschools. in

North America though '-h y have not yet been brought togetherin an HMO training package to our knowledge.

The discussion will.consider interYiewing

rd history-taking skills, competencies for

_

physical examination, and

instructional aids for problem-solving and dee' ion making.

interviewinf _ _

_

_

A numbe

History Takinp

and Patient Interaction

of medical. .schools have developed instructional programs

using simulat-ed or actual patients to train medical students:in more ef-

fective doctor-patlent relationships (2,3).

The participant interviewees

have included mothers of essentially healthy children A), college students either role pinying

scr bing aspects of their own lives (5,6)

with significant medical problems (7).

and pe sons

Trained counselors (8) who can

guide med icat students in improving their techniques for the gynecologic exami nat 1On have also bean used, thereby combining aspec ts of patient interac t fun

t a in i ui l; with instrtction In physical dingo

Voluntary and paid p;lrticipants have been utiliz d.

It appears that

the major [neell tive for hoth groups has bec;n to. contribute to the training

330

of new physieia

and to directthe medical students' attention

patient as a person.

The pool of potential participants is-large and Generally high levels of satisfaction of

available in Most:communities.

both instructors and students have beet reported regardless of the

-up .

of interviewees used. Commonly a student-patient encounte- is videotaped for subsequent,

review and eValu tion by the student and his tutor (9)0E the exercise can vary.

The program

The objectives

__y focus chiefly upon the_ quality

of the relationship with the patient, on cognitive issdes related tajnaste f history taking, or on perfecting specific skills associated with the physical examination.

Of course, several objectives may be combined (I0)..

Physical Exam_ior tion

Instruction in physic-1 exa ination has long relied upon pa tents for teaching purposes.

Recently, however, new devices have become commer-

cially available that students can practice certain components of the physical

These in'lude heart and-breath sound simu-

examination: on nonhuman mpdels.

lators; severe._ simulators for the ophthalmoscopic and otoscopie examination; breast, pelvic _

and re_tal examination models; intubntion simulators; and

least three types of resuscitation,mannequins.

development and evaluation stage

Other devices are =n

(11,12,13).

These d vices can help students init ally develop and then practice examination skills so that less rime is taken in learning fund .antals with actu-1 patients (14,15). cu

Practice can be arranged prior to or con-

ent with ivn experience, but need not be in the h1O fa ility.

The

costs or purchasing, operating, and maintaining the equipment can be assigned to the m lical schoo1.

not the HMO.

Such laboratories are currently

esrrililii,lied at Michigan State University nnd the U 'vomit), of Illinois (13).

Clinical Prbhlem

The applications of simulation to t ach and evaluate clinical problem olving and decision making can be grouped into

e broad categories:

protocols and algorithms, low fid lity simulations, and complex simulation games.

lach has relativei.y specific purposes.

Protoe9ls and Alg2rithms.

Flowcharts, algorithms, and decision trees

are all effective ways to learn the recommended way to work up and evaluate mnny specific clinical, problems (16,17,18,19).

tional aids should he encouraged.

Broader use of these instruc-

One source of resIstance to their adoption

ems to be that medical educators have historically e phasized the implic char

of rul

s for wo king up patients and making decisions.

Certainly

the aim of medical education is not simply to teach a set of techniques, but also to teach unders them.

of the principles and rationale underlying

However, the logic of clinical decision making can be madeexpllc±t

nnd is more easily learned when it'is.. B,ckground materials for protocols can illuminate the rationale for

cps in a workup and guide the students

in an orderly and efficient decision process.

While these learning aids

van be useful to medical students on an inpatient clerkship experience, their value as an aid to efficient patient workups ts mos't likely to be .ipprivC iat

1

iscLous NO.

in a c

Low Fidelity Simulations =--_

dIcunscd present a mec of

_

The flowcharts and decision

a] problem at a particular level, of abstraction

T1 _y nnnumL the student can imagine n pa ient and provide lines

the orderly collection and evaluation of cintn from that

332

It is also pos 'ble to present patient problems 1n a format that

tient.

more closely simulates the realitY of natient interaction over-time Computer-based simulations include those prepared by groups at the

.

Univesity of Illinois (20), Massachusetts General Hospital (21), and-the University of Wisconsin -(22).

A range of computer-simulated cases are

now available through the Health EduCat on Network.

The topic has been--

ecently reviewed thoroughly (23). Simulations in paper and pen_il _ormat are also available _or use.

as both instructional and evaluative ins can be objectiv

uments (24,25,26,27).

Performance .

scored and relatively prompt response-contingent feedback:.

to groups of students is nrovided.

As instructional devices, however,

they need to be supplemented, since many relevant clinical c es are nonverbal.

Simulations with film clips, slides, and Other non erkl presentations clinical da a can be q ite portable (28), but the process of design and revision is more time consuming than for verbally mediated simulations.

Thus the level of fidelity to be sought in a pa ticular design situation nds upon the intended audience, the purpose of the simulation, the expected frequency of revision, and the funds available. The f'delity of can be Nu.

.

paper-and-pencil Simulations to clinical reality

i ed by niter i t-

the amo.nt

aphic and pictolial material provided,

and by the de-ision to use either a linear or branching format. linear_ format

in a fixed

the student moves from one sect on of the case to the next

sequ

At the beginning of each new see Lion, optimal reso-

lutlon of the irccetl I ug section is often -Ammarise Anct L,

In the

the student

,2(i).

In the branch-

odiraiiy offered a choice from among several

alLernatiV.es.

The Content of subs quent sections and the number of sections

traversed before clic problem is concluded are a function of prior cioices (24

7

The use of simulations need not be limited to self-instruction and evaluation.

They can also he more closely int grated into classroom or

clinical teaching, by serving as the fo us for group discussion or tutorials (29,30).

Complex Simulation Camrs.

_

Some siniiiltion

.

combine an interactive

problem-solving instructional, format with a still higher level of fidelity to clinical reai.ily.

A preceptor plays a diagnostic and management 'game"

with one or more students arid-' subsequently debriefs their performance.

The

patient's report of complaints in the medical history is provided by the instructor in the patien

wn language so that the student can practice

t-Hislating these verbal descri-Aons into formal medical cues.

Physical

ination data and labor -ory tests are proviled in the form of films, pictures, x-rays, laboratory slips, and audio tapes where appropriate. By eXtt'il]

1 T1

the time frame encompassed-by- the Simulation,

to prov ide eith.r

fs

1

-06ssible

nse to va ious treatments or compli-

cations :ir isi ng when approp late action is delayed or not undertaken.

Simulation games with these capabilities have been designed by Mantsch, Holzman, and Greenbaum (31 32)

.

The initial cases simulated

pri-

marily mccl ical and obstetri. 11-gynecological emergencies at iindcgradurate ,

levels of complexity.

The cases selected are not frequently encountered

during clerkships and residencies. The s inn Intion game forma, has been a useful adjunct in helping medi-

cal students broaden their experience and sh,

n their diagnost ic and

management skills ln the a --1 -e of rcal pnt ent experience. is easily adapted

to

The technique

the needs of a particular 11190 by jointly asses ing

the instructional needs of the students and the caseload of. the HMO. most preval ent cases and

H40 setting can be

tlm

The

functions the student is to perform in the

tablished so that-the lett r can -be practiced under

simulated ga e condi ions until a desired level of proficiency is reached. If an existing game fits, it may be employed with Telatively_little-traip7:,_.

of tutors, or new game can be designed rather easily by mol-

ying

,

exist

ing 1NO case files of appropriate pn ients.

rv _

All simulation techniques have the common property of represen

n-

-tajn features ,of the clinical process without direct involvement of the _

lents or personnel of an actual clinical se _ing. The learner

is _

then

better prepared and more able to function effectively during subsequent real patient encounters in ambulatory settings.

priration i

Simulations serve as pre

for clinical experience, not as substitutes for it.

The optimal

titian of those techniques and the medical content,to be stressed,

r

depend upon the -gonls and sp cific ol

clerkship.

tives of a pnrticular'HMO

With f_ dnmentnls mastered in simulated clinical experiences,

ne ttial pntient contric Ls in the 11190 should be more rewarding for both the

student and the organization.

RFFERENCES Craver, P _,.

Teaching Primary Car- in the HMO: -Design, .Evaluation

Proceedings of the Fourteenth AnnUalConference on.

and Costs.

search in Medical Education.

Association o

Washington, D.C.:

American Medical Colleges, 1975. Froelich, RJi:.

A Course in Medical Interviewing.

44:1165-1169, 1969. 3.

Ba- ows, U.S.

Simulated Patients. 'Springfield IL:: C-C

1971. 4.

Helfer, R.E., Black, M.A., and Teitelbaum,

A Comparison of

Pediatric Interviewing Skills Using Real and S mulated Mothers. Pediatrics, 55:397-400, 1975. 5.

Jason, H., Kagan, N., Werner, A., Eistein, A., and Thomas, 3. New Approaches to Teaching Basic Interviewing Skjlls to Medical Students.

6.

Am. J. Psychiatry, 127:1404-1407, 1971.

Werner, A. and Schneider, J.M. actional Skills: Relationship.

7.

Teaching Medical Students Inter-

A Research-Based Course.in the Doetor-Patient

N. Engl. J. Med., 290:1232-1237, 1974.

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A.S.

A New Type of Facility in Medical

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Human Interaction. Psychology. 10.

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Michigan State University, 1975.

The Medi al Interview. Unpublished.

Syllabus for Clinical Science, Ye2r 1.

College of Human Medicine, Michigan State University,

1975..

11.

Arsham

C.M., Colenbrander, A., and Spivey, BE.

Curriculum Development in Medical Education,

A-Prototype-for-

J. Med. Educ., 48:

78-84, 1973. 12.

Instructional Materials in Ophthal ology for Medical Students -An Update -- Fall, 1975.

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Pacific Medical Center., 2340 Clay Stree_, San Francisco, California 94115 (ALL: 13.

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Sajid, A., Lipson, L., and Telder, T. Medical Education. Pen

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FOOTNOTE

A- earli-- version of this paper was presented at 1 Conference

on Teaching Primary Care in the MO, held at the University of Rochester Mediell

Sclool,

March 13-14, 1975, under the sponsorship of tle AAMC

Preparation of this text -ras supported in part by grants from-the Robe

_

Wood Johnson Founda_ion and the Commonwealth Fund through

the Center for the Analysis of Health Practices, Harvard School of Public Health, while the senior author was on sabbatical leave.

340

Resource Paper No. 9

REPORT OF EFFORTS TO DEVELOP A STANDARDIZED TEST OF KNOWLEDGE AND ATTITUDES RE,LEVANT TO THE HMO SETTING

Edwin B. Hutchins, PhD.

March 30, 1976

Submitted to the Association of American Medical Colleges as part of a pruject to develop curr cula for physician traini-lg in H 0 s

TABLE OF CONTENTS Page

Introduction

1133dr

Purpose of the HEPKAT

£301

Description of the HEPKAT

11.3c1

Method

dr3te

Results of the Pilot Sample

3t--

Summary and Projected Plans Appendix A.

HEPKAT

Appendix B.

HEPKAT Answer Key

Appendix C.

Timetable

References

so R33

Report of Efforts to Develop a Standardized Test of Knowledge and Attitudes Relevant to the HMO Setting Introduction

Jerome Bruner in The Process of Education has pointed out that "examinations can also be allies in the battle to improve curricula and (1)

teaching."

In undertaking to develop curricula for physician training

in HMO's, the AAMC proposed an evaluation of the results of efforts of the six participating medical schools.

While each individual school was

free to undertake an evaluation designed to serve its local purpose, the

development of an evaluation tool derived from a common core of educational objectives was also considered as a cooperative effort.

Such a tool

should ultimately serve, as Bruner suggests, as an ally in the broader

efforts to improve teaching of an HMO curriculum, not only for the institutions participating in the project, but in medical schools generally.

This report describes the preliminary efforts to produce a

common core instrument, the HMO Education for Physicians Knowledge and Attitude Test (HEPKAT).

While the report describes in some detail the effort undertaken to date, it is not final either with regard to the instrument itself or the developmental work required to achieve minimum essential standards (2)

basic to sound test construction.

A more complete report is antici-

pated by the end of this year.

Pur ose of_ the -HEPKAT

The HEPKAT is under development to se.ve primarily as an achievement test.

While it includes a section measuring attitudes, the essential

43

purpose for the entire instrument is that of an assessment device designed to measure changes in students' knowledge and attitudes as a function of exposure to curricular experiences organized to meet a specific set of educational objectives.

These objectives, which have

(3)

been described elsewhere,

represent

defined area of interest sig-

nificant to the development of manpower in health care delivery settings. As such, the test is being so designed'as to be useful for long term evaluation efforts,

.g., to assess fi st year to fourth year change in

medical students) as well as the short term evaluation of the effectiveness of'a single course, a clerkship, or an intersession experience in achieving the stated objectives.

Description. of the. HEPKAT

The HMO Education for Physicians Knowledge and Attitude Test (HEPKAT) is a four part instrument.

The sections of the instrument

include: I

II

III IV

Knowledge items; True-Faise Knowledge-Judgment items; Multiple-Choice

Attitude items; Likert Scale Career Choice Information

Minimum biographical identification information can be-obtained on the cover sheet.

The three sections testing knowledge and attitudes

contained 30, 20, and 77 items respectively in the first administration of the test.

The number of items will not remain constant in subsequent

administrations of the test, since test statistics will be obtained and used to improve the instrument.

Nevertheless, in its present form,

it requires approximately 40 minutes for administration.

Since a

practical goal was set to produce an instrument that could be administered within the limits of a 50 minute class period, the testwill be lengthened somewhat in subsequent drafts.

Keeping the test

sections at maximum length compatible with testing opportunities defined by the purposes set forth above is an objective that derives (4)

from the known relationship between test length and reliability. The response format for each section of the test is standardized to assure easy familiarity by any group ,of respondents and also to

expedite the development of test statistics to be used in test development. n its present form the test is a mimeographed document available from the author without cost in exchange for data that can be used in its development.

Method

The initial impetus for this effort derived from a joint conference f the six schools held at Cambridge on September 29-30, 1975.

At this

conference, interest was expressed in the preparation of common evaluation devices to avoid duplication of effort, to allow inter-school comparisons, to evaluate the project in its entirety and as a useful byproduct for future research purposes. A later meeting of the project evaluators was held at the instigation of Marcel infeld, AAMC project officer, on November 9, 1975.

The participants in this meeting reached

the consensus that an instrument reflecting a core of curricular objectives common to all schools could and should be developed.

The

steps involved item writing, editing of items and rational evaluation of the content validity, preparation of the test format and a -prelimi-

nary draft copy, and finally collection of data from readily available samples of students.

To date these steps have been completed, although

only a small sample of students has been tested.

Results for this

sample are presented here in order toliVe some preliminary statement of the range and type of responses to the proposed items and to encourage further use of the HEPKAT so that development of the instrument can proceed.

In addition to the completed steps outlined above, further plans call for the addition of items according to a map of the curriculum

content domain outlined in the University of Pennsylvanizset of educational objectives.

Table 1 presents the initial plan for item writing

distinguishing between two categories of items:

(1) those designed

primarily to assess learning of cognitive materials at the knowledge level, and (2) those designed to assess affective learning as'reflected in attitudes.

For the first category, the assessment of knowledge, two

iteu types were,used, true-false and multiple-choice.

The measurement

of attitudes was approached using Likert type attitude items as a basis (4)

for later scale development.

While the format in Table 1 indicates

the intent to spread items over the various content categories as a means of assuring content validity, in practice the preliminary draft of the HEPKAT falls short of this objective (see Appendix A).

More

true-false andLikert type items were obtained than called for ,in the

plan and fewer than the desired number of multiple-choice items were

"46

Table 1.

Item source and distribution plan for development of the HEPKAT content and format (Ni entries are estimates of final'number of items to be derived). Curriculum modules

1

Taxonic Content

Item Format

Primary Health Care Comprehensive Care

2

4

3

Health Active Care Consumer Team Participation

6

5

One Quality Health Care

Change of HMO's

'and

Innovation

TrueFalse Ni.60 Knowledgeftitiple Choice Ni.48 .

Semantic Differential Ni.8 Attitudes Likert items Ni=54

available.

These differences will be rectified as the test is revised

and item data from larger samples become available.

Thus, items with

extremely high or low difficulty levels or with poor item-total correlation will be discarded before the test format is finally set. Items were obtained by several means.

Source documents such as

An HMO Dictionary and A Medical Student's Guide to Health Maintenance Organizations were carefully reviewed.

As another step, the provider

staff of the Penn Urban Health Maintenance Program was extensively employed and, through the use of guided interviews, encouraged to

generate both knowledge and attitude items.

From this latter effort,

we were more successful in obtaining attitude items as opposed to cognitive items, the latter being most readily generated from the (5,6)

source documents. The essential activity in-volved in the construction of a measurement

instrument is that of mapping stimuli, usually test items, into a number system.

A test score or a profile of scores represents the final

product of an entire set of mapping operations.

To assure that the

numbers assigned to students as test scores have meaning, we strive to achieve a number of characteristics for our test.

One characteristic

sought is often referred to as the functional unity of the test and implies that some degree of.consistency exists in the way we mapped out the test and then subsequently assigned scores or scale values to the particular stimuli or test items.

The operations of test construction

affect the functional unity and are implicit in decisions made in the development of the HEPKAT, such as selection of item format, number of items, range of scale values, and practical considerations in the use of the test for assessment as opposed to prediction.

These considerations

are particularly of concern in the development of attitude scales.

In

addition, two other characteristics of a measurement instrument, reliability and validity, required attention.

The mapping described in

Table 1 above is important to the content validity of the test, while decisions on the number of items will later affect the reliability of the test scores, which in turn can affect its utility in assessing the adequacy of a new curriculum change.

The objective test items cast in the true-false and multiple-choice format in Parts I and II of the test were designed to test cognitive material in the curriculum.

While the majority of the items would

generally be classified at a low level in the taxonomy of educational objectives, calling as they do for factual knowledge or information, some require higher order processes.

As the test is further developed

every effort will be made to include additional items that require the higher cognitive processes.

Inthe construction of attitude items in Part III, the fundamental requirement is the opportunity for the respondent to express some degree of orientation either for or against the object, person, relationship, or activity being described. of the test.

The Likert method was employed in thispart

It involves an,initial compilatien of a set of statements

related to an attitude object which are then presented to a group of respondents to be rated according to the extent of their agreement or _(4)

disagreement.

Once we have obtained data from a group of students,

some items will be eliminated, others rewritten or improved, and on the basis of the interrelationships

among the items, an attitude,scale of

some consistency will be cast.

The first opportunity for use of the HEPKAT preliminary draft_ was with a group of 27 students who attended the Intersession Course on,Comprehensive Care at the University of Pennsylvania.

This week

long course is staffed by primary care providers in the Penn Urban -Health Maintenance Organization and is an intens ve experience involving

approximately 35 contact hours with the students.

In the group tested

a with the HEPKAT, there were Seven students from medicine, six from nursing, five from social work, and nine from allied health, law administration and other fields with a related interest.

The inter-

sessiorTexperience was a short, intensive introduction to most aspects of the HMO curricular content developed in the AAMC project.

A pre-

test was administered folloWing introductory comments the first-morning and a posttest was employed at the end of the fifth and last day.

Some

personal rating scales were dropped from the posttest administration due to time constraints; otheTwise the test was identical for both administrations.

One development anticipated for the future will be the generation

of alternate form of the test designed to be comparable in conten difficulty level, etc.

Results of the Pilot Sample The first three sections of the test.were initially analyzed

separately."The analyses focused primarily on item data and rapid approximate non-parametric techniques were employed. Part I of the test, the true-false section, yielded pretest scores on the 30 items ranging from 14 (a score that .could be obtained by ohorr

to 27.

For the posttest, the range was essentially the same,

i.e., 16 to 27, although the average score increased.

Part II, the,

multiple-choice section, had Pretest scores ranging from 10 to 18 and posttest scores ranging from 11 to 18.

The rank order correlation of

pretest scores on Parts I and II was .41.

When Parts I and II were

combined to yield a total score.for the knowledge section

scores

ranged from-24 to 43 on the pretest and 28 to 45 on the posttest.

The

pretest mean for the combined Parts I and II was 33 3 and 36.5 for theposttest, indicating an increase of three items answered correctly for the group.

While this is statistically significant, it may be somewhat

more meaningf01 to indicate' that of 24 students for whom the test data

were complete from pretest to posttest, 20 improved their score, one stayed the same, and three experienced a decrement in their scores.

The

raw score:imeansjind _angWare. presented in Table 2.

Table 2.

Pretest and posttest means and Paw score ranges for 24 intersession students on objective test items.

Raw Scores

RFEETTITOW

Part I

Pretest Posttest

21.2

Part II

Pretest Posttest

12.5 13.4

10-18 11-18

Total Score

Pretest Posttest

33.7 36.5

24-43 28-45

23.1

rho

II

14-27 16-27 .41

Item difficulty levels were also examined, as were the item total

.

correlations, but the sample size is not sufficient for these analyses to yield data of any ysychometric interest pertinent to test development. It is of casual interest that the items did range in difficulty level from four items, which no one answered incorrectly to ten items of

sufficiently highAifficulty level that the group didno better than a chance response on the pretest (Table 3). In brief, the objective test tems covering the knowledge component of the test are promising and, if the pilot sample is at all indicative, should, with further development, yield a reliable, valid and discrtminating instrument. Finally, Part III was analyzed by comparing pretest and posttest responses item by item for the total group. Complete data for this analysis was available for 23 students. Pretest and posttest item means are presented in Table 4. These give some Prospective indication of the direction of scoring for the items but further development of Part III awaits a sample size sufficiently adequate to subject the items to a factor analysis as a preliminary step in scale development. A

minimum sample size for such an analysis would require at least three times as many subjects as we have items. Thus, at a minimum we will need approximately 250 students.

Again, for illustrative purposes, we have presented ia Table 5 those items which yielded significant chi-squares when pretest and posttest responses were compared. Item responses were dichotomized as close to a median split as possible and a chi-square computed from the resulting four-fold table for each item. Eight items had response changes from pretest to posttest at less than the .10 level of confidence. Since 77 items were analyzed, one might expect eight such results by chance alone, not an auspicious finding. Examination of the content of the eight items is interesting, though, inasmuch as there is a communality represented in these items which1 is antithetical to the concept of random

3tf Table

3. Percent Correct Response for Objective Test Items for Pretest Group (N=27)

True-False Items

Item No.

Percent Correct

Item No.

Percent Correct

Item No.

Percent Correct

1

96

11

59

21

89

2

41

12

48

22

82

100

13

74

23

48

4

37

14

93

24

70

5

100

15

96

25

100

6

85

16

67

26

100

7

89

17

85

27

85

63

18

93

28

59

82

19

44

29

44

20

33

30

26

9

10

Multiple-Choice Items

1

89

B

56

15

89

2

85

9

22

16

30

63

10

63

17

93

41

11

56

18

67

63

12

63

19

78

6

93

13

78

20

48

7

89

14

89

4

Table 4.

Item means for HEPKAT attitude statements for pretest and post test.

Item No.

Pretest Postest Mean Mean

Item No.

Pretest Postest Mean Mean

Item No

23)

(N

Pretest Postest Mean Mean

Item No

Pretest Postest Mean Mean

1

4.83

4.65

21

2.30

1.78

41

1.26

1.43

61

4.22

4.26

2

3.78

3.48

22

2.17

1.87

42

1.78

1.96

62

2.61

2.39

1.70

1.57

23

2.04

1.87

43

1.61

1.65

63

4.04

4.30

4

4.09

4.00

24

4.56

435

44

4.09

4.09

64

2.70

2.61

5

1.30

1.26

25

1.74

1.61

45

3.83

3.91

65

3.91

3.87

6

2.83

3.26

26

2.22

2.48

46

2.96

3.04

66

4.00

4.26

7

3.57

3.91

27

3.91

3.83

47

3.87

3.78

67

2.96

2.91

8

2.26

2.57

28

1.87

1.96

48

2.43

2.35

68

2.35

2.65

9

2.78

3.43

29

2.83

2.48

49

1.87

1.65

69

2.30

2.26

10

3.57

4.04

30

3.57

3.17

50

2.04

1.91

70

2.96

2.91

11

2.70

3.22

31

2.96

2.57

51

2.57

2.17

71

1.83

1.87

12

2.61

2.48

32

3.26

3.00

52

3.22

2.65

72

3.74

4.00

13

2.87

2.70

33

3.04

2.74

53

3.26

3.74

73

1.61

1.35

14

2.26

2.09

34

2.61

2.30

54

4.04

443

74

2.39

1.83

15

4.13

3.65

35

3.87

4.00

55

1.96

2.13

75

2.00

1.61

16

4.39

4.48

36

4.26

4.30

56

1.87

1.83

76

3.39

3.61

17

2.52

2.13

37

1.52

1.52

57

3.78

4.00

77

1.96

1.78

18

3.52

3.43

38

2.00

1.91

58

2.09

2.22

19

1.91

2.04

39

1.78

1.91

59

1.91

1.74

20

3.57

3.52

40

1.61

1.70

60

1.48

1.39

Table 5.

HEPXAT attitude statements yielding significant changes from pretest to postest in order of magnitude of the,chisquare obtained. (N 23)

Attitude Statement

Prethesti Poatest* Item Mean Item Mean

X2

P

Direction of change

The primary health care provider should assume responsibility for Integrating the patient's health care.

2000

1.61

9.68

<.01

A4SA

Many physician assIstants do not have a college education

3.22

2.65

9.13

<.01

p1.11

The major function of nurse practItioners is to do histories and physicals w th diagnosis and treatment being left up to the physician.

3.26

3.74

,7.56

<001

u D

In a health care team, the design for diagnosis and treatment i6 the sole responsibility of the physician.

4.13

3.65

5.85

<005.

The function of nurse practitioner is to take physician's orders

4.04

4,43

4.57

<005

D- SD

In a health care team, the nurse prac tioner monitors the patient's progress over time and modifies treatment accor-

2.57

2.17

3.70

<10

u-i0A

It is important that therphysician directly obtain the inforMation essential to a complete history and physical

2.78

3.43

3.14

<

0

u4hD

To do good primary care you have to know everything

3.57

4.04

2.99

.10

u4D

Strongly

-e;

3

Uncertain; 5

4 - Disagrees

Strongly Disagree

111

findings.

Most of the items are in some way concerned withthe

relationship between the nurse practitioner and the physician vis-a-vis their role responsibilities.

In general, the results of this small pilot sample are most promising and a number of first order objectives were serve-cL

We Aid

hot show draMatic changes from the Monday to Friday pretest-posttest

Administrations of-the test, but both test and curriculum are,inthe first stage of development and the exposure-time for .the students was -very limiteA.

In retrospect, those areas for whichthe -students

showed, a good deal ofAnterest and motivation,: such as the- team.'

concept or the physician-nurse practitioner relationship were areas in which the test showed some sensitivity.

As important as the statistical data, was the opportunitpto observe student response to the type of items being tried, to observe their behavior in the test situation, to estimate the time required to take the test, to find editorial correct ons in the instructions,...and.

to develop some confidence that the general format and content of the tems appear to be serving our purposes.

In the next use of the test,

several items will be dropped, such as those which were of such ease that no one marked the item incorrectly.

We can learn from even this

small bit of data that many of the multiple-choice incorrect answers do not serve adequately as seductive distractors and may therefore need to be rewritten in order to raise the difficulty level of the item.

These and other corrections and improvements will be-incorporated into

the next draft of the HMO.

rt M

Summary and Projected Plans Preliminary efforts to develop an instrument to test knowledge and itudes relevant to core content in curricula for physician training in .HMO's indicate-the -feasibility ef such a plan.

kesults of. a.sMall

pilot :sample.eXPesed, to the curriculum content fer.a. one.week-intensive.

experience indicate that the .items produce:a range of response-04f'.

are sensitive to Change over even shOrt'exliesure to the- turriculiim

need for revision of items isApparent and next steps in the develoOment of the test include adding items in certain content areas,'-'testing a-

larger sample and subjecting the attitude .itemS to a factor analysis for

the purpose of developing reliable and coherent subscales. Follow-up plans are outlined in the Timetable presented in Appendix C.

This tentative outline is contingent upon the continuing

interest of the cooperating schools and ethers who may wish to

participate in this developmental effort; Mest critical to continuing' progress on the test-will be access to students for'testing.time. the next effort opportunistic samples will serve our purpose.

In the

final stages of test deVelopment, though, representative_samples of medical students will be required in'order to establish norms to enhance the general value of.the instrument.

In

HEPKAT HMO EDUCATION FOR PHYSICIAN KNOWLEDGE AND ATTITUDE TEST

Identi ication items Name

Field of study

Year.in program

Preliminary Draft Edwin B. Hutchins, Ph.D.

JanuarY, 1976

es HPART I.

Each of the statements below are generally true or generally fa a Please indicate your response to each statement by circling one o two following alternatives: T=Pltrue, F.mfalse

T

F

T T T

F F

.

F

T T T

F F

T T

F F

10.

T

F

11.

T

F

12.

T

F

13.

T

F

14. 15.

T T

F F

16. 17. 18.

T T T

F F F

19.

T

F

20.

T

F

21.

T

F

22.

T

F

23.

T

F

24.

T

F

25.

T

F

26.

T

F

27.

T

F

28.

T

F

29. 30.

T T

F F

5. 6. 7. 8. 9.

F

the

The goals of health maintenance are preliention of disease and disability and early identification of abnormalities or threats,to health. Blue Cross and Blue Shield is a fee-for-service plan. The social worker has specific knowledge about community resources. The first medical cooperative in the United States was o ganized in the late 19th century. Environmental factors strongly influence the health of an individual. Economic factors strongly influence the health of an individual. Psychosocial factors strongly influence the health of an individual. A carrier does not underwrite risks in health care insurance. For the most part, at the present t me the American medical system is directly accountable to patients. Community corporations are.being developed mostly by large insurance companies. In November of 1975, major employers in the United States were required to offer a dual option to their employees. A "hesitation payment" is a charge required of a patient who misses an office visit appointment. A voluntarily enrolled group is one in which the employer can exerc his option to enroll his employee. Periodic followups are not an essential component of comprehensive care. For the patient, finding a place where appropriate health care is delivered at a reasonable price is a major problem. A provider is an insurance carrier providing the mtans to pay for health se Twenty-four million Americans have no health insurance of any kind. An individual's race can be a deciding factor in the quality of the health care that he receives. Capitation payment is the amount of money required per person to provide covered services for an unspecified period of time. Reciprocity implies the right of a group health plan member to receive medical care from any other HMO in his home area. P epayment provides in advance for the cost of predetermined benefits for a population group through regular periodic payments. An option offered an employer between two provider organizations is referred to as dual choice. An extended care facility provide": primary, secondary, and tertiary levels of medical care. Cost centers are functional areas that generate the ba ic costs incurred to provide the plan's range of benefits. Comprehensive care provides for that broad spectrum of health services necessary to the prevention, diagnosis and treatmene of physical and mental illness and to the maintenance of health. Blue Shield is a prepaid health plan designed specifically to cover the n of municipal employees such as policemen and firemen. in some HMO's, expansion is computed as part of the capitation rate to provide capital for growth. A fee schedule is the schedule of payments a fee-for-service patient makes when subjected to catastrophic illness. The term health maintenance organization is specifically defined by law. A noncontributory arrangement is one in which the employer, union, or third party pays nothing.

I II

For the following items, select a single best answer. Please indicate your response by circling the letter in front of the alternative you have chosen as the correct answer. Third party payments A. are payments for health care made by theamneficiary in his awn behalf B. are payments for health care when the beneficiary is not making paytent in whole or in part on his own behalf C. are payments made by'a parent or guardian in behalf of a dependent D. are payments made tiy a third party in behalf.of-the consumer.. Placement in an extended 'care facility should not be based Upon A. medical problems B. ability.to pay C. social problems D. functional impairment

In 1848 the first British public health legislation was primarily concerned with A. mandatory vaccination B. sanitation C. The Royal College of Physicians D. medical education In the period from 1960 to 1970, hospitalization costs IL the United States increased A. equivalent to the standard of living index B.

25%

C. D.

100% 300%

Under a union-sponsored health benefits program, f -da to finance the program may come from all but one of the following A. federal government matching funds B. union members contributions alone C. employer and union members contributions D. employer contributions alone In the provision of health care, accountability should be to A. one's professional colleagues alone B. to the patient alone C. to the patient and the profession D. to the patient, the profession, the counity and society at large

Which of-the following practice arrangements do not generally have salaried

physicians.L A. B. C.

D.

Kaiser Permamente fee-for-service practice foundations for medical care the Public Health Service

The Health Maintenance Organization Act P.L. 93-222 did all but which of the follo-ing? A. provided prospective eligibility to both PPGP plans and MCF plans B. made optional the dual choice clause C. added support to existing plans through grants and loans encouraged the development of new HMO's D.

360

reason that some HMO's are not "qualified". is that A. they are comprised of multi-specialty groups B.

they, did not 'apply, for federal 'funding

C. D.

they have a recognized medical group they have become a recognized Individual Prac

concept of comprehensive care focuses on A. the development of extended care facilities for the elderly B. the maintenance of-physical and mental health:as opposed to i lness C. patient education so that the care provided is comprehensible and therefore followed by the patient D. a broad spectrum of health services including physician services and hospitalization 11.

2.

Of the following quality control groups, which one als_ perfo A. certified hospital admission program B. professional standards review organization C. quality assurance program D. medical care foundations Which of the following is not a health status indicator? A. activities of daily living B. morbidity C. D.

13.

third party_functiade

race

functional assess en

Medicare is a prodTam designed to A. pay most of the health care expenses of the indigent B. pay most of the health care expenses of the elderly C. experiment with national health insurance redistribute the wealth Accessibility implies that health care A. paid for by a third party B. close to one's home C. within the reach of all D. geographically, financially, and socially available on an equitable his s

Which of the following is not a basic principle for developing an effective HMO? A. prepayment B. a dependent, externally-governed Physician's organization a contractual responsibility between the plan and its members D. physician's' payment influenced by shared financial re ponsibility 16.

are careful to allow the members free choice by avoiding mutual contractual commitments suggesting alternative providers whenever they indicate dissatisfaction C. leaving issues of accountability entirely to the members' consumer organization D. allowing the members to choose from among the HMO's accepted physic A. B.

EValuation of HMO performance has been done:,throu findings show A. :lower hospital-Utilizatiein,and elective higher family health care expenditures C. :,no change,in infant-mortality:rates D. ne change in mortality rates'for the'.elderly 13_

11), 1980 the'need for physicians practicing in HMO's is ' A. 10,000 B. 20,000'' C. 40,000 D. 80,000

e traditional distinction between the pri role of nursing lies in A.H application of:the."curing" and "caTing" B. -the level of cOmpetency achieved C. the quality and comprehensiveness of the re pective educational programs D. acceptance by the patient .

-

of the following is not true of home care programs A. they are easily organized B. it is one of the least utilized services'a ho pital_offer C. it is aa important and recognized alternative to inpatient dare D. it:is one.of the more expensive medical services

Indicateyour react on to each Of Oe following statement Oyy circling 'one of the five following alternatives: SA Strongly Agree

.A Agre6 Uncertain Disagree SC :Strongly Disagree U D

Please do not omit any items.

SA A U D SD SA A U D SD SA A U D SD

SA A U D SD

SA A U D SD SA A U D SD SA A U D SD SA A U D SD

SA A U D SD 10. SA A U D SD 11. SA A U D SD 12. SA A U D SD

13. SA A U D SD

14. SA A U D SD

15. SA A U D SD 16. SA A U D SD

17. SA A U D SD 18. SA A U D SD 19. SA A U D SD 20. SA A U D SD 21. SA A U D SD 22. SA A U D SD

23. SA A U D SD

24. SA A U D SD

Recognizing the impact of chronic disease on patients and family is not a concern of the primary physician. In medicine, competency is directly related to the amoun'i._ schooling., Physician assistant and nurse practitioners, because of differing educational and professional emperiences, bring added dimensions to the health care setting. Nurse practitioners who seek to serve some of the physician's functions are practicing medicine without a license.

Regardless of station in life, all citizens have a-right to-quality-health care. Social services are primarily made available for lower socioeconomic clasp patients. In a health care team the primary concern of the social worker is the patient's difficulties, with finadces and housing. Because providers generally come from middle class backgrounds, they have problems relating to lower class patients. It is important that the physician directly obtain the information essential to a complete history and physical. To do good primary care you have to know everything. Physician assistants and nurse practitioners are primarily well trained in physical diagnosis.' It is reasonable for a nurse practitioner to have a signed pad of prescriptions fcr prescribing specific drugs under protocol. Because the government only reiMburses at given levels of payment, publicly supported patients will necessarily receive health care of a lesser quality than that received by private patients. An important function of the social worker is to stimulate positive change in health care delivery. In a health care team, the design for diagnosis and treatment is the sole responsibility of the physician. The primary care physician need not maintain communication with the patient during the period when a consultant is involved in a specific course of action. Any inadequacies in health care in this country are especially felt by those who are not white or male. A nurse practitioner is a nurse with a few added skills. American doctors are generally chauvinistic. The physician who utilizes the services of nurse practitioners is constantly risking malpractice suits. Middle and upper socio-economic families have psychosocial needs which must be met in any truly comprehensive health care delivery system. In working with familie-, where the incidence of psychosocial problems :r could be the primary care provider. is high, the social Because of her nursing b.., Aground, the nurse practitioner brings to the health care team skills and attitudes different-from those of the physician. Information obtained from consultants is medical in nature and need not be shared with other members of the hes.lth care team.

WoUld:Personally feel,comfortable being treated by a nurse practi oner working Lu ta.health care team setting if it waq for; 25; SAA U D SD a "bad celd", WA-11 D SD, painfUl=burning-on urination SkA V tvSD:.--head.trauma, with7loss of consciousness for 2 minute ,SA'A U D SD ,a headache Of 1 day duration 9.i!A A U,D_SD ',followup on a lab test which indicated an elevated fasting blood , SA A U D SD depression of 3 weeksiduratien U D SD my feats of dying,following removal of a cancerous pancreas 3,2. SA AU D SD my 18th,month old infant who has a temperature of 104 and is pulling his ear ,SA A U D Sp my 6 year:old child who has sta ted bed wetting after being to let trained for 3 years

4. SA A V D SD

Physician assistants working in hospitals should be Able _o write orders under protocols. A U D SD _ Nuraes_are_p_rimarily trained to make patients feel comfortable.:A U D SD The psychiatrist is the only provider competent to deal with mental problems. A U D SD The patient should.be a participant in the health care team s decisions regarding his health care.' A U D SD In a health care team, the social worker is concerned with the patient's life stresses and his ability to cope'with them. A U D SD The individual physician has an obligation to help change, the health care'delivery system in this country. ,

5. __ SA 6..SA .

SA SA

_

le-following situations are valid reasons to consult with other phys_ deo appropriate use of their advice: 'SA A U D SD The patient's family requests another opinion. SA A U D SD The physician feels that theAaroblem exceeds his competency. -SA A U D SD Patient care can be instituted more efficiently or economically by another physician. SA A U D SD The relationship between the physician and/or family is unsatisfactory.

SA AiU D SD . SA A U D SD

0. SA A U D SD

-SA A U D SD ; SA A U D SD .

SA A U D SD

SA A U D SD SA A U D SD SA A U D SD SA A-U D SD

/SA A U D SD

In a health care team, the principal task of the nurse practitioner is,to record the chief complaint and measure the vital signs. While other consultants are involved in.a patient!s_care, the.primary care physician is temporarily removed from the ongoing management of the patient. It is dangerous to give a person a few skills and then turn the person loose with patients. HMO's are a form of communism. A physician should be able to trust the physician assistant to presdribe certain drugs under protocol. The social worker enhances the physician's understanding of the patient as a whole person with definite environmental factors impinging, on his health status. An important function of thesocial worker is that of patient advocate. In a health care team, the nurse practitioner monitors the patient's progress over time and modifies treatment accordingly. Many physician assistants do not have a college education. The major function of nurse practitioners is to do histories and physicals With diagnosis and treatment being left up to the physician. The function of nurse praci idner is to take physician's orders.

55. SA A U D SD

important role of the social wo'rker Is to ,fac litate competenc es of health care team members in the assessment of psychosocial factors in the health care of the patient. SA A U D SD. The social worker aids the physician in appropriate use providers through collaboration or direct referral. 57.. SA A U D SD In a health care team, the principal task of the physician is to obtain the history and perform the physical examination. -58. SA A U D SD Specialization is important because you can't know everything. .59. SA-A U D SD Many of the traditional functions of a physician can be adequately served by a nurse practitioner. 60. SA A U D SD Regardless of the method of payment, all patients in a comprehensive health care setting should receive the same quality of care. SA A U D. SD The social worker's primary function is to help the patient obtain welfare monies. 62. SA A U D SD In a health care team dealing with a child performing poorly in school, it is the responsibility of the social worker to obtain records from the school. --63. SA A U D SD Primary care is not intellectually challenging. 64. SA A U...D SD Under protocol, physician assistants should be able to treat common chronic diseases (such as hypertension, chronic heart disease, diabetes), including ordering and interpreting tests and making the decision for prescription of medication. 65. SA A U D SD Different levels of health care are to be expected for people of different socioeconomic classes. 66. SA A U D SD There is no need for a social worker in servicing middle class obstetrics patients. 67. SA A U P SD The principal role of the nurse practitioner is to execute the simpler tasks traditionally assumed by physicians. 68. SA A U D SD In a normal family situation', the social worker should be an integral part of the primary health care team. 69. SA A U D SD Physicians should be willing to sign prescription forms filled out by a nurse practitioner colleague. 70. SA A U D SD The level of competence of a nurse practitioner approaches that of a general physician. 71. SA A U D SD In dealing with a family having limited resources, knowledge about available community fund agencies can be as important to health care as medical information. 72. SA A U D SD Nurse practitioners should not be allowed to deal with patients except under direct supervision by a physician. 73. SA A U D SD Patient education is an important function of an HMO. 74. SA A U D SD Nurse practitioners are co-equal with physicians as members.of the health care team. 75. SA A U D SD The primary health care provider should assume responsibility for integrating the patient's health care. 76. SA A U D SD would feel more secure working in a limited field than in general practice. 77. SA A U D SD The health care team represents one of the most efficient means of delivery,quality health care.

bc

Career Choice Items

This section of the test asks for information on your plans for-the future. We would.like to obtain here your best zstimate of the -kind of career you would like to have when you finish your training. 1.

Please estimate the-percent of time you plan to spend in each of the following professional activities. Time in Percent Patient Care Research Teaching Administration Other please specify 100% Please indicate which field best describes the medical practice you plan to enter. Check one only Anesthesiology Basic medical sciences Dermatology Family practice General practice Internal medicine, general Allergy, Cardiovascular disease Endocrinology

Gastroenterology Hematology Infectious diseases Pulmonary disease Neurology Obstetrics/gynecology Ophthalmology Otolaryngology What type_ of practice do you plan to enter?

_

Solo Partnership Group Hospital based HMO based Other; please specify:

Pathology/clinical pathology. Pediatrics., general Pediatrics, allergy Pediatrics, cardiology Physical medicine and rehabilitation. Psychiatry .

.

Public...health and preventive medicine.:

Radiology Surgery, general Surgery, neurological Surgery,. orthopedic Surgery, plaSticSurgery, thoracic Urology Other; please'specify:

Check one only.

APPENDIX B

HEPKAT scoring key for preliminary draft Parts I and II

Part I Item

Correct

Item

Answer

Correct

Item

Answer

Correct Answer

1

T

11

T

21

T

2

F

F

3 4 5 6

T

22 23

F F

24 25 26

T T

10

27 28 29 30

T

F F F

12 13 14 15 16 17 18 19 20

1

D

8

B

2 3

B

9

B

B

10

D

4

C

11

D

5 6 7

A

12 13 14

C

7

8 9

F

T T T

F

F

T F

T T F F

F

F

T F.'

Part II

D

B

15 16 17

18 19 20

B D

367

B

-D

A

c A 0

APPENDIX C

Project to Refine the HEPKAT Time Table for 'Implementation

Target Date 1.

2.

S.

.Send copies of preliminary report on HEP- T to Project Evaluation Consultants

Return critique Of preliminary report and. .suggestions for item reviSion and addition of new items

May 1, 1976

Readminister to opportunistic samples

April, May 1976

Pooling of available data from six schools for test analysis: (a) Item anayses, Parts I and II (b) Factor analysis, Part III (c) Item correlations with Part IV'information on career choice Construction of attitude-scales

7.

Refined form of HEPKAT completed and printed

8.

Testing of entering first year classes of cooperating schools Scoring of test protocols and development of normative data for entering classes

10.

Correlation of data with career choice information

11.

Feedback via return of individual school profiles to cooperating schools

1

.

April 23, 1976

Revise draft of HEPKAT; delete and add items

6.

9.

March 28, 1976

Final report

June 30, 1976 July 30, 1976

July-30, 1976 August 15, 1976 September 1, 1976

September 30, 1976

October 30, 1976 November 15, 1976

December 1, 1976 December 30, 1976

3311( REFERENCES

Bruner, J.

The Process.of gducation. Cambridge:

2.

APA, AUA, ACME Test Standards

3.

Hertz,.C., Hutchins, E. B., and Williams- Harriet. develo

a curticulum for

report.

Harvard Univ. Press, 1960

Pr ject to

h-sician training in HMO's

Penn Urban Health Maintenance. Program,

Unpublished-

Philadelphia:

December 15-, 1975, pp. 8-56.: 4.

Blalock, H. M., Jr., and Blalock, Ann B. -search.

New York:

Methodology in social

McGraw-Hill, 1968.

An HMO. Dictionary.

Unpublished manusCript.

Group HealthAssociation of America, Inc., 1717 Massachuset s Avenue, N.W., Washington, D. C. 6.

Creelman, W. L., Gocker, Marianne, Millican, Jean, and Simon, J. L. A medical studen

guide to health maintenance organizations.

Department of Community Medicine and International Health, `----!;!,.8,

Georgetown University School of Medicine. 1975.

369

Unpublished manuscript,

DRAFT Resou. ce Paper No. 10

AN HMO BASED PR MARY CARE CURRICULUM FOR FIRST YEAR MEDICA.L STUDENTS DESIGN EVALUATION AND DISCUSSION

Paul L. Grover, Jr., Ph.D. Sanford M. Meyerowitz, M.D. Harold H. Gardner, M.D. Warren Glaser, M.D.

The project cited here was supported by a subcontract from the Bureau of Health Manpower, Health Resources Administration, to the University of Rochester School of Medicine and Dentistry through the Department of Health Services at the Association of American Medical Colleges. Dr. Grover is Associate Professor and Director in the Division of Educational Communications, SUNY Upstate Medical Center. Dr. Meyerowitz and Dr. Glaser are, respectively, Associate Dean for, Medical Education and Professor, Department of Medicine, UniVersity of Roch-,ster. Dr. Gardner is Executive Director and Director of Primar; Care Programs, Wayne State University Clinics. He was formerly Medical Director, The Medical Group of the Genesee Valley Group Health Association.

Submitted to the Journal of Medical

Education, June 9, 1976.

ABSTRACT

Although the role of curricula in the determination of

physian career choice is obscure, it is generally accepted that.career options such as primary care will atract more subscribers if they are better represented in the curriculum.

This

project designed, applied and evaluated a semester long series of HMO' based primary care experienceS'for first year Students.

HMO based students were compared with students in other primary care settings as to:

1) knowledge of primary care and the

doctor/patient relationship; 2) knowledge of a variety of modes of structuring health care delivery and 3) effect on career choice.

The project structured'experiences which allowed students

a maximum amount of direct contact with both health care providers and patients in the Hi,10 setting.

Pre/post comparison showed

small, but significant, differences within the treatment group. Evolution of student career choice and the ',imitations of meeting health manpower goals by curricular changes are discussed..

AN HMO BASED_PRIMARY CARE CURRTCULUJI FOR FIIRST YEAR MEDICAL STUDENTS DESIGN EVALUATION AND DISCUSSION

Although predicting that economic and social factors would be the most potent determinants of an increase in the number of new primary care physicians, Alpert and Charney (1, p.7) recognized the important role of the medical school in this process. To improve the preparation of medical students for careers in

primary care, they recommended (1, p.62) that teaching and curricula be modified to incorporate the following elements: a.

... criteria for selecting students who will be suit-

able candidates for careers, in primary medicine practice." b.

.

an overall program for primary care education at

the undergraduate and graduate levels." C.

sites for primary care education under

the med

cal school's) auspices-"

Beginning in the fall of 1974, the University of Rochester School of Medici'ne and the Genesee Valley Group Health Associa-

tion cooperated to design, implement and evaluate a course instruction in primary care for undergraduate medical studen in the spirit of these recommendations. At that time there were three competing prepaid health care delivery systems available. in the Rochester area:

an independ-

ent professional association, a prepaid group prac ice based in a number of urban neighborhood health centers, and the Genesee Valley Group Health Association (GVGHA)

372

-

a prepaid group

2

3 practice basEd aL the doeph C. Wilson Center.

It was felt that

invol ing all or some of these community resources could improve the teaching of primary care delivery systems.

The resulting project had two distinct phases, one for first year and the second for fourth year medical students.

The first

phase of the project which is reported here, was developed in the context of a course offered by the Department of Preventive M_dicine and Community Health during the Spring semester, 1975. akjeotive., and_Biases:

The objectives of the project's first

phase were design, apply and evaluate a curriculum centered around a semester long serfes of HMO based experiences for a limited number Or students.

cur-iculum would produce:

It was postulated that such a 1) acquisition of knowledge about

primary care and the doctor-patient relationship; (2) knowledge of simularities and differences among a variety of modes of tructuring health care delivery, and (3) an effect on the development of career identity and student career choice plans. In de5iyniny such an educational expe.ience a number of background issues and biases came into focus. ed was timing.

The first to be consid-

Many faculty believed that'the earlier the expo-

sure, the greater the impact on career orientation and subsequent career choice.

year stude

H lever, other facul y planners felt that first would derive only a limited benefit from exposure

to patients at the HMO.

In their judgement, the students had

33 insufficient knowledge of both the basic seiences and clinical methods to fully appreciate clinical problems.

Another issue

was duration: the bias of some faculty was that thirteen halfday experiences would not create revolutionary changes in the career plans of students. Still another consideration 146S structure.

Frequently clin-

ical learning experiences are unstructured and are dependent upon

a va iety of unpredicteJ and unplanned circumstances such as the run of patients encountered at any time period, the assignment of n.imary care physicians to serve as preceptors who must also maintain their patient contact responsibilities, a d the different roles assigned to students in various health care settings.

Could

the educational expe ience be made more even and predictable for all groups of students? Furthermore, objectives of primary care teaching are .often vaguely articulated.

Are these specific or unique things to

observe and:learn about primary care compared.to traditional specialty based health care? :Faculty of traditional departments often disagree on this issue with faculty_based in family medicine Descri

the HMO. ion

were defined.

'e

o ra

Cognitive and affective objectives

These included mastery of organizational and

operational definitions of both the structure and person6e1 of primary care delivery systems.

They also included detailed

analysis and description of the processes whereby Patients encountered and were served by the HMO.

374

Af ective objectives,

-3vaOerilir0

I ruin

numL,Of of

truCtuId as well as unobstrusive

incloded stodents

meacurement

attitudes toward a variety of

personnel encountered, and toward their experience of observing and participating in prima y care.

The course met one-half day per week for thirteen weeks. Each meeting consisted of three phases.

The first 45 minutes

individual students rotated through each of 11 units in the HMO,

nfor

Following a brief lunch

!ing thP head of each unit.

period, the group reconvened for a,seminar which presented the bulk of thc p dagogic content of the course.

Seminars were a

combination of lecture by a content expert and discussion involving the students, Follo .ing the one hour seminar, groups of three students

dispors0d to ob-erve their physician preceptors at work with patients.

This observation period lasted from one-half hour to

several hours.

In addition to these organized activities, each

student was assigned a patient to follow through the duration of the course.

The student was responsible for presenting a

detailed case history of the patient. Using retrospective intervie students, Plovnick

_

of ist and 4th year medical

f U riu-4 4.hat both primary

ex-

and role models were influential factors in the choice of primary care career.

The program reported here structured experfences

which would allow students a maximum amount of direct contact with both health care p- viders and patients.

This direct

experi nce was to interact with the more abstract content presento-A in the semina.rs.

The HMO's clinics, laboratories,

administrative offices all became sites of teaching as well as patient care.

The entire HMO staff was informeu- that the project

was an important part of the ongoing activities of the HMO and were enlisted as ad-hoc instructors in their own area of activity. _Evalu_a_tion D_g_sLiri:_

A major constraint placed upon the evaluation

f the project was the necessity of constructing a design which

would not interfere with the pattern of instruction. rznde

As such,

ssigment of students to groups was considered undesir-

able since it would interfere with the student's self-determined pattern of interest.

This initial lack of comparability among

groups weakened the power of the evaluation design from the viewpoint of systematic research.

However, it strengthened the

design from the viewpoint of representative research (3), thereby increasing its generalizability.

The curriculum developed

here will be applied in circumstances similar to our own, that is where student% have an expressed personal interest in HMO's.

Therefore, subjects chosen by self-selection Were more comparable to those students with whom the curriculum will untimately used than if they were chosen by random selection.

The resultant evaluation design was a non-equivalent control grour model with pre= and post-testing.(4)

For comparison

purposes, t.ree groups of students were tested.

Group 1 were

the 12 students at GVGHA's Wilson Health Center.

Group 11,

called related, were 10 students participating in similar LI 7 6

activitiT- at otflr prepaid primary care organizations.

Group

_II. called non-related, were 11 students serving at chronic care and social service facilities.

The two basic goals of the evaluation design w re fi A: to quantify the cognitive and affective effects of the cu Ticulum; and second to anal ze correlations between demographic/personal characteristics and outcome measures to identify possible p rti

;Live arhiev ment or a fective change.

Oata:

Personal characteristics assessed for later cor elation

.were:

sex, home town size, physician parentage, undergraduate

major and Medical College Admission Test (MCAT) score profile in

e four areas of verbal, quantitative, general know-

legP and scince and the Edward's Personal Preference Schedule which measures

115

rmal personality chaTacteristics.

Student attitudes were assessed by: 1.

An Osgood (5) type semantic differential which asked students to evalua,,

,

as w_11 as rate the potency and activity of the

concepts of HMO, primary care physician, medical school, nurse and medical specialist.

A career choice questionnaire which asked students to.select preferences of career type, practice type and specialty type. A semi-structured intervi.ev with which the evaluator inquired

about the student's reaction to the course's content, teaching and impac

1 1-o4

choice.

Student knowledge was assessed in the areas of: I.

General concepts of primary care including definitions of primary care, family medicine, HMO, Urgent Visit Clinic and Prepaid Group Practice.

2.

The functions of health care providers including primary care physician, nurse practitioner, medical specialist, staff nurse, medical social worker, medical secretary, medical receptionist, patient advocate.

3.

The contrasting structures of t o types of health maintenance organizations including financing, organizational hierarchy, marketing, hospitalization, and legal basis.

4.

The events of the physician-patient encounter. At the comp etion of the course, all students completed an

activity summary in which they tallied: I.

Number of patient meetings that they had had during the semester within the context of the course.

2.

Whether or not they had, as.the result of _heir task force, developed an in-depth patdent contact.'

3.

The number of meetings witFL health care professionals.

4.

Whether Dr not they had developed an in-depth contact with on_

or more health professionals.

In addition to testing and interviewing, theproject evaluator observed all seminars and rotations through the Service units and several patient visits.

This level of involvement was

neces.sary to complement a-d validate the other sources of evaluative informatioii.

378

Resul-

Analysis of covariance found si nificant between and

within group differences for evaluation of the HMO by the OVOHA task force on the semantic differential.

No other differences

at the .01 level were revealed for the remainder of the semantic di-ferential. (Table 1)

Chi-square analysis of the pre- and post-career choice

questionnaires used the .05 level as the criterion of signifi,cance.

For career type, at pre-test a large proportion of the

OVOHA group expressed a preference for general practice. post-test this proportion did not change.

At

However collapsing the

two control groups in a pre vs post chi-square comparison revealed

a shift towards general practice which was small but significant.

For practice type, specifically HMO based practice, there was a small but significant positive shift within the OVOHA group. For specialty type, student selections of family practice,

pediatrics and internal medicine were combined into a single primary care category.

At pre-test, the membership of the related

group was significantly more inclined toward these primary care specialties

than the OVOHA group or the non-related group.

How-

ever, at post-test, the proportions of the other groups selecting these specialties had increased, so that th-e differences 'were no longer signifitant.

able 11) Analysis of covariance with subsequent t-tests revealed significant pre-post differences.at the FrS.01 level for the GlIGHA

group a one on two knowledge

ariables:

general knowledge of

primary care concepts and the structure of health maintenance organizations.

Analysis of the other knowledge variables, the

activities of primary care staff and events of the doctor/ patient relationship revealed small but non-Significant gains for all groups. (Table

I

Analysis of variance among groups and Tukey s honestly significant difference test for between group .comparisons were used to analyze the summaries of student activity.

Overall, the

GVGHA group had more patient meetings, more in-depth contact and more contacts with health ca:e professionals than the comparison groups

The program succeeded in bringing students into contact

with p Aents and care providers. (Table IV)

Relative to the second objective of the evaluation, the laentification of demographic/personali y predictors, Pearson correlation co-etficients were computed for these student characteristics and all outcome measures across all subjects.

An

analysis of all correlations exceeding the .01 confidence level indicated that students who have a high'need for dominance as measured by the Edward's Personality Preference Schedule tended to rate the concept of the primary care physician as relatively low in powcr or

*Mnsi

In similar fashion, students with high

need- for change tended to rate the concept of the primary care

physician as low in activity.

Home town size was also negatively

correlated with students' concept of the activity of the primary

080

care physician.

These and the remaining characteristics and

their rnrrelations contributed to a general profile of an agressive, highly intelligent, sci nce o-iented, medical student from an urban environment who tended to view the medical specialist positively and saw primary care as a less interesting, less int'llectually 'Challenging, less important career. (Table. V)

The Final two sou-rces of evaluative in o mation, the evalu-

ator.s observations and the semi-structured interview at the conclusion of the course verified, the more formally,derived information presented here. Analysis and Comment:

As anticipated, the HMO based students

demonstrated real gains in their knowledge of and attitude toward Health Maintenance Organizations.

Also as anticipated, the

experience produced only a limited number of shifts in individual career plans.

The career choice results for all three groups

showed a trend toward varying forms of primary care.

But only

Lhu GVGHA group framed this choice of primary care in the HMO These results are interesting since all members of the

ntext.

related group were also involved in other forms of prepaid group practices We

.

uggest the causal bases for this more focused HMO-prefer-

ence among the GVGHA students can be found in their knowlgdge growth and their HMO/patient related activities.

Analys

variables clearly indicated that knowledge of -t12

pinnings and day-,o-day operation of prepaid gro

f the knowledge tual under-

p ice was

-3to effectively conveyed to the students.

Interviews of the GVGHA

students confirmed that their contact with patients and p oviders demonstrated the challenges and satisfactions of the primary care career.

Although testing revealed the GVGHA students' mastery of the conceptual information presented in the structured presentations, -it is their less clearly demonstrated mastery of the concepts presented in the unstructured portions of the experience which may have greater implications for medical education.

it was the

unstructured experiences which presented that bulk of material relevant to.the students' knowledge of the events of the doctor/ patient relationship.

In this area, students showed great inter-

est but little gain in knowledge;

Fi st year students have yet

to master the full range of prerequisite basic medical sciences. They have had no exposure to pathology, microbiology or pharmacolegy.

As a result, they are probably unable to infer and

understand the component processes of the doctor/patient relationship such as the physician's interpretation of the primary data, clinical reasoning and decision making.

The comments--of one of

the medical students in the GVGHA group supports this insight. He stated that although he found his primary care experience surprising in its intellectual challenge, it also served to emphasize his need to master basic sci-ence material to be

effective in the role of the primary care physician.

The r lationslipbetween curriculum .a dmiti,mate career, choice is part of a larger process.mherebyAhe.evolvi,hg physi fah develops his professional,identity, E:riksoh .(6) sugges s .

that..4.0v.

.

individual's identity evolves through a process of experimenta-,

tion, c ystallgzation, reJection and reformulation. process, the individual in effect "trie identities -and roleS

on"

In this

'succession o.

each in succession dffectihg ahd being

affected by the others in the segaence.

Even afte: the fndiVid-N

ual rejects a -role as unsuited, an app eciat'iOn or an underStand-

ing of that role .--emains which affeets iiiS-SUbsequent cholceS as

well as his overall Career perspective.

Such a conceptualization of the development of ,the phystctans identity negates many of the, eonterns.regarcling. the quest-ion .of!

indoctrinating medical students toward a Tartic-1 ar.career choice.

If experiencing a variety of roles and adopting a series of,

tenta

tive identities is,a. necessary process in .the formati.on of a

mature professional identity.. then medical _education shomid rec_g-,

nize that the advocacy of a variety of career types

ithi:n:the

educational expe ience is a positive ..benefit tp,theHmpOtal student.

This logic suggests that this adv:ocacshou,14 not .be

bland presentation but instead should be presented, mith,ell. of .

the enthusiasm and detail necessary to induce studens to "try on" a variety of roles, pe spectives .and career plafis in the

course of their unde graduate experience.

The danger of indoctrina ion is further mitigated by the recognition that students are not passive subjects but are re-

active participants in the learning process.

As such, they will

critically analyze as well as respect or reject the role mod,pls they observe.

Studen

will filter, select, defend themselves,

and test the roles with which they are presented against their own personal ideals and their own developing conceptualization of what it means to be a physician. We recommend on the basis or our experience in this project that student work in primary care settings should hot be allowed to continue in its traditional controlled execution.

pattern of loose planning and un-

Simply placing students on their own in

the primary care environment, asituation similar to the related group in this project, is not enough:

When planned, executed

and evaluated with the rigor of the best medical school courses, HMO based experiences or other primary care experiences can

contribute to student learning.

When they are not so planned,

executed and evaluated, they produce frustratIon and serve to

reinforce the weak intellectual image from which primary care suffers.

In their review of research on career choice Held and

Zimet (7) report that career preferences expressed by first year students have low predictive value.

The students in this project

must therefore be followed to assess their ultimate career choice.

Such outcomes will be informative.

.But the press to

achieve contemporary health manpower goals should not obscure

381

the of its studcnt

function of the university:

to aid the developmeit

t- drd their full, self-defined potential.

In

this sense, no matter what the outcomes in terms of career choice anything learned here or any attitudes changed, no matter how transient, will not be completely lost.

These outcomes have

become a documneted part of the educational progression of twelve developing physicians.

Intimate exposure to and_knowledoe of

modes of health care delivery is in itself a valid phase in the ed cational evolution of medical students, regardless of any demonstrated effect on ultimate career.

TABLE 1

Summary of Significant Results - Seven Point Osgood Semantic Differential Scale applied to Primary Care related concepts (Ancova controlling for pre-test with subsequent t-test analyses of differences

Variabl

t-Tes_t

Post

Pre_

HMO:

Evaluation

11.06**

aLTL2

Mean

S_D

Mea_n

SD

OVOHA Related Non-Rel -ed

5.49 5.72 5.27

.804 .829 .770

6.40 5.70 5.27

.598

4.30** .621 -0.10 .711 0.0

**P < 01 Non-Significant Variables: HMO:

Potency, activity

.Evaluation, Potency, Activity Ratings of:

Primary care physician, medical school, nurse, medical specialist

TABLL 2

to Prim ry Care (chi square test)

Career Type: (Oenrl. Proc.

P-st

Pi

0 her GVGHA

4

Related

Non-Related

12

GVOHA

4

8

12

10

Related

2

8

10

Mon-Related

3

0

10

10

5

27

32

Practice T (HNO Prac.

.5046

Post

Othe

GVGHA



0-_-her

11

12

OVUM

3

9

12

0

10

10

10

10

29

32

Related

1

9

10

Related

Non-Related

0

10

10

Non-Pelated

32

P

Spacialty Type: Fam. Prac., Peds., Int.) GVGHA

2

Post 10 Othe

Other

Related

7

10

13

GVOHA

4

8

12

10

Related

7

3

10

Non-Related

5

5

10

16

16

32

10

19

32

4_

2.933

X2

6.43

X2 P

12

6

Non-Related

.03

P

Pre 1°

5.5167

X2

.9951 = NS

X2

.05

=

P

NS

Career Tape: (Oenrl. Proc.) Group:

Collapsed Controls Post

Pre

sI

1

0

32

P = NS

Pre 1°

23

X2

.05

P

10

9

4.945

X2

Other

10

ier

119

1

15

6

134

X

2

- 5.32 .05

20

20

3 TABLE 3

Ident Kno ledge of Concepts Related to HMO's and rimary_Care (Ancova itrolling for pre-test with subsequent t-test ana ysis of dif erences

**p 'iable:

Organization Iximum score: 16) )

c .01

F

13.28** Group GVGHA Related Non-Related

Pre

Post

Mean

50

Mean_

1.75 1.82 2.00

3.22 1.66 2.00

7.58 0.91 4.00

50 4.25 1.45 4.23

:t

4.42** -2.09 2.19

mary Care eneral ximuth score: 20)

8.19** Pre ou.

GVGHA Related Non-Related _y Care taff

ximum score: 24)

tor/Patient elationship ximum score: 14)

Mean 4.92 6.64 5.55

1751 (NS)

2LTIR GVGHA Related Non-Related

Po=

SD

2.23 2.11 1.51

Mean 9.25 6.45 6.45

Pre

5D 2.49 1.44

2.95 Post_

Mean

50

8.08 8.55 8.55

2.02 3.20 2.70

Mean

11.08 9.45 9.00

SD

3.03 5.50 3.26

1.09.(N5) prp

GVGHA Related Non-Related

Post

Mean ---

S0

Mean

SD

4.92 3.63 5.64

1.78

6.92 5.00 6.81

2.91 2.29 1.89

1.80-

1.69

5.69** -.35 1.15

35tf MALL ummary of SLudent Activities (Alcova among groups, Tukey's HSI) Test between) **P

ariable:

Number of Patient Mtgs.

8.75**

21:D1R

N

Mean

SD_

GVGHA Related Non-Related

12 10 11

24.0 4.2 13.4

9.8 3.0 16.0

Group

N

Mean

SD

GVGHA Related Non-Related

12 10

75

45

HSD Test:

GVGHA > Related* -Depth Patient Contact: (yes . 1, No . 0)

12.1

11

.10 .09

.32 .30

Mean_

SD

20.1 15.1 4.5

12.5 7.0 4.7

tlean

SD

HSD Test:

GVGHA> GVGHA>

Related* Non-Related*

Number of Contacts w/Health Care Professionals

g7q**

Pr:DIE

GVGHA 'Related Non-Related

12 10 11

HSD Test:

GVGHA> Non-Related* Related> Non-Related* In-Depth Contact w/Health Care Professionals (Yes . 1, No = 0)

10**

Group

GVGHA Related Non-Relat-d HSD Te

GVGHA > Non-Rela -d*

[I_

12 10 11

1.0 .6

.27

0.0 0.5 0.4

.05 .01

cc TABLE

mmary of Significant Results Correlations of demiographic and personal aracteristics (predictor variables) with outcome measures (dependent riables) across all -subjects (pears on Correlation Coefficient, all P -.01) Predictor Variable

Dependent Varjable

EPPS dominance

primary care phySician potency primary care physician activity Primary care physician activity Medical school _ eval uatiOn medical specialist evaluation Medical specialist evaluation Number of Patient meetings Number pf HCP meetings Importance of primary care General concepts of primary

EPPS change Home town population EPPS affiliation MCAT verbal Home town population EPPS succorance

EPPS change MCAT science MCAT verbal

DirectiOn of Correlation negative negative negative

negative positive positive

negative negative negative positive

care

I

Home town population

Events pf Phys ician/Patient encounter

negative

REFERENCES Alper J.L. and Charney, E. The Educa_ for Primary Care. U.S. DHEW, Pub. _o. 2.

Ph sicians 74-3118-.-

Plovnick, M.S. Primary Care Career Choices and Medical Student Learning Styles. J. Med. Educ. 50:849-855, 1975.

Grover, P.L. and Ravitch, M.M. Issues and Methods in Curriculum Evaluation. J. Med. Educ. 50:1100-1105, 1975 4.

Campbell, D.T. and Stanley, J.C. Experimental and QuasiExperimental Designs for Research on Teaching. In Handbook of Research on Te_achi.n -. Gage, N.D., (Ed.) Chicago: nu mcNal y, 1963, p-O.

5.

171-246.

Osgood, C.E. _uci, G.J. and Tannenbaum, P.F. The -easurement of Mean.nl. UrbanaIllinois: Universi y of Illinois P-r-ess,

6.

Erikson, E.H. The Problem of Ego Identi Y, Psychological Issues, Vol. 1, 1:113-114, 1959.

7.

Zimet, C.N. and Held, M.L. The Development of Views of Specialties During Four Years of Medical School. J. Med. Educ. 50:157-166, 1975.

Resource Paper No. 12

EVALUATION INSTRUMENTS*

*

A.

Knowledge/Opinion Questionnair-

B.

Career Choice Questionnaire

C.

Student A_ ivity Summary

D.

Course Evaluation Form

From the University of Rochester Final Report, Project to Develop Curriculum for Physician Tra ning in 1fOs

15e-

Date Name/Number Undergrad Major Home Town Population MASTER*

KNOWLEDGE/OPINION OUESTIONNAI E

Define briefly the following terms: (4)

a.

(4)

d.

Primary care: first contact care; availability; continu7-ng responsibility for management; basis of pre-paid group practice. Family medicine: a primary care specialty; combines medicine, peds, ob/gyn, surgery; contrasted to family care process; debate over who should provide family care. Health Maintenance Organization: Another name for prepaid group practice; organization providing comprehensive health services; enrolled population; restrictive legislation. Urgent Visit Clinic: Subsystem to provide care; no appointment with health necessary; recognizes appointments can interfere care.

(5)

e.

Prepaid group practice: Voluntary association of professionals; at risk; prepayment of pr3mium; comprehensive medical care; group dual choice of member.

personne Describe briefly the function of t-e following health c_ e (4)

a.

3)

b.

(2) (3)

c.

(3)

e.

d

f.

(4)

g.

(3)

h.

Primary care physician: a physician who gives first contact 'lity; basis high avab care; has responsibility for continuity; of prepaid group practice. skills, indeNurse practitioners: R.N., additional diagnostic pendent professional. Medical specialist: M.D., specialist training. supportive rather than Staff nurse: Punctions under direction; independent role; R.N. or L.P.N. health care organ Medical social worker: A social worker in a agencies; works to resolve social zation; coordinates community patient's site of habitation. and environmental problems at understands and communicate Medical secretary: A secretary who organizes patient charts and records. in the language of medicine; receives the Medical receptionist: Acts as patient advocate; schedules patients in the system; patient; coordinates flow of patients. of Patient advocate: A spokesperson for a patient or group interpre s interests of patients; patients; acts to represent the the health care system to patients.

Answers te questions in Italics

Describe and contrast briefly the structure of cwo types of health financing, orgalizational maintenance organizations as to: hierarchy, marketing, hospitalization, legal basis.

a

0

HMO types =,--

=

(16)

Inulalci_ga.2111auss.LsLI .Tndpendent'professlonal associations (medical foundation Financing:

a)

b)

Organizational Hierarchy:

prepayment on part of client contract for services vs. fee for serv ces from premium pool initial backing from government or private insurers

Decentralized coZiection 'of indep'mdent professionals

Marketing:

Same

Hospitalization:

Same

Legal Basis:

Federal Law

Quality Control:

Group at rlsk and peer revic review only

versus no risk, peer

Describe in general terms what takes place in the physician/patient expectations each party holds for the other, encounter, including: kinds of data the physician uses, how a diagnosis is made. Expectations: 1, The patient approaches a physician with his problems ald solicits his help to resolve them. 2. The patient's need for help and the physician's capability to help are the bases for initiating a relationship. 3. The physician defines explicitly and implicityly the conditions under which he can best provide help. 4. The patient attempts to establish the conditions wider which he can best convey his needs and be assured of help. 5. Communication and a relationship are established. Kinds of Da_ta:_ 6. 7. 8.

9.

Observation of patie7 be avior and conduct during Tn e and examination. Interview. Physical examination. Special'diagnostic examinations.

4.

4, 4) 0.

P-Lagaaal.iLi

10.

The patient's report of perceived physica and/or behamoral changes, and the physician's observations of behavioral and physical characteristics are utilized for first order hypotheses. Rypothese are tested by further interview, physical examnation and laboratory special diagnostic procedures. The patient's problems are identified and classified (W ed). Specific diagnoses are made. Physician expects patient to believ diagnosis and follow instructions. .

1, I

l/1

0

11.

of=

et:1

o r--

12. 13. 14.

QJ

6.1 CC

5.

The following are a list of medical specialty areas which you_ might pursue. Please rank them in order of your personal preference, from most favored 1_ to least favored _10 .

c .ammJ1Lm

Psychiatry Internal Medicine Oncology Pediatrics Orthopedics

Pathology 15,31.9 Family Medicine

Cardiology Preventive Medicine Obstetrics/Gynecology

I

The following is a list of health care characteristics. Please rank them in order from most important 1 to least important 10_

_x

Competency Accuracy Availability Frequency Economy

Selicency Components

x Consistency x

Safety Comprehensiveness Equity Diversity

7.

Please rank them a list of professional., The followina in order of your perception of their importance-f om 1_ to least important 10 most important .

De_tist

High scho-ol teacher Lawyer x x

-x x

nedical receptioni Cardiologist Nurse practitioner

__

Intern-f-

nurse Biochemist Electrical engineer-

x Saliency Components

For'each of the followi-- please complete a semantic differential indicating your perception of that role. For:example, if you perceive the role.of nurse practitioner as active, hut hot very active, you would check theform this way: Active

Passive

X

Health laintenance

rcaniz. t ion

BAD

GOOD MILD ACTIVE INTERESTING WORTHLESS STRONG SLOW COLORLESS FAIR SHALLOW RESTLESS

INTENSE PASSIVE UNINTERESTI G VALUABLE WEAK

,=*c

FAST.

COLORFUL UNFAIR DEEP QUIET

Primary Care Physician GOOD MILD ACTIVE

-=

NTERESTING WORTHLESS STRONG SLOW COLORLESS FAIR SHALLOW ESTLESS

=ffi

--

BAD INTENSE PASSIVE UNINTERESTING VALUABLE WEAK FAST COLORFUL UNFAIR. DEEP QUIET

Medical Se fi

GOOD MILD ACTIVE INTE ESTING PORTHLESS STRONG -SLOW

=fie= BAD .fi==fi

==. ===

=1=6

==.

7-

CO ORLESS --FAIR SHALLOW RESTLESS

=IL=F

=.=

INTENSE PASSIVE UNINTEREST NG fia== VALUABLE,== VEAK FAST COLORFUL UNFAIR DEEP-

=is=

==.

QUIET

=A=

Nurse

GOOD MILD ACTIVE INTERESTING VORTHLESS STRONG LOW COLORLESS FAIR ==la SHALLOW RESTLESS

BPD INTENSE PASSIVE UNINTERESTI G VALUABLE

=,=1.

=q= zffef=

wnroc

FAST COLORFUL UNFAIR. DEEP QUIET

=.1=. =,=1.

==.

Medical Specialist GOOD MILD ACTIVE INTERESTING WORTHLESS STRONG SLOW COLORLESS FAIR SHALLOV RESTLESS

HAD INTENSE PASSIVE

=.1=

UNINTERESTING 6=.= VALUAPLE WEAK

=.=

FAST.

==.1 =el.=

===.

s==

==. =a=

.397

COLORFUL UNFAIR DEEP OUIET

you to select Desc 'be those factors whIch rwtivatedInclu c your goals your community medicine task force. and expectations.

398

CAREER CHO Present year

OUESTIONNAIRE

n medical school (cir 2nd

3rd

one) :

4th

Ch ck the type'of medical caree ul mately devote all or most o

Internsh'ip

Other

to which you beli ve you will. (Check ond) your time.

General practice Specialty practice

Research and/or

teaching

Combination of specialty practice, research, and

teaching.

Other (Specify) Ifldicate the-type of pr ctice in which you plan to.eneage'. (Check one).

qaw=1

Individual pr vate practice Partnership practice Private group practice HMO practitioner Hospital consultant (except federal hospitals) Full-time teaching and research (practice confined to medical school hospital(s)) Part-time teaching 'and research; part-time separateprivate or partnership practice. Part-time teaching and research, part-time separate group practice Federal government service Public health (w th or without teaching and research)

If you plan to enter any typeof career other than_unsnecialized ctice, please indicate the area in which you plan to specialize. your specialty area is not listed below, but can-be .considered a sub-category within one of the fields that is Please check only one field. listed, please check that field. .

.

Family

dicine

An sthe

ology

Basic medical scIences .=FJ. Do rmato logy

Internal Med eine: (check (a) or (b)).

a) subspec alty b) primary care Ct

ri

specify nternal

Neurology

Obstetrics/gynecol gy Ophthalmology Otolaryngology

Pathology/clinical pathology Pediatrics: (chebk --7 (b))

(-a)

or

a) sub p cialty

ecify)

-ri a_y __re p-diatric-

Physical medical and rehabilitation Proctology

Psychiatry

psychiatry

Public healtill and preven_ive medicine

Radiology Surgery - gen.ral

Surgery - neurological Suraery - orthopedic.

Surgery - plastic Surgery - thoracic Urology

Cardiology Other (spec

400

.:ame

Ta k Force -Date

AAMC PRIMARY CARE STUDY ACTIVITY SUMMARY

With how many patien s have you had contact of any kind (presented in class, rounds, home, office) so far in your task force assignment?

-Please list the type (s) of settings, nu -er.(er of- your interactions with patients'

Setting

Number of Meetings

equency) and avera e duration

Avera-e Duration

If you have developed a relationship with a patient(s),in Some depth (two or .more meetings), please briefly 4escribe the patient, his/her problem, your activities relative to this patient, any significant knowledge you have gained, and any role you have played in the process of providing care to them.

401

Please list the tyPes of health care professionals (HCP) with whori you have interacted in your task force assignment. Indicate the setLincj, number tor frequency) , and average duration of these interactions:

Professional

Setting

Number of

in s

Average Dura

HCP(s) on more than one occassion dur ng your task If you have worke (a) purpose, (b) set ng force, please dcscrie your interaction(s) in terms of: (d) opportunities to apply your scientific knowledge, and (e) what (c) your role, you:learned about the-HCP's role.

402

AAMC Primary Care Study COURSE EVALUATION FORM

Group

-1.0

Teaching: 1.1

Describe the instructor's style of presenting ideas.

Your precepto

1.2

Ilere the class presentations well organized?

1.2.1

2.0

The clinical expe iences?

1.3

Was your preceptor accessible?

1.4

Were your instructor's preceptor's expectations clear?

Contcnt :.

2.1

How appropriate were the topics covered?

2;1.1

The clinical experi nces?

2.2

Was the course content well organized?

2.3

Was the level of detail appropr a

2.4

What additional topics should be cov

2.4.1

Deleted?

ed?

3-.0

At '_tu0

3.1

Did the course effQ Why

y0 ur attittla

3.1.1

Toward Primary Care?

3.1.2

Toward medical education.

towal:

choice of career?

lerti

3.2

.Do you thin k you

3.3

Did you choose to partici

3.4

What are the most important chOactoXist.i" of primary ca e for the patient?

1 chOose add

°flal electives in primary care?

in the sacorld year ISP program?

4

3.4.1

4.0

For the phYsieial

Overall -valuation: 4.1

What werethe best =-

4.2

What were the wOrstap

exPeri

4 4

ee?

Resource Paper No. 13

PROPOSED EVALUATION INSTRUMENTS *

EXHIBIT

1A.

Student Log Recording Form

EXHIBIT

1B.

Sample Computer Prepared Summary Report Of Student Clerkship Experiences

EXHIBIT

2.

Student Progress Report

EXHIBIT

3.

Student Course Evaluation

EXHIBIT

4.

Student Assessment of Preceptor and Training Site

EXHIBIT

5.

Preceptor Progress Report

EXHIBIT

6.

Course Achievement/Grade Report

EXHIBIT

=7.

EXHIBIT

8.

Patient Feedback .to Students

Site Visit Repor

From Appendix K of the University of WashIngton Final Report Project to Develop Curriculum for Physician Training in HMOs

405

APPENDIX 3

:

PROPOSED EVALUATION INSTRUMENTS

EXHIBIT

- la.

STUDENT LOG RECORDING FORM

EXHIBIT

- lb.

SAMPLE COMPUTER PREPARED SUMMARY REPORT OF STUDENT CLERKSHIP EXPERIENCES

EXHIBIT

STUDENT PROGRESS REPORT

EXHIBIT

STUDENT COURSE EVALUATION

EXHIBIT

STUDENT ASSESSMENT OF.PRECEPTOR AND TRAINING SITE

EXHIBIT

PRECEPTOR PROGRESS REPORT

EXHIBIT

COURSE ACHIEVEMENT/GRADE REPORT

EXHIBIT

PATIENT FEEDBACK TO STUDENTS

EXHIBIT

SITE VISIT REPORT

406

1;t

$»110 POI MI 1011,

INA k

I IIS

EXHIBIT 1 a, STUDENT LOG RECORDING FORM

Site.of xperience

0

r- 0

1I u

C

Date of Surname of Student

Diagnosis

tC/LAr.

Experience

Code

0 4 C) 0

O=IZLLJ

Mo. Day Yr 2627

PROBLEM

Procedure

0

SYSTEM(S)

2

4C 4

Code

triurriphs, crisis, etc. Please describe any noteworthy impressions, anecdotes,

409

PROPOSED EVIIIATION INSTRUMENTS

--APPENDIX K EXHIBIT 1b:

SAMPLE.00MPUTER PREPARED SUMMARY REPORT OF STUDENT CLERKSHIP EXPERIENCES (Abbreviations Explained on Previous Page)

LEVEL OF STUDENT RESPON.

SITE OF EXPERIENCE 0

H

1

1

3

FREQ.

DIAGNOSIS CODE AND NAME

OBS

0

N

0

2

0

2

2

500

2

1

0

1

2

3

511A

ADULT RIN, PHYSICAL

0

0

0

1

1

5118

PEDIATRIC PHYSICAL

PRE/POST PART. EXAM

HC

NH

ER

PR

AS

0

0

0

a

0000

ONGOING OR NEW

PAP SMEAR

1

0

0

0

0

1

1

0

0

0

0

0

1

0

1

0

1

352A

0

3

0

0

0

3

0

0

0

3

3

351

ROUTINE DELIVERY

1

0

0

0

1

1

722

ADOLES. COUNSELING

01

0

0

1

1

586

FAMILY PLANNING

10000 10000

MARITAL COUNSELING

1

0

0

0

0

1

0

0

1

0

1

704A

1

0

0

0

0

0

1

0

0

1

1

283, HERNIA

1

0

0

0

0

1

0

0

0

1

1

242

SORE THROAT

0

4

0

0

0

7

2

1

1

9

10

240

UPPER'RESP. INFECT.

0

1

1

0

0

1

3

4

1

7

8

183

OTITIS

0

1

1

263

NOSE BLEED

0

1000 1000

2

0

0

0

4

4

0

0

2

0

0

1

0 1

0

1

0

1

0

1

241

INFLU. SYNDROME

0

0

0

2

1

1

2

398

RASH-NOT SPEC.

0

1

2

5

6

2

8

372

BURNS

2

0

0

2

0

2

405

RHEUM. ARTHRITIS

2

2

0

1

3

4

480

SPRAIN

2

2

0

3

1

4

425

LOW BACK PAIN SYND.

0

9

1

1

9

1

400

CERVICAL PAIN

1

2

0

2

1

3

086

ASTHMA

1

0

0

0

1

1

170

CONJUNCTIVITIS

000 3000 000 4 0

0

0

100

0

0000 10000 3

1

2

0

0

0

1

2

0

3

1

4

262

DYSPNEA

1

0

0

0

0

0

1

0

0

1

1

267

UNDIFFERENT, COUGH

2

2

0

0

0

1

3

0

4

0

4

247

BRONCHITIS

3

1

1

3

0

4

0

4

255

CHRN. OBSTR, PULMON.

1

4

0

0

0

4

1

0

2

3

5

246

PNEUMONIA OR OTHER

1

2

0

0

0

2

1

0

2

0

2

130X

1

1

0

0

0

1

1

0

1

1

2

147

HEADACHE

1

1

0

0

0

0

2

0

2

0

2

134

DEPRESSION

0

4

0

0

0

2

1

1

3

1

4

155

STROKE

000

0

1

0

0

1

158

SEIZURE

0

1

195

CONCUSSION

10

000

ANXIETY

1

0

0

0

0

0

1

0

2

0

0

0

0

0

2

0

1

1

2

200

DIZZINESS

2

3

0

0

0

2

2

1

4

1

5

306

ABDOMINAL PAIN

3 71 'APPENDIX K:

PROPOSED EVALUATION INSTRUM NTS

EXHIBIT 2:

STUDENT PROGRESS REPORT

Please describe briefly how the Clinical Clerkship is going'from your point of view. We are especially interested in (1) how you see your relationship with your preceptor developing (2) any problems you think are distracting from your experience.

Please rate the following and comment:

Responsibility

0 enough

not enough

Eltoo much

fl enough

0 not enough

Ej too much

0 too fast

0

Comment:

Supervision Comment:

Pace Comment:

Exposure and experience with problems

El enough

0 not enough

Comment:

Continuity experiences

adequate

Comme

412

0 not adequate

too slow

374. Exhibit 2

!family orientation

not enough

J enough

Comment:

Patient acceptance

ok

DI problems

Comment:

Office staff acceptance

0 problems

-anent:

I- this experie-ce meeting your expec a one

?lease comment on the seminars.

(Con

nued)

APPENDIX K :

PROPOSED EVALUATION INSTRUMENTS STUDENT COURSE EVALUATION

EXHIBIT 3:-

DATE

NAME Print

COURSE EVALUATION BY STUDENTS

CLINICAL CLERKSHIP

_the

Student;

Your evaluation of this clerkship experience will be very helpful faculty in continually improving this clerkship. Thank you in advance participation.

Check one box for each

Are you in your third

uestion:

_or fourth

year?

What quarter did you take this clerkship? Summer-

.

o the or your

'Year, 19

Fall

W nter

Spring__

.

Who was (were) your primary superviso

s:_

DIRECTIONS. -

Please circle the number of the scale (l=low and 5=high) which best represents the extent to which this clerkship facilitated your learning with respect to the course objectives and each major experience undertaken. There are a few open-ended questions at the end of the questionnaire for additional comments:

4 1 11

EXHIBIT 3

I.

e

Course objectives: A.

[*

379'

(Continued)

Please rate the extent to which the course objectives were: Not communicated

1

2

3

4

5

communicated

Unclear

1

2

3

4

5

clear

irrelevant

1.

2

3

4

5

relevant

Unrealistic

1

2

3

4

5

realistic

To what extent did this course provide you opportunity to acquire knowledge and skills in the areas outlined below (representing course objectives)? Rate each item on the scale. II you are unable to evaluate an item, indicate why in the space provided. CLINICAL_ GOALS A.

Low

High

To gain knowledge and skills of common medical problems, in terms of: 1.

Which are common important problems

1

2

3

4

5

2.

Natural course of ihese problems

1

2

3

4

5

3.

Techniques of problem identification, diagno_ s and treatment

1

2

3

4

Cemmonly applied preventive 1 techniques for these problems

2

3

4

5

Human interactions in the immediate environment which are important in dealing with these problems.

2

3

4

5

5.

1

To gain skill in: 1.

Interviewing patients

2.

Making appropriate judgments in terms of: a

Clinical problem solving 1 by selection of history, physical examination and laboratory data in, terms of common high probability of problem entities

2

4

Cannot evaluate

B.

2 (CoPt'd)

Low

High

b.

Referral to other medical disciplines versus continued minagement

1

2

C.

Recommending consultation

1

2

Referral to specific agencies

1.

2

The interval of follow- 1 up and the mode of followup - the use of phone, return appointment, or by use of other personnel

2

4

5

2

4

5

4

5

e.

3

3

4

5

4

5

4

Maintaining clinical records which aid in problem-solving and provide continuity by: a.

Organization of data which is readily con'municable to others

b.

1 Organization to assist in formulating diagnostic and therapeutic plans

1 Effective use of the telephone to record clinical data, manage patients, make referrals, and make consulta-

5

tions 5.

C.

Appropriate prospec ive analysis of risks to Che hea th of patients by: a.

Identifying risks for the patient's immediate future

1

2

b.

Knowledge of measures that might reasonably reduce those risks

1

2

1

2

To gain skill and knowledge in providing comprehensive, continuous health care on a longitudinal basis.

416

3

4

5

4

5

5

Cnnno

EXHIBIT 3 (Con

_nued)

PRACTICE MANAGEMENT COALS

Low

_KO

To_gain: A.

D.

Knowledge of business applications in practice

1

2

Knowledge of the types of office personnel and their role and contribution to the family practice setting

2

Ability to establish appro- 1 priate priorities in approach to providing medical care

2

4

5

4

5

4

5

3

3

The "art" of personnel, staff, and peer relations

4

Ability to outline realis1 tic plans that provide time for self, family and community involvement while providing continuous comprehensive care for patients

2

Ability to apply the principles of cost effectiveness in health care delivery

2

3

4

5

4

5

4

5

4

5

. COMITNITY_COALS Tp_

A.

Ability to identify the major health hazards in the community

B.

Ability_to identify the appropriate role of the family physician with respect to these hazards

2

C.

Knowledge of persons other than in the hospital or the clinie in the community whose functions relate to health or medical care

2

Skill in ability to work with other agencies

I

2

3

5

4

Cannot evalua

EXHIBIT 3 (Contint d)

Low

HMO EXPERIENCE_COALS

Cannot evaluate

High

To sain: A.

Knowledge of the function, theory, organizational' structure, and legal and economic aspects of HMO's

B.

Knowledge of the differences between IIMO's and fee-forservice settings in the use of common medical practices, including:

C.

III.

1.

Telephone management of patients

2.

Telephone consultation

3.

Patient referral

4.

Walk-in emergency service

5.

Management of the health care team

1

2

1

2

3

4

4

5

5 1

Knowledge of the advantages 1 and disadvantages to the consumer of prepaid medical service vs. medical insurance

2-

4

5

4

2

5

Please rate the extent to which the following activities were of value to you in helping you meet the objectives of the course and your own.-expectations. First, circle those which you experienced. Then, rate the quality of each circlecL.. A.

Clinical Ex erienees

Rate those circled Low

1.

Orientation

2.

Initial patient

3.

Follow-up of pati nts

4.

Labor and delivery

2

5.

Major.surgery.

2

6.

Minor surgery

2

7.

Counseling patients

2

B.

Counseling families of patients

2

k-ups

1

2

3

4

1

-2

3

4

1

2

3

5

=I IT 3 (Continued)

Low 9.

B.

1

UtilIzing consultants

2

keeping

10.

Patient record

11.

Emergency room care

2

12.

On call rotations

2

13.

Performing special procedures in the office or hospital (e.g., proctoscopies)

1

14.

Rounds at the hospital

1

15.

Staff meetings at the office

1

16.

Library and other learning resources

17.

Informal conferences with your CCU faculty

18.

Formal teaching semihars with your CCU facu:

19.

Other:

20.

Other:

4

5

4

5 5

3

4

5

4

5

5

2

5 2

4

5

1

2

4

5

Y 1

2

4

5

1

2

4

5

4

5

Community Experiences

MEDICAL Alcohol and Drug Abuse Programs

1

2

County Medical Society Meeting

1

2

4

5

Hospital Staff or Committee Meeting

1

2

4

5

4.

Medical Staff Meeting (Non-hospital)

1

2

4

5

5.

Mental Health Croup or Clinic

1

2

4

5

6.

Other local community health agency or program

4

5

7.

Planned Parenthood Clinic

1.

1

2

4

EDUCATIONAL 8.

Local college

1

9.

Local high school or grade school

1

10.

Teaching of allied health personnel

Teaching of lay people

419

2

4

5

4

5

4

5

EXHIBIT 3 (Contint d

COUNTY 12.

County Health 0-fice, Public Health Nurse

1

2

4

13.

Welfare Department

1

2

4

14.

Chamber of Commerce

1

2

15.

City Government.meetings

1

2.

16.

City Maintenance

1

2

17.

Community melqIig on curent issues with other non-health related agencies or groups

1

2

18.

Local Law Enforcement agencies

19.

Local Court System

1

20.

Local Industry

1

21.

Other informal consultation with individuals (not patients)

1

2

4

22.

Service Clubs (Rotary, Lions, etc.)

1

2

4

23.

Special-Programs for local minority groups, e.g., migrants, natives

1

24.

Other

1

2

25.

Other:

1

2

CITY

.

C.

Practice Mana ement Ex eriences_

2

4

2

4 4

Low

Work with office manager, faculty or others regarding: 1.

Answering Services

2

2.

Billing procedu_ s

2

3.

Office _r hospital audits

1

2

4.

Personnel management, hiring firing

1

2

5.

Continuing Medical Education activities

2

6.

Record keeping systems and forns

2

3 4

EXHIBIT 3 (Contin -d)

Low 7.

9.

7.

Referral systems & forms

High 2

3

4

Scheduling patients

2

3

4

Use of dictating equ pment

2

3

4

5

4

5

4

5

4

5

.

10.

Use of telephone

11.

Other:

12.

Other:

1

1 2

3

5

Please indicate h-- comfortable you felt handling the following types of patients or procedures: Inadequate

Confident

Well patients seeking health maintenance care -

At the beginning _f the clerkship

1

2

-

at the end of the clerkship

1

2

3

4

5

2

3

4

5

1

2

3

4

at the beginning of the clerkship

1

2

at the end of the clerkship

1

2

3

1

2

3

Children with non-emergency problems at the beginning of the clerkship -

at the end of the clerkship

Children who were quite sick or inju ed

-

Obstetric patien s in normal pregnancy, labor and delivery at the beginning Of the clerkship

at the end of the clerkship Adults with non-emergency problems at the beginning of the clerkship at the end of the clerkship

Adults who _ere quite sick or _njured at the beginning of the clerkship at the end of the clerkship

2

4

5

4

5

EXHIBIT 3 (Continued)

Jnadequatc

ConfIden

Perform ng dlagnostie and tilerapeLilic procedures, such as proctoscopy, casts, etc.

at the beginning of the clerkship the end of the clerkship

2

4

Performing minor surgery -

in the beginning of the clerkship

2

the end of the clerkship

2

4

Treatment of emergency room pa ients in the beginning

of the clerkship

at the end of the clerkship Counseling patients and families regarding health maintenance and psycho-social problems -

in the beginning of the clerkship at the end of the clerkship

What were the most beneficial experiences of this clerkship?

VI.

VII.

VIII.

IX.

What were the least valuable aspects of the clerkship? problems for you?

Do you have any speci

Were there any important

suggestions for the faculty?

What was your general att =ude towards this clerkship?

Did this clerkship affect your career aspirations in any way? if so, how?

Do you plan to take further clerkships?

Yes

No

Yes

If so, where?

No

APPENDIX K =

EXHIBIT 4:

PROPOSED EVALUATION INSTRUMENTS

STUDENT ASSESSMENT OF:PRECEPTOR AND TRAINING SITE

Date:

Dates of Clerkship: Location of Clerkship: YOUR NAME (Optional) :Prin

PHYSICIAN FACULTY'S N (Print

A.

Please indicate your percep.ion of the quality of.teachingand_supeT;:'! you received from this faculty member by rating his/her performance following areas: (circle one number on each.scale.) Poor Average Superior Clinical'Competence 1 2 3 4 5 2.

Quality of Teaching

1

2

3

4

5

3.

Interest in Teaching

1

2

3

4

5

4.

Awareness of current literature

1

2

3

4

5

5.

Relationships with patients

1

2

3

4

5

6.

RelationshiPs with students

1

2

3

4

5

7.

Attention to community problems

1:

2

3

4

5

Ability to manage professional responsibilities, personnel,

1

2

3

4

5

-s.

office, 'etc. 9.

10.

Effectiveness in maintaining quality control with reference to patient management.

4

The extent to which this faculty member was willing to give you responsibility.

423

1

2

3

4

5

::!r

EXHIBIT 4 - (Cont nued)

On a typical day, about how much time does your preceptor spend with_you Was the amount of time your preceptor devoted to you (in your opinion): completely inadequate minimal adequate

generously adequate too much

Does your precepton have any qualities Which you for a teacher of this course? Please.describe:

nd highly,desirable

4. _Does your preceptor have any qualities which you find undesirable fo teacher of this course? Please describe:

5. .

a

Are there characteristics about your- preceptor's office--.(staff, space patient mix, pace of work, partners; loCation, etc,) which You find highlY::. desirable in a teaching_site for this course? Please describe:

Are there characteristics of your preceptor's office which you find undesirable in a teaching site for this course? Please describe:

Overall, how would you rate your preceptor as a teacher __n this course: 1.

poor

2.

barely adequate

3.

average good

5.

outstanding

424

BIT, 4 - (Continued)

Overall, how would you rate your preceptor's office as a training site for this course? 1.

poor

2.

barely adequate

3.

average good

outstanding

CO-

NTS:

45

APPENDIX

:

PROPOSEWEVALUATION:INSTRUMENTS

EXHIBIT 5:

TO:

CLERKSHIP PRECEPTORS

FROM:

COURSE COMMITTEE

SUBJECT:

KEEPING US INFORMED.

PRECEPTOR PROGRESS REPORT

.

Please tell us in a few sentences how the Clinical Clerkship is Trogressing from your point of view. We are especially interested in knowing about ( you think your student is doing and (2) any problems that may be emerging.

We would also like.to know how the preceptorship has affeed -our Productivity loss is about when the student is there.

% or

patients during the morning

b.

The student spends about

e.

In additiOn to the student-contact time, I am spendirigabout minutes per week planning, organizing .0r:otherwise preparing for the student.

d.

Any other ways, positive or nega effected you or your practice?

Wnutes, hours) per week in my praCtiee.

ve, in which having a student has

Name

c)

-APP,ENDIX

K:

EXHIBIT 6:

PROPOSED.EVALUATION INSTpUMENTS COURSE ACHIEVEMENT/GRADE REPORT STUDENT NAME

COURSE ACHIEVEMENT

E REPORT

Coals

Not evaluated or .do not-care

Exhibits kno-ledge and skills of:

0 a.

.m

Which Are common imPortant problems

5

Natural course of these problems Techniques of problem iden cation, diagnosis and treatment

1

Commonly applied preventive techniques for these problems

1

Human interactions in the immediate environment which are important in dealing with these problems Exhibits skill in: 1. 2.

Interviewing patients

1

2

Clinical problem solving by selection of history, physical examination and laboratory data in terms of comMon high probability of problem entities.

1

2

Referral to other medical disciplines versus continued management

1

2

4

5

Recommending consultation

1

2

4

5

Referral to specific agencies

1

2

4

5

4

5

4

Appropriate judgment in: a.

b.

The interval of followup and the mode of followup - the use of phone, return appointment, or by use of other personnel

427

3

4

to rate

Not evaluate or dojtet can

Ability to,Maintain clinical records which aid in problem .solving 4nd provide-continuity

tuzate _

-by:

Organization of data whiCh is readily communicable to othera'Organization to-assist in-formulating diagnost and therapeutic plans, EffectiVa,use of, .the teleOhone

to recordClinical data, manage patients, make- .referrals, and

make-conaultations 5.

Appropriate prospective analysis of risks to the health of patients by: a.

Ability to identify risks for the,patient's immediate future

1

b.

Knowledge of measures that might reasonably reduce those risks

1

4

--Exhibits-skill-and-knowledge-in providing comprehensive, continuous health care on a longitudinal basis. II.

4

Practice ManageMent Goals A.

Has a general knowledge of business

1

applications in practice.. B.

lias knowledge of the types of office personnel and their role and contribution to the family practicesetting.

1

Exhibited abilit es to establish appropriate priorit es in approach to providing medIcal care.

4

D.

Exhibited appropriate "art" in personnel, staff, and peer relations.

1

E.

Exhibited ability:to outline realistic plans that provide time for self, family and community involvement while providing continuous comprehensive care for patients.

1

498

5

5

2

4

5

_XHIBIT 6

Continded r-4 Ca

44 W 4.1

M

0 ed

Not evaluated

1-1

W

or do not carc!to rate

11)

ts-e

F.

Exhibited ability to apply the ,..principleS'of cost effectiveness _An health care delivery.

1

2

3

4

Able to identify the major health hazards in the community.

1

2

3

4

Able to identify the appropriate role of the family physician with respect to thesellazards;

1

5

Coimnunity Coals

Exhibits a knowledge of persons' other..than in the hospital.or the clinic'in the community.whose functions relate to health or medical

2

4

5

4

5

care. Exhibits skill in ability to work

1

2

3

with other agencies.-

Zelote Special abilities, accomplishments or problems that the student displayed the,course.

429

EXHIBIT 6 .(Con

nucd)

GENERAL.ATTRIBUTfS* 0C >1 t-S-.,-. ASI 4-4 sn u s-

-

c 4-

.

Fogy of Medical Knowle st

1

A titude

1

As

2

Educability

Motvatfon Pe sonal Attributes A.

Dependability.

B.

Initiative and in e est.

1

C.

Likeability.

1

D.

Communication and relationshIps with patient's.

V

E.

Composure and abil ty to function under stress. 1'

F.

Organization of time and commitments

Potential of becomlng a competent

physiciam

WE:

1

1

2

It is understood that ratings. given in this section will.be based on .subjective impressions and judgments'of the facUlty-evalua or.

my:additional comments:

(46E ONE:

Honors

Pass

Fail

FACULTY.1E DER

APPENDIX K :

EXHIBIT 7:

PROPOSED EVALUATION INSTRUMENTS PATIENT FEEDBACK TO,STUDENTS

u recently saw a medical student, Mr./Ms. , in my office. In an effort to help students see themselves as patients see them, I would appreciate yout-answering six questions as honestly and constructively as you can. This information will be seen by the student for his or her own benefit and will not be used for grading purposes.

Sorry, but I can t remember the Student well enough to answer. About how many times have you-had contact with the student?

Do you (or would you) feel Comfortable discu sing yoUr Medical problems with the student? (Please:elaborate.)

Do you (or would you) feel comfortable discuss ng personal or family Anoblems with the student? (Please elaborate.

Are there any qualities or characteristics about this medical student which you-find very appealing or important _in the doctor you Would choose? (Please describe.) .

Are there any qualities or characteristics about this medipal student which you think he or she should try to change or improve in order to become more like the ideal doctor for you? (Please:describe.)

Is there anything else you think this student should know from a patient' point of view?

Thank you for your help.

Your signature is optional.

Sincerely,

431

APPENDIX K: PtOVQSED -EVWATION INSTRUMENTS EXO1BIT 8 .SITENISIT REPORT

Meet with Preceptor and-Student in office. Discuss

_)

Longitudinal patient contacts

,

ook at print out

b)

Corr. :ith'b--asic science courses

revieW

c)

procedure- in office practice

supervision

office management

responsibility othe

Watch student with patient Observe:

smoothness of relationship among student

preceptor and patient,

review of charts, etc.

Chat with other office .personnel Discuss

1)

their involvement with student

2)

mechanics of integrating students into office routine

3)

solicit suggestions

Feedback and impressions from Course Conmiit to preceptor.

Site visit report filed here.

Fo

-up chat with student.

432

---

Resource Paper No. 14

NEASURING THE COSTS AND BENEFITS OF

MEDICAL EDUCATION IN THE

0 SETTING

By

Christine E. Bishop Assistant Professor of Economics Boston ljntversitY School of Management-

TABLE OF CONT_ENTS I.

II.

Issues in Cost-Benefit Analysis for an H A.

Relevant Costs and Benefits.......... ..

B.

Arriving at a Net Benefit (Net Cost) Measure......,

. . .

.

Costs and Benefits oUEducation -Programs . .............. A.

Dollar Expenditures for Reaidents' Salaries . ............ and Educational ..

B.

Diversion of Resources to Use in Teaching....... 1.

Space used for classroom teaching.............. . .

2.

Staff time used for classroom teaching..... .

3,

Clinical teaching

Staff Satisfaction and Effort. .

.

D.

Recruiting Costs..... .

E.

Changes i- the Value of Care-to Membera

.

.

Appendix A - Definition of Terms

434

.

.

Measuring the Costs and Benefits Medical Education in the HMO Setting1

Christine E. Bishop

Innovative training programs for medical students and residents are cur-ently being designed and mounted in health maintenance organization (HMO) settings.- These programs will add a new dimension to the education of these students and residents, who will be -

able to learn at fi-st hand howcare is .provided under prepaid goup practice plans. -The programs will also open new opportunities for the HMOs.

Howeve-

direct-involvement In medical education is

expected to have costs as well as benefits for an HMO, and both

cos-s and benefits must be evaluated before an HMO begins atraining program.

When all relevant aspects of the program are taken into

account, it may be predicted that the value of benefits minus costs is negative, so that the program has a net cost

2

to the HMO and

1

This paper was prepared for the Association of American Medical Colleges HMO education project. It draws upon the work of the medical school-HMO teams participating irk:this project, as reported at a conference September 29, 1975; the presentations of Gregory Pawlson, Richard Watkins, and Robert Lawrence were especially helpful. This paper has benefitted from comments on earlier drafts by Michael Lawson, Harold Luft, and Marcel Infeld. The author is Assistant Professor of Economics, Boston Univ rsity School of Management. 2

Definitions of technical terms defined and used in the text are reviewed in a glossary in the appendix.

45

should not be undertaken; or that the program has a positive net benefit to the HMO and should be adopted

Clearly 'the determination

of net cost or net benefit must rest on more than prediction of money expenditures for the operation of the training program..

value of oth : costs and benefits are relevant as well.

The

It'is

important that the individuals responsible for deciding whether an

HMO should unde take an-education program "the HMO dee_

referred to here-as'

ionmaker"3) have enough information to make a wise

choice; otherwise, very costly programs may_be started which cannot be continued, and others with a net benefit for the HMO may be mi-takenly rejected.

The HMO decisionmaker must determine which

aspects of!the proposed education prog_am have an impact on the HMO's operation; how these impacts are to be measured; and how these costs and benefits are to be weighed against each other to dete -ine whether the program is ..on balance worthwhile for his HMO. in

It isithe purpose .of this paper to discuss these questions

-ordehatm re uSeful information may be provided to the HMO decision, J

maker considering an education program.

The focus here is on pre-

diction-of-costs and benefits from the. point of view of the RMO.

It is hoped that the methods developed by the AAMC project and applied for evaluation of its experimental programs can alco aid other HMOs in predicting the costs and benefits of involvement in

3

Depending on the way the HMO is constituted, the -be made by an administrator, the medical staff, a board the membership at large, or some combination of these. exposition, the individual or group responsible for the be referred to ns "he".

decision of direc For ease decision

may ors, of will

education.

In Section I below, the costs.and benefits relevant to

the HMO a-_ defined, and a discussion is presented concerning how

these may be used to determine whether a training4mogram is while for an HMO.

orth-

In Section II, potential sources of costs and

benefits are discussed, and means are proposed for gauging their impact.

I.

ssues in Cost7Eenefit-Analysis _for an HMO

A decision about undertaking a training program will be based on evaluation of costs and benefits th t are relevant to the HMO. These must be defined in light of the HMO's goals and objectives: a cost is any impact of the program which hinders the HMO in the achievement of its objectives, while a benefit is a positive effect on the HMO.

When costs and benefits are measured in the same terms

(for example in dollars) costs can be subtracted from benefits to find a net benefit figure.

Equivalently, the net cost of a program

is calculated by subtracting benefit from cost.

By definition,

a program -:ith a positive net coat has a negative net benefit; these cone -pts are analogous to loss and profit for a

Since it may

be very difficult to measure all impact of a program in the same terms, we may have to be satisfied with presenting.the decisionmaker with measurements and estimates of a program's impact on a number of dimensions, leaving him with the problem of evaluating how much each cost and benefit is worth to the HMO.

4 t.1

It should be emphasized at the oltset that---alysis of the costs and benefits of a teaching program will be done on an incremental basis: the situation before and after the intr duction of the program is to be compared, and its net impact benef

-) or negat

which may be positive (a net

(net cost) is determined.

A. Relevant COSts and Benefits.

The costs and benefits that are important to the HMO decisionmaker are restricted to those that have an impact on the achievement of HMO objectives.

The term "cost-benefit analysis" is often employed to

mean the determination of social costs and benefits for use in deciding whether a new public program should be introduced.4

Ideally,

the social benefits of a program are weighed against its social costs. If the ben fit to society exceeds the cost, the program is worthwhile. However, the individual firm or organization can also use cost-benefit analysis,,when the analysis is geared to its own goals and needs.

In

the case at hand, the HMO decisionmaker implicitly follows the rule that benefits to the HMO must equal or exceed its costs; both costs and benefits measu ed in the light of the HNOTs objectives.

It is

not appropriate to expect him to consider all the costs and benefits to society or the costs and benefits to other organizations, like medical schools or other HMOs.

For example, the following may be

4

For a comprehensive review of cost-benefit analysis, see Leonard Mcrewitz and Stephen Sosnick, The Budget'ti New_Clothes.: A Critique_pf_rlapaing=r2.gram Budgeting_anci Bone4t_Cost_Analvsis_: Chicago: Markham, 1971.

43

seen as potent al impacts of the t _ining program, and thus candidates for a list of cost and benefit measures; however, only some of them are relevant to the HMO decision.

1. change in dollar outlays made by the HMO for labor, supplies, plant, and equipment 2. change in the attitudes of current and potential physician'and other staff members toward working at the HMO

3. changes in .the value to cuent HMO.members of the health care provided change in the rate of growth of the HMO 5. change in dollar outlays made by the medical school involved in the program 6. changes in the dollar and time outlays made by students for transportation to their training site change in student's satisfaction with their medical education program 8. diversion of residency candidates to HMO training from other specialty training, or from other alternatives 9. change in the attitudes of future physicians toWard work in an HMO setting 10. change in the attitudes of future physicians toward provision of primary care. Items 1 through 4 clearly involve potential costs and benefits ththe HM0-decisionmaker should evaluate; the remainder are pimply not relevant-to an internal HMO decision about progra_ adoption, although they may be relevant Co other decisionmakers.

For example, changes

in the dollar and time outlays of mediCal students, skills and itudes they acquire and their satisfaction with the total medical education program may have an impact on the cost to society -f physician training, and may also have an impact on the achievement

439

Vo3

a

of medical school objectives; however, these aspects of the training program are not costs and benefits to the HMO, and are not relevant to its decision about undertaking an education program.

B. Arriving a

Net Benefit (Net Cost) Measure.

Ideally, the various costs and benefits should be measured in similar terms, so that the HMO decisionmaker can determine whether benefits exceed costs.

This can only be done if.we know what these

benefits and costs are worth to the HMO.

This would not be such a

difficult problem if the HMO were attempting to maximize profits; predictions of revenue gains or losses and predictions of increases or decreases in expenses would put the analysis directly into.dollar terms, so profit or loss due to the program could be calculated. However, non-profit HMOs probably have different objectives.

The

relative weights placed on various benefits and costs in determining whether benefits exceed costs must depend on the HMO's goals.

For

example, suppose that the teaching activity increases expenses so that yearly premium per m.ember must -increase by a dollar, while the

physicians providing care in the HMO are overwhelmingly in favor of the teaching'program; there is no change in the quality or convenience of care as perceived by the members.

How should the moneY cost to

members be weighed against the increase in satisfaction to the physician staff?

If the HMO is run as a physicians' cooperarive, so

that benefits to the physicians are highly valued, it is likely that the teaching ptogram will be accepted as having a net benefit to the HMO.

the However, if the HMO is run to maximize the benefit to members,

cost to teaching program may well be rejected as having too great a

benefit they receive.

members for the .

Other aspects of the HMO's goals become important when other

potential costs and benefits are considered.

A teaching program

prospects; or might raise costs now while enhancing long run growth requiring so much extra a program might appear to be costless while increases and effort from physicians and other staff that turnover salaries have to rise.

Members may dislike the presence of medical

them around; members student observers, while the staff enjoys having affiliated with a medical may value the fact that their HMO is now is driving up school, while complaining that the teach ng program premium costs.

Unless strong assumptions-are made about how the

it will not be RMO values these conflicting costs and benefits, benefits possible to make a technical determination about whether exceed costs.

However, this by no means implies that benefits and

evaluate should be ignored costs that are difficult to measure and "subjective" and somehow unreal.

When presented with a set of

impacts of a predic ions about the various positive and negative with a yes or no answer; program, the decisionmaker will come up

conflicting costs and he implicitly makes the tradeoffs among the net cost or benefits, even if he cannot specify a figure for the

net benefit of the program to the HMO. benefits in Section 11, In the discussion of specific costs and made about the objectives of the RMO: an underlying assumption has been

that it is maximizing net ben-fits to members'.

This implies that

if members' yearly premium rises by a dollar, there must be a compensating dollar's -orth of benefits to members; if staff satisfaction is increased by the program, this Is a benefit to members insofar as it is translated into lower salary cost- or recruiting costs, an4 thus into lower premium costs, or into higher quality of care for members. The HMO decisionmaker is assumed to choose to start a trairIJLtigl program

only if benefits to members exceed costs -o meMbers.

Of course, if a

particular HNO has a different objective, benefits and costs will be measured and evaluated in a somewhat different light.

H_ ever, the

list -f probable sources of costs and benefits will not be much different from the list that follows.

A decisionmaker with a

different set of objectives for his HMO could use the same information, although he would evaluate it differently and could arrive at a different decision.

Costs and Benefits of Education Programs

Following the rule that the HMO should undertake a program if it- benefit exceeds its cost requires incremental analysis, which compares the "before" and "after" pictures of HMO operation, wIthout and then with the training program: what has changed? do the.changes have a net beneficial effect?

In this section, potential impacts

induced by a training program will be discussed.

The most straight-

d impact of education is increases in dollar expense due

4

directly to the program, for example residents

salaries and expen-

ditures on teaching materials ana extra furniture for program participants.

No less real is the cost of changes in the use of resources

which the HMO would be purchasing anyway: no increase in dollar expenditure occurs, but conference roOms are used for students rather than for staff meetings, administrators plan programs and giVe lectures in time they would otherwise spend on administrative tasks, add so on. This shift in resource use must reduce HMO output,

-these resources

were being used -at full-capacity .before the teaching program was-, introduced.

The question is, what is the wo th to the. HMO of the

resources Aiverted from other uses into teaching?

The most. intere _ing

aspect of this question concerns the production of patient care without and with teaching: clinical teaching goes on simultaneously with the production of care, so that it is not possible to distinguish between resources going into teaching and those going into medical care for the -patient.

This does not mean_that clinical teaching is costless:

it is

likely that the output of a given set of health care resources will be different before and after teaching is introduced.

For example, less

care may be produced because the physician or nurse takes time to discuss cases gith the student observer, or more care may be p- duced

when a resident is added to the existing health care team. 'This increase or decrease ill the productivity of health care inputs must be evaluated.

Other potential impacts of teaching programs are

changes in recruiting costs and staff satisfaction.

Finally, it must

be recognized that care without teaching may be worth more or worth

less to HMO me bers than care with teachin-7 the members

percept

of the amenities, convenience, and quality of care may change R.sitively or negatively.

A. Dollar expenditures for residents'

salaries and educational supplies.

Residents' salaries will increase the expenses of the HMO.

A

medical education program may require the purchase of specialized instructional materials and equipment

like books, reprints, xeroxed

handouts, audiovisual aids, and classroom or study area furniture. These outlays add directly to HMO costs. Data required:

total re idents' salaries and fringe benefits;

quantity and price of materials and supplies; amor ized value of equipment purchased for educational purposes.

B. Diversion of resources to use in teaching. Wl_en resources k_e diverted from the production of health care

to

teaching, comparison of the situation at the HMO without and with

teaching (incremental analysis ) will show that some output is lost.

It is assumed here that the HMO will have to replace the output lost in order to maintain its level,of health care, so that.output losses are valued at their incremental replacement cost.

This is a part of

the cost of teaching activity. 1. Space used for classroom teaching.

The teaching program

will increase the current cost of providing care for the HMO's membership insofar as it diverts conference rooms, study a --as

4 4.4

and leUnges

from other productive uses.

Ideally, an estimate of the cost of

replacing output lost is required.

However, a rough estimate of the

value of space diverted from -ther uses might be calculated using the proportion of time the students use the conference rooms and so on and the cost of building space per unit time. An interesting question is raised when space is used in teaching that has no other use for the HMO.

In some expert_ental progams,

students' nonclinical activities have not displaced administrative or 4irect production -ctivity, so that the Cost to the HNO of serving its membership is not inc,.eased by student conferences, lectures, and the like. present.

In other -ords, the cost of thisspace is zero at

Nevertheless, it may still be appropriate to count a

portion of the HMO's space cost as a cost of the teaching program, since in the long run, with optimal use of building assets, more space will be required wIth the teaching program than without it. It should be emphasized that these costs would not affect a short-run decision to start a training program. Data required:

amount of building space used by students;

current utilization by HMO activities; student utilization rate; estimated cost of space per unit time. 2. Staff time used for classroom teaching. nurses, administrato s

Physicians,

and other personnel may be diverted fro

their usual tasks to provide classroom teaching, discussions with students.

lectures and

Some staff may also be involved in planning

and administration of the teaching program.

When these manpower

inputs have highly specialized functions within the HMO, thIs time may have a very 1_ gi

value in terms of production lost:

when the

chief administrator and head nurse take time away from tasks that only they can do, the operation of LI

HMO must suffer.

The value of

these specialized inputs is probably more than they are paid

but

at least their salary rates can serve as minimum estimates of the value of their time.

Other manpower inputs used for classroom'

teaching can be seen as more replaceabln; the value of producti n lost when a staff physician or nurse meets with .students can be restored by hiring a part-time physician or nurse to fill in.

The

cost of these inpUts is their salary rate. Some teaching occurs outside the clinical setting and outside the time that staff would ordinarily be paid. to devote lunch hour time

f physicians choose

to stude ts, or stay after hours to talk

with them, it might be argued that this time should not be valued this rate; wben at the wage rate, becuase it need not be replaced at

physicians choose to spend thei

"personal time" in this way, it in

its expenditures no way diminishes the product of the HMO or adds to on inputs. run.

Ho ever, this time should not be seen as free in the long

If the HMO implicitly includes this kind of "voluntee

effort '1 its physician job description be paid for.

it will eventually have to

if If more rewarding uses of personal ti e appear, or

who are the teaching program expands to include physician-teachers will fail in not so philanthropic, either the teachi-g program quality or costs to the HMO will indeed rise.

Predictions about

the long run value of personal time inputs to a particular HMO should be made by the decisionmaker on the scene, but should probably be set near the current salary rate. Data required:

number of personnel engaged in classroom

teaching and administration by type. hours of student contact, preparation and administration; salar es.

A distinction may be made

between "regular" and "personal" time if the use of personal eime resources is believed to have a lower cost for the HMO. 3. Clinical Teaching:

production gains or losses.

The

most important impact of an education program on the RMO is likely to be due to production losses or gains in the clinical teaching setting.

A set of inputs (for example, 1 physician, 1 nurse

receptionist, 2 examining rooms, etc.)

ordinarily produce a certa n

average number of patient visits in a session of a certain length.

The addition of a student observer or participant to this health team may decrease or inc ease the number of visits produced per session.

The most straightforward way to evaluate the cost of a

the loss of production is to find the incremental cost of replacing

lost visits.

If visits per session drop from 14 to 12, and the

Incremental cost of adding an extra session that vary directly with patients s

not counting expenses

ved) is $100

the cost of lost

production in each student session is approximated by: $100 14

x 2 = $14.28.

Our cos- Calculations here must consider both the direct cos

adding a session (salary payments of workers directly involved in producing pati n

care) and variable overhead (additional reception-

ist time, maintenance of examining rooms in use for one more session, light and heat, etc.).

The inremenral cost per session does not

include costs of marketing, general administration, pharmacy operation, and Cho like, since these fixed overhead costs are not increased by the addition of an extla session.

Supply and variable laboratory expenses,

which depend on the number of visits produced rather than on the number of sessions held, are also not included in the incremental cost per session.

Thus the measure for the replacement value of lost production

is somewhat less than the average totar cost per visit. 5 5

Expansion of the num- 'cal example may make this argument more Assume that current membership of.40,000 can becared for with an average of 2800 visits per week, and average number of visits per session is 14. This implies that 200 sessions per week must be scheduled. 2800 visits er week = 200 sessions per week 14 visits per session clear.

If students participate in 28 of these sessions, visit production in these 28 sessions will be reduced, with total visit production now (200 - 28)

sessions without students

x

14

28

I-

productivi y without students

sessions with students

12

x

= 2744

productivity with students

where the visit production with students present is 12 per session. The HMO is now 56 visits short of its previous weekly level of service. To replace the visits lost due to lower productivity, four sessions, must be added: 56 yisit_ deficit_

14 visits per session

4 sessions

costs $100 to add another session, not counting costs that vary h visits, an outlay of $400 is required to bring the HMO back to s previous service level. It is important that a distinction be made between costs that vary with visits produced and those that vary with sessions scheduled. If a patient visit on average requires about $2 Worth of supplies, laboratory tests, and drugs, the cost of these inputs for 2800 visits will be $5600 whether the patients are seen in 200 sessions cwithout the teaching program or 204 (with the program).

In like manner, if residents increase the number of visits the health care team can produce, fewe- non-t-aching sessions will need to be scheduled.

Assume that a resident and a physician working together

with other direct patient care inputs can produce 20 visits in a sesSion. The value of the six extra visits may be estimated by determining how much they would have cost if produced in a typical session. example, the cost saving would be 6 x $7.14 = $42.84.

In the-

This will eventually

be weighed against the stipend paid to the resident, which istincluded as an increased expense in part A-above.

The value of the residents.'

total production may very well exceed their stipends, even when lower productivity in some sessions is taken into account. If residents see patients on their own, their impact on costs and production can be evaluated in a similar way.

Assume that a resident

working with a nurse and other inputs can see nine patients in a session. This is an increase in production which the HMO would not have without its teaching activity.

Valuing this at its replacement cost of $7.14

per visit, the value is 9 x $7.14

$64.26.

But this increase in

production could not occur without expenditure on the other inputs involved; if these cost $40 per session, the resident is making a net additiOn to produc ion worth $64.26 - $40

$24.26 per session.

This

calculation in effect takes into account the fact that the other health care inputs would be more productive working with a staff physician'.

6

6 Another way of looking at this is to see the HMO as replacing

The resident combines with a regular session with a resident session. 9 visits; paying a staff.physician plus $40 worth of .inputs to produce 5. additional the other .inputs cost $100, or $60. more, but produced $60. and lost 5 vi-sits, which The resident has saved the HMO visits. session; the HMO $35.70 to produce in a regular will cost 5 x $7.14 = is $60. - $35.70 = $24.30 ahead.

449

It s_o ld be noted that the above approach to the costs or lost or gained production assumes that care for.the populat on is being provided efficiently at present, so that a decrease in the number of visits per session must be accompanied by an increase in the number of sessions while an in- ease in visits provided will allow a detrease in the number of regular sessions.

Since the output of the HMO is not patient visits but care for a population, a more comPlete productivity measure would consider the number of individuals that can be carried by a typical teaching -d a baseline nonteaching health team.

This productivity measure

weuld allow for the possibility that teams including students or residents may produce a higher proportion of return visits, so that loss in productivity as measured by members served may be even greater than loss in productivity measured by reduced patient visits. Such a measure would require a baseline count of the number of members cared for by each team, and the change in that number due to a given amount of teaching involvement.

If teams including students or

residents use more supplies and laboratory tests per patient.than do nonteaching tea s, the resultant increase in cost should be charged to the teaching program. Data required:

baseline productivity for specific input combin-

ations, measured.in terms of patient visits and/or members cared for; productivity of the same input combinations when involved in teaching; incremental cost per session under baseline or standard production methods

not including supplies and tests that vary

directly with patients seen; this would require collection of data

450

on salaries for all staff involved, staff input in hours allocation of variable overhead costs

,amining rooms, equipment,

receptionists, heat and light) p r sessiont investigation of possible increases in use of supplies or laboratory tests per patient visit by teaching teams, and cost per teaching session of this excess use.

C. Staff satjsfactlon and effort Staff involved in teaching both in clinical and nonclinical settings may gain extra satisfaction from this activity, and may feel that extra effort is required of them.

Over the long run these

effects are expected to show up in salary offers necessary to attract staff to the HMO.

These salary changes will be difficult to predict,

but the presence of these effects and their strength can be approxi-mated by surveys of staff.

Surveys should include questions about

whether staff cu rently involved in teaching have an overall preference to return to their pre-teaching job content, or prefer the teaching activity; and whether teaching involvement would be a job attribute they would actively seek if they changed jobs. Data n eds:

staff surveys-to dete-mine changes in effort

level and satisfaction level with and without the education pro -am, and to determine how the staff evaluates these changes.

D. Recruiting costs prestige If teaching activity adds to the general sa isfaction and of working at the HMO (in addition to increases in direct personal

451

action, discus ,d above in Part

it wilI be easier .to

recruit new physicians and other staff, quality of:job applicants may rise, salary offers may not be as high as they otherwise:would

.be all else constant, and turnover of staffmay fall.

In addition

a teaching program allows information to be gathered about particular

potentiaLjob aPplicants -- the students and residents themaelves. The RHO will face less risk in ---aking

job offerto a. physician who

has trnned there, since the RMO has observed him or her in -acti and the physician is better prepared for _ future job at the HMO. Data required:

survey of all staff, including- those no

directiy involved in teaching effo ts su veying preferences for working in a teaching institu ion; survey of students,. and residents

in training to assess whether the applicant pool has expanded;,

baseline measures of recruiting expenditures and changes over time in these measures. It is- recognized that the costs and-benefits to members

changes in stafl satisfaction, effort, and recruiting will bdiffictat to measure in an individual _1MO.

The HMO decisionmaker

considerirg taking on an education program should at least have information about the direction of probable changes in staff satis fa tion, effort, and recruitment, a d their iMPortanCe to HMO. CoSts. Only then can he determine whether net cost savings from this source the costs of the education program worthwhile, given benefits.

7

Recruiting benefit was a major argument for hospital nursing training programs, and stndies have shown that hospitals with diploma schools,were actually able to make lower salary offers due to this (This has changed over t me due to shifts in recruiting advantage. nursing education.

If both HMOs and HMO medical education programs become more common, it may eventually be feasible to carry out a national cross-section study to determine whither HMOs with teaching programs actually .experience reduced staff costs, reduced recruiting costs, and lower staff turnover.

E. Changes in the value of care to members. The discussion above has focused on the impact of teaching on the Costs of providing health care services at an HMO.

..The net

effect of teaching will be to raise or lower ,the average cost per member, and, if prices are set at average cost, the premium cost .

per member.

Teaching activity may also change the value of the

care as perceived by consumers, since care provided by a teaching

institution may be sienas a different product from care provided without teaching.

If care with teaching is more valuable to members,

they would be willing to accept a higher premium cost to support the teaching activity; if teaching reduces the ._enities or convenience of care, members will find their wellbeing reduced by the introduction of teaching, unless premium costs can be lowered to compensate for this decrease in the value of care.

The impact

teaching on member satisfaction will therefore be a key-variable for a decisionmaker working to maximize wellbeing of members.

The direction and amount of change in value to members can be gauged by a numb,r of _eans.

The rate of membership growth may be

.

with special observed before and after the introduction of-teaching, attention to any changes in the rate of exit from membership.

These

observations should at least give an indi ltion of whIeLhIc!r con umer

willingness to pay for HMO coverage has risen or decreased after the introduction of the program.

Surveys of members can provide

information about member satisfaction with the prograM; questions asked about response to increases or decreases in premium prices due to a teaching program.

The teaching program may be seen as

decreasing the amenities of care by producing a

clinic' atmosphere,

invasion of privacy, and/or longer waits for care.

The program m

increase perceived quality if ca e conne ted with medical education is especially respected in the community. Data required:

rates of membership increase and dropout

rates before and after the introduction of the teaching progra

'

or interviews or surveys of members, including both users of care and the general membership.

45i

Terms

th.t increases the UNO's ny impact of the teaching program bjectives. cost.

any (impact of the teaching prograp

that deer .s s the

VMO's achievement of its objectives. output costs directly ubunuuktuixku units of associated with minus the sum of costs whe: all ben LIIL sum of benefits net benefit for example in dollars. are measured in the same terms,

direLt cost

;ts

net eost

use of

the stall of costs minus the_sum of benefit

opportunity c arcu resource.

value to the HDO of the best al .rwtive .

activities whjc costs incurred by the HMO for overhead costs Fixed overhead of output. .,not,directly a.so _ated with particular units Costs vary with the level of output;.variable overhead

,:-costs do not vary :141th' the level of, output. evat

at hand. costs that are affected by the decision

455

Resource Paper No-, 15

COST BENEFIT ANALYSIS

From

Section V of the University of Washington Final Report Project to Develop Curriculum for Physician Training in HMOs

Resource Paper No..

15-

COST BENEFIT ANALYSIS

.

Overview

ntroductipn

1.

Cost aCcounting is always an issue in curricUlum planning. However, as ,Group Health is pringipally a health care- inttitution_with itsfirst respon--.

-sibility to its owner-Members, any proposed.activity which might have a dollar.. :impact:must'be very carefully scrutinized.' A cdt.t.studY was -therefore alMost.

an absolute prerequisite to changes in or even continuance Of .an educational program which does not obviously directly benefit theCooperatiVe._ An issue which is hot purely "dollar" cost, but.which also-needed tb be

:considered was that the cOnSUffiers .. who might be less aware Pfobscure adMinistra7

-.tive costs would have direct, first hand knowledge of- adverse.effeCts- of teach ing..and the reallocation of patient care services.

_This is especially apparent

in a cloSed tystem where physicians who reduce their patient care effort in

.ordeh Wteach reduce their availability to patients who have contracted for servicei.- Jhe pre-paid consumer will be served, and the result may be-that .the non-teiching physicians" patient. loads may increase as,a direct consequence

of-this-reduction by the teaching' physician.

When these hidden human costs

are coupled with the inflationary prestures'aiready present_in health services, 'the suggestion of even continued teaching roles .for the medical staff, without _thorough considerations of dollar and subjective costs., is likely to be met with

vigorous debate if not outright rejection by consumers and/or professionals. Assigning costs to specific teaching-activities is often ignored, but the Group Health - School of Medicine project provided an important arena to confront _this..issue.... It offered,boththe impetus and the setting in which to approach

what in education is becoming,the'increasinglY important ecOnomic dictum of .maximizingblenefits from a fixed resource. This translated Into "How much can and should we teach at GroUp Health?" 2.

Methods

In this report cost is construed as any factor causing an increase in expense or effort, or a decrease in satisfaction. The approach used was that of management-based, cost-benefit analysis. Management analysis, as contrasted to strIct accounting or theoretical

45

economic approaches, allows for a practical analysis considering both those costs-and benefits readily quantifiable in dollar terms, 6S- well as those

costs and benefits which may be of great importance but which 'cannot be readily, assigned an unequivocal dollar cost.

For example, the quantifjable.costs and _

benefits Liclude labor, spabe, materials and incoMe

_The non--quantifiable ceSts

and benefitsincludejob-satisfaction, enjoyment, effort-, morale, and patient. attitudes. ,

The precise costs and benefits derived from this managment analysis of,

Group-Health teaching are directly relevant only within the'framework of the-. Cooperative.

Costs and benefits from the standpoint of Group- Health,.the -School

of Medicine, governmental agencies or society at large, are not ,precisely, the

.

same because of differences in the values and need dispositions of tneSe disparate systems.

However, for the pir.poses of. this project and its sequels,

the subjective costs might be Oven mutually agreed upon dollar values for negotiation within and between the managements of Group Health and the Univer, sity.

An input/output model was created to document elements in the pre-vaid_ group which impact upon or are impacted by the teaching process.

These were

measured in three areas: - Actual teaching site - Direct support site

-Group Health as a-Whole Under each area

the inPut such as labor, space, and effort, and the outputs

such as:education and enjoyment were listed (Appendix L, Table I).

,Methods were

developed to practically measure theseeither quantitatively or qualitatively. The term "practically" is quite important, for there are some quantitative data obtainable only at a cost exceeding their value to the system.. In translatiiig- the analysis into educational dollar cost, two problems

arose:

One was the lack of a readily defined market value on many of the inputs

and products of the educational process. The other was perhaps an even greater problem in that there was simultaneous production of more than one product (health care and future physican training) from the input system. The result

of this latter factor, termed joint production in economic terms, is that there is no unique cost ascribable to either product.

Issues revolving around joint 1

production have generated a geat deal of controversy in previous medical educa-

From Appndix L, Final Repor University of Washthgtoii

TABLE 1

ANALYS S

_CostBenpfit Analysis -- Related to Teaching in Group. Health.Cooperative. JeaChing Site Persons involved:

preCeptor, nurse,.receptionist,..s uden non-teaching physicians

patient,

Items considered (can be increased or deCreased by teaching) Space Time Effort Materials

Income.

Education

Enjoyment Care deliVered. (numbers, ouality) .

Support Level

Persons involved:

precep_or, nurses, adminis_ra -ors, educational support staff

Items involved

Planning Administrative Orientation and indirect ins ruction

III.

Group Health Cooperative as a "Whole" Personnel involved:

employees, consumer-proprietors

Items involved

Factors relating to consumer

membership cdst professional reputation queing net effect of teaching encounte s on patient satisfaction community service image Factors relating to staff recruitmcnt staff turnover staff morale

A

ci

From Appendix L, Final Repoi University of Washington

Methódology I.

Interview -

partly structured

Used to collect .initial information. -Used becuase of small numbers,' personal contact afforded, and relative flexability. E,specially valuable.where largely sUbjective deterMinations yere involved 'II.

Questionnaire For follow up-information And where large numbers were involved.:

III.

tlinic Records, Logs Used to provide infOrmation on patients Seen on job, etc.

IV.

cost per viSit, hours

Personal Logs

Used to provide additional information on time spent and activities lhat appeared to have a ma or impact. TiMe-Motion.

Used to provide detail and to vafidate logs.

:Jign cost studies.

jhere are faCtors in pre-paid, group practices which to some-.extent.miniThe primarroduct of a- pre-paid .health maintenance lie theSe problemS. ,:organiiation,.such as Group Health.is health care. service. d0

Unlike'Schools of

medicine, research and teaching aresecondaryactivities at best.

Al5o,due7to

-*the'siie of-Group Health, the:number Of different settings-in which care is. ..cielivered,and their thorough and ongOing accounting system,- it 'is.quite-pOssible-

to look,at the same or virtually equivalent patient.care:service-,Settinvin-the presence and absence of teaching and evaluate changes:in terMs of:aMount and_ The cost td-the Cooperative for .

patterns of._patient care services delivered.

teaching at a given site can thus be equated to the value of-loss,ln services. services -This solution to the joint production problem assumesjhat patient care

are Of-highest value to the,system-and .that the Value of a,_given unitof health care Is not altered...as a function of the presence or absence of. teachi* .

This form of analysis was applied to both the'family-practitereSidency previoUsly in the program and to a series of undergraduate clerkships described ,curriculum section. a)

In brief, these consisted of:

Introduction to Clinital Medicine - Human Biology 413, 422 and435.

A first year required course series conducted largely at_GrOup Health. )

c)

Family Medicine Preceptorship--Tamily Medicine 401. An elective course primarily for fiT.st year students in which approximately one-fourth of the students are taught at Group Health clinics by their medical staff. Family Medicine Continuity Clerkship - Family Medicine 420, 421 and 422 A second year elective course series which includes 'Group Health preceptors among the faculty. Independent Field Study - Public .Health and.Community Medicine 531.

An elective in which students independently arrange for special projects at community health agencies - commonly including Group Health.. Since both first- and second-year Family Medicine clerkships were considered, it was decided to include a third-year clerkship for the purposes of continui y in the cost analysis which follows.

al

C. -11

B.

1.

E

CAL STUDENT COURSES

flemily Medicine Clerkshia Because of their siMilarity, the three year family practice series has been

considered together here.

.

The first year-interviewing course and the health

services research course are.considered separately. At the clinjcal teaching site for the.three Course serieu and education are produced jointly.. as follows:

patient Care

Costs shown in Table V-1-Were determined

visits displaced by teaching' were measured by comparing- the'

patient visits per day under' normal circumstanCes.to:the-daily patient visit., rate when the students were present. This data collection was..accomplishel. .

by use of clinic logs..

.

The number of visits.displaced is normalized to whole

clinic days to facilitate comparison among courieslaught for-both full and partial days at the teaching site.

.The derived displaced visits were multiplied

.

by the unit labor cost to give the physician cost per student per day. Table V-1 shows that.the major cost determinant was .the.joint cost of physician labor.

Physicians are salaried and "full-time", but nurses contract for a.standard.

week and teaching costs incurred through nursing needed also to be addressed. In courses where the physician worked longer hours to produce their normal number of visits per day, the nurses also worked longer.

A direct and readily

quantitative cost occurred in some instances as nurses-.claimed overtime paY.

Since a case can be made that use of visit count changes is an incomplete assessment of the impact of students upon a health care delivery-setting, an

.

extension of the clinic records study was begun to validate the.data, pilot test a method, and gather data regarding the student-preceptor interaction.

This

portion of the project involved a time/motion study tailored to the ambulatory clin setting and conducted in a third year elective course in Family Medicine taught

at a Group Health satellite clinic (Appendix 0. 'Table V-2 contaips..the non-4oller tosts and hpnefits of the three studied Family Medicine experiences reported byphysician and nursing staff.

No patient

satisfaction data is currently available due to delays in obtaining Group Health approval of the methodology and instruments to be used. study will be completed at a later time.

462

This portion ,of the

TABLE V-I:

'Joint Costs

CLINICAL TEACHING SITE - OBJECTIVE COSTS

visits displaced)

*Labor

Unit cost

Physician

$8.77 visit

Nurse

$2.31 visit

0(0 0(0

$2.22 visit (building, clinic, office, administration, general administration

$35.08 (4)

$13.86.(6).

$ 9.24 (4)

Not applicable

visit $ Materials (linen, injectables) '*Overhead

$52.62 _6Y

2

0

$1

0

$79.80

6

$ 8.88

4

'TOTAL JOINT COST

Direct Costs

*Labor $4.50

0

0

0

0

Income

0

0

0

Cost Savings

0

0

0

Nurse

Materials (books, tapes, e c

TOTAL COST

$4.50

$79.80

$53.20

All costs are dollars er whole student day, i.e., one student day represents one student present for one full day or two students present for one half-day

TEsion, etc. *labor - joint costs

visits per day displaced x unit cost

**overhead included since it would have to be redistributdd to other visits if not accounted here - no overhead is directly assigned to teaching.

TABLE V-2

CLINICAt TEACHING SITE - SUBJECTIVE ANALYSIS

COSTS

1st. Yr. FM Obs. a.

2nd. Yr. FM Lim. Part

3rd. Yr. FM Urn. Pa

Time in minutes spent per day beyond normal working hours with no compensation. * Physician

30

20

45

Nurse

10

0

0

Physician

6/6

3/3

3/3-,

Nurse

2/5

0/3

0/2

_rt - Number reporting increases/total involved.

c.

Enjoyment - Number reporting decreases/total involved. Nurse

0/2

1/5 .0/3

BENEFITS a.

b.

C.

Enjoymen

Educa

- Number reporting increased enjoyment/total involved in course.

Physician

6/6

3/3

3 3

Nurse

3/5

2/3

1/2

Physician

6/6

3/3

2/3

Nurse

3/5

1/3

1/2

0/5

2/3

02

on - Number reporting increases/total involved.

Effort - Number reporting decreases/ total involved. Nurse

* No increase in personal income was reported by either physicians or nurses. was usually reported as represen ing a reduction in personal time available.

Time

SUpport_tite analysis revealed-no easily quantifiable cotts,forat Hthe individual course-level it is 4ifficUlt to assign direct adMinistr4tive'Otts .(TableV-3 ) .tors

.

Four of the most,dfrectly.'involved.Grou0 Healtir.admintStra--

estimated that very little-time was spent-considering iny_.MedieetttUdent _

--'Aeaching 'Vv..20 total hours).

An additional cost-Sourde would:bp.displaced.:.

[Ipatientcare services As-a'functicin of tcheduling edue4tional.014nning/admini -

strative meettngt during.OffiCe_hourS.

.it was noZ pottlble tii make.a':definite

.Aeterminatton of the magnitude of this cost source....

-As indicated earlier in this report, some:objective aspects of..thecost/ . .

.:beneftts totheCooperative as a whole fram teachinv mediCalstudents couldApt readily:be studied within the scope of this project. HoWever,intervieWs...with.. .' nurses, physicians and administrators did notreveal any ayea of 110tOle increase,

..or'decrease in cost with respect to such areas at professional and nOn-pro

Jessianal labor, stIpply usage, spaCe contiderations'andgeneral oVerhead.HOverail subjective costs and benefits to.Group Health for this teaching effort are.: .

Included.with others later in this report (page

.$6).

However,.current &liar ,

Pts for these courses are identified and tummarized in Table V-3.

TABLE V-3 SUMMARY

OBJECTIVE ANALYSIS - FAMILY MEDICINE COURSES

1st. Yr. FM

Teaching Site per Student Day

Obs.

2nd. Yr. FM Lim. Part.

4.50

$

79.80

3rd. Yr. FM Lim. Part. $

53.40

Support Level

III

Group Health Cooperative

4.50

Total Cost per Student per Day Number of Student Days .7-1-74 6-30-75

0_

(1) --

Total Cost per Year

X 50

$ 225.00

0

0 $

79.80

X

59

$4708.00

$

53.20

X

40

$2123.00

Cost Savings

Teaching Site Support Level Group Health Cooperati'

Income (2)

Teaching Site Support Level Group Health Cooperative

(1)

0

The number of total whole days of student instruction in each course at (i.e., 50 student days = 50 s-udents for one Group Health Cooperative. day, 5 students for 20 one-half days, etc.) At present the University pays Group Health a sum of money each year for support of teaching programs as part of the affiliation agreement. Althoug this is accounted by Group Health as part of income for the residency program, the agreement provides for access to Group Health by University of The student teaching includes several courses Washington medical students. not analyzed here so no apportioning of this income has yet been made.

2.

Introduction to Clinical Medicin

An impact review of the first year interviewing course is found in Table V-4.

Note that for some nurses there was a problem expressed,a reduction

in enjoyment coupled with their increase in effort.

This reduced level

of nursing morale and job satisfaction could lead to reduced patient satisfaction as an indirect result of teaching, even if direct effects of teaching do not. As was mentioned in the Human Biology 413 course description, nursing time was spent in making lists of available patients suitable for student interviews.

In most cases this was accomplishedjoite easily.

'Yet at times when under-

staffNocclwredthis minor task became a burden.

Another problem, though

the data is anecdotal and not formally .summarized on Table V-4, was that there

were times when patient treatment or housekeeping tasks were delayed when students were conducting patient interviews.

These items may seem rather

trivial from the overall perspective, but they constituted significant negative impact to the involved individuals.

On the positive side, it should

be pointed out that these problems were generally minimized by careful coordination by medi.cal education specialists.

Most of the dollar cost for teaching this course series is borne directly

by the University in terms of salaries to two educational assistants responsible for coordinating interviewing space, students and patients. Without this "income", the educational objective costs at Group Health would increase considerably, and the course would presumably have a

ch greater negative

impact upon the, satisfaction of the nurses, their support staff, and,directly

or indirectly, on the patients. Physician time is also a hidden cost.

Course descriptions note that one of

twelve preceptors for the University-based portion was a Group Health physician. This preceptor's teaching and travel time came from personal time and time scheduled for family'medicine residency precepting. This latter cost is subsumed under residency costs and so represents no direct cost to Group Health, but it is a medical student teaching cost. The estimated loss of one hour of clinic time for each of the eighteen weeks is $475. With einht students present per session, the effective cost is $26.50 per student day for this pft,sician'S- time.

This

should legitimately be deducted from the residency program cost and be added h:

TABLE V-4

TRAINING COST SUMMARY Interviewing Course - HB 413-422-435 Objective Costs to Group Health

Value - Reported in terms of dollars per student day 0 unless otherwise noted.

Source Physician

Nurse *

0.25

Educational

Assistants

4.90

Space **

0

Materials

0

Total per student day

$5.15

# of student days * * *

580

TOTAL COST

$2900.00

Incume

$2842.00

Cost savin s

0

58.00

Net cost

Subjective Costs to Groui Health Effort

Classifitation

Enjoyment

Time

Outside teaching site)

30 min/session (8Student 18 sessions)

Physician

Nurse

5

Educators

2

0

.Not applicable

Student - see eValuation section Patient - currently being assessed - delay due to generation and reviews of survey instruments by committees at Group_Health Cooperative. Other hospital employees - not directly assessed *Nurse - Computed at $8.08/hr. including wages and fringe bene:its. **Space - One conference room was used 4 hours per day, 2-3 days/week. No other use was displaced or projected for the time occupied for teaching purposes, therefore no cost is imputed to teaching program. *Student days - computed by number of students multiplied by the number of hou they were present divided by 8 hours.

468

Public Health and Community Medicine - Health Services 531

This course is an elective and the content for each iteration may vary according to the specific interests of the student and preceptor.

At the

time this course was reviewed for this project, only one student was both enrolled and studying at Group Health.

The involved preceptor reported that the

normal parameters of cost we have considered in this phase of the study, e.g.

professional and non-professional time, space requirements, special or excess

materials, additional overhead,etc., were not increased at all by the presence of a student.

In other words, there was no excess direct or indirect dollar

cost.

Additional time was consumed by both the preceptor and the stUdent as a function of the course experience, but it was time not directly related to the project nor to Group Health interests.

For the preceptor this was estimated

at thirty hours and for the student, eighty hours.

It was time spent in mutual

discussions about health related affairs and in academic pLirsuits which origi-

nated with the project, but which were not directly required for project completion..

The expenditure was generally discretionary use of personal

time, and hence is not charged to this course as a cost, nor is it credited as an objective benefit.

On work directly related tothe special project addressed in the course content as developed for the student and the preceptor, the student invested approximately one hundred and fifteen: hours'in accomplishing the goals agreed upon for the project.

A research assi..stant who otherwise would have to have

been hired to accomplish the task fdr!the Cooperative would be paid approximately $6.0 per hour.Tifterefore, one could infer that Group Health realized

a net benefit of $747 as a result of their cooperating with the University in the offering of the course.

Additionally, the work was completed in a

timely manner and the outcome satisfied internal requirements of the organization.

On the subjective level, the physician and student both reported having expended considerable effort on the special project. However, each also reported that-the enjoyment, learning, and personal enrichment they re=

ceived for their efforts far outweighed any personal cost. In spite of the glowing reports above, it should be stated that several special conditions were met in this particular.educational encounter: .The project was of direct interest ancrbenefit to the Cooperative. - The project was of personal interest to both the preceptor and student.

- The preceptor invested his personal time in the completion of the task.

- The student was academically advanced and had special competencies which qualified him for the particular, research topic. - The student was mature and had the ability to work within the Cooperative with a minimum of direct personal support. The outcome might have been less mutually satisfactory with a different student, preceptor, or project. 4.

Subjective Impact of Courses oR Group Health Subjective cost/benefits to the Cooperative as a whole need to be addressed.

These have been estimated in most cases from interview data. their value 'are to continue.

Efforts to quantify

However, asmentioned earlier, the effort required

to quantify manyof the subjective factors placed their measurement beyond scope of this project.

the

,Despite this, it is felt that these qualitative issues will

be given due weight in eventual negotiation between the University and Group Health over continuance or modification of medical student teaching programs. The subjective costs and benefit accruals were: -Community .Service:

The four administrators and two board members interviewed fel

that Group Health had an obligation to do its "fair share" of service to the community at large.

However, thoumh they

agreed that medical student teaching was an important service which they should

render to the community, they were unsur_

as to what portion ethe service obligation should be allocated to this teaching. ecruitment:

Three of the four administrators saw benefits in:

4

-The eventual recruitment of the students exposed to Group

Health

into the service of this, or other, health maintenance organizatill

-Enhanced recruiting potential

of physicians in general because

of the teaching opportunities within Group Health, and -Reduced cost of orientation for those physicians recruited who had previous exposure to health maintenance Organizations in their resident or undergraduate curriculum.

Within the Cooperative, a feasibility study is being made to assess the extent to which the above might be quantified and assigned a functional dollar value).

470

Interviewers felt enjoyment, self-esteem, and

-Reduced s a f Turnover Rate:

Therefore,

general morale were increased as a function of teaching

job satisfaction is fncreasedboth for nursing and physician staff. Introduction of teaching into a system would seem to increase overall satisfaction and to thereby reduce the turnover rate.

However, this benefit maY be outweighed by decreases.in direct

Patient services as a function of theteaching or the decreased job satisfaction of those nurses and physicians who increase

their production to compensate. (A comprehensive study of this Phenomenon is planned by the University and the Cooperative Addit

.1

ques ions raised by the study which need to be addressed are the extent

to 01 eh there

s:

-Enha °cement of the GrouP Health image:

Involvement with medical student teaching

could lead to a number of positive inferences by present and potential members.

This might be reflected in increases in membership

aPplioation rates or to increased retention rates for current Cooperative members. -Qual

lye C re changes as

a function of teaching:

The quality of health care

delivered may change either positively or negatively.

To evaluate

this element would require a major commitment to compare teaching

versus non-teaching physidans and/or sites on parameters such 4s patient satisfaction, or the patient management procesSes and outcomes. -Los

enr0

1

es:

Changes in withdrawal patterns may occur due to dissatisfaction

with either being subjected to direct teaching activities or to increases in queuing due to losses in productivity incurred due to the teaching program.

Queues at present are four to five weeks -

a 500 visit per phYsician queue.

Queue increase estimates based on

the current program for Family Medicine and teaching are as follows:

1st yr FM

_tbs. cstimated increase In visits/year/ teaching physician at current level.

0

Number Of physicians now involved

6

2nd yr FM Lim Part.

120

3rd yr FM Lim Part.

40

.

Finally, it.is the inten ion of project p rticipants from both the University .

and the Cooperative that these: issues be more thoroughly Investigated.after_the

111

termination of the contract. 5.

SumMarY

This i,hase of the project produced three interrelated, yet disparate outcomes..

Firstly, there was the generation and pilot testing of a method for applying cost analysis strategies from common business use to medical practice and educational settings.

This strategyincluded structured interviews of participants,

observational schedules and logging participant's daily activities with and without presence of students. analysis itself.

Secondly, there was the data generated from the cost/benefit:

And finally

there wzs the conceptualization'or insight which

followed the presentation of the studies' outcome to those upon whom the Group Health medical student educational program impacts.

The model has been thoroughly presented in the earlier body of this section,

.

and with certain caveats,it would appear that the business strategies used here, as well as others not used, could be used to analyse d.iscrete cost to units of bo health care delivery and health care education.

The caveats are generally:

-Quantity:of care assessment here was tied to gross numbers-of patient visits This was not deemed to be entirely satisfactory due to:

a) the nature of the-.

visits themselves was not homogeneous, and a larger sampling in more settings would be required to dilute the effect and to make the data more generaltzable and b)

there were other benefits accrued to the Cooperative such as patient a

health care deliverer satisfaction and education which were not readily assign ,

a separate cost.

-Quality of care may have been affected by the introduction of students.

Introduction of students may have led to more careful scrutiny of laboratory: reports, a more thorough consideration of the presenting problems and resultin differential diagnoses, and as cost-effective medicine was being taught for,

cost-effective practice ideal may have been more closely apprOximated with the presence of students. c.tArred.

Alternatively, the very opposite effects may also have

Though it is felt that student impact on patterns of health care

del.wered should be dealt with, they

were neither studied nor assigned a

cost here.

-Joint production of more than one outcome from a given set of inputs confou cost assignment.

Patieht care, medical student education, and such intangib

effects-as in-service education of staff and changes in level of morale occurred,

Which outcome -really should be assigned what portion of the "cos

mr C.

FAMILY PRACTICE RESIDENCY TR,

NIN5

Introduction

Though the original project did not stipulate a cos /benefit analysis of Group Health's Family Practice residency program, such a study is included for two reasons.

Medical student teaching at the Cooperative and their family practice

residency were considered together in the memorandum ofunderstanding betweeen the University of Washington and Group Health Cooperative of Puget Sound that formalized each institutions' roles and responsibility regarding these physician training programs at the. Cooperative.

Secondly, use of the analysis model with the residency

program both demonstrate its applicability to a higher level of clinical teaching in the health maintenance organization setting and provides some valuable data for use by the responsible medical educators.

As with medical student courses, a managerial analysis approach was taken with the residency.

Thus, in this study when-

This methodology is based in practicality.

ever the magnitude of the cost or benefit exeeded the cest of its determination, an evaluation and translation into dollar amounts was made.

Costs and benefits

interpretable in terms of dollars have been labeled objective.

Those not readily

interpreted in terms of dollars either because of theirsmall relative importance or large determination costs, have been termed subjective. to the medical student teaching portion of the study.

This is analogous

The initial step was the

application of the cost/benefit model developed for the medical

student cost

benefit analysis with the major difference having been the greater number and variety of teaching sites within the Cooperative being studied so as to'include specialty rotations, coverage settings a d classroom work as well as the family practice setting proper. 2.

Teaching Site Family Practice Setting_

The first setting considered was the Family Practice Unit.

Geographically

unified, this is a group of offices and examining rooms in which residents conduct a continuous family practice beginning with two half-daY per week in their first year with eventual expansion to five half-days per week.

Along with the residents,

there are two family practice preceptors in the unit who manage their own- practices on half-time and preceptone-half time.

Overall, the residents spend approximately

Iv 40% of their time in this setting.

To objectively assess costs and benefits, one must look at the total cost of setting versus the total service output of the twe ve residents and two preceptors

in :his setting.

By comparing what it would have cost the Cooperative to produce

the same or equivalent services through its usual system, one may discover the

eXtess or marginal cost of maintaining the family practice residency program in the given setting. As with the medical student teaching phase of the eostiber_fit analysis, the only practical way available to measure health care serivice provided is through the use of the patient visit unit.

This use necessitated the assumption that

residents engender the same number of visits for a giveo population as other Group Health family practitioners.

This assumption was felt to be reasonable in ,view of

the marked influence of the preceptors who are experienced and respected practitioner

and in view of the common perception that third year residents are very like the other practitioners in every aspect of their practice.

On the other hand, the

assumption was only made in the absence of the preferable methodology, which would have been to identify the precise characteristic of the population servud by the residency and to discover the cost of serving an equivalent population within other settings at Group Health.

Such a methodology would measure, without

the necessity for further effort, the frequency and cost of primary care visits, laboratory; X-ray, drugs, consultations, and clinical hospital facilities.

As

was.noted in the medical student analysis, this methodology was not deemed applicable since patient panels are not clearly defined, neither are they readily definable or manipulable for study purposes.

Use of the patient visit methodology revealed an overall annual residency production of 21, 000 visits at a cost of $326,000.

This represents a cost of

$15.53 per visit versus the Cooperative's general experience of $13.92 per family practice visit.

Thus the excess cost of resident'produced services in the Family

Practice Unit is $33,810 or, dividing by twelve for the,number of residents, $2,818 per resident year.

This excess cost or marginal cost and a breakdown of

the cost per visit, is found in TableV-5,The cost of Family Practice residency health care is only 12% in excess of the usual Group Health cost for the same services.

Further, the excess is

entirely accounted for by the increased cost of nursing services per patient visit.

Sli ht changes producing greater efficiency might allow the resdiency

to break even in the Family Practice Unit.

First year residents see an average

of 13 patients per full office day, the second year 16,-and the third year 19,

and since there are only slight differences-in salary year by year, it appears that the older residents are, in a sense,. "subsidizing" the younger residents.

Therefore increased output in the,earlier years would reduce cost as would increasing efficiency of resident use of

nursing sta-f.

b.

§ELijIlq_Bale=11,J21

The second major resident teaching setting is the specialty rotation in which time is spent in limited participation in the daily practice of various specialists.

Residents spend approximately 35% of their total time here.

specialists have one resident in their practices

., The

from two weeks to four Months

out of the year.

Whether or not specialists reduce their patient loads during this time is decided by the individual specialist by agreement with associates in the same specialty, for a cut-back by a given specialist is reflected in the workload of fellow specialtists.

The practice reduction decisions are variable:

General Surgery does not; some subspecialties of Internal Medicine do, while others do not;

Dermatology does, and Ophthalmology does not; Urology does, while ENT does not. Where cut-back are made, theyj'vary from 10 to 25% reductions. In contrast to the family practice setting, no Staff are displaced by the

introduction of residents lnto the specialty rotation setting, nor is there a net increase in services attributable to the residents' efforts. Contrarily, there is a net cost in effort and personal time on the part of the teaching specialist and/or a loss in production of patient services.

Where there is no

productivity loss (i.e., no-cut-back in patient load) there is a greater expenditure.through increased effort and reduced personal time

.

To discover objective costs and benefits in the Specialty Rotation Setting, one must measure the decrease in productivity accompanying teaching.

Once again, the patient visit must be accepted as the best available productivity measure.

At Group Health an estimate of productivity loss was made through interviews of teaching physicians.

Over the range of specialists, some of whom cut back

'and some of whom do not, the overall estimate of productivity loss is 10%.

Were

it not for the donation of personal time and effort on the part of those who do not use the cut-back in workload that is allowed them, the value would more likely approximate 20% productivity loss. The 20% figure was used in a previous presentation of this study's cost estimates, and whether to consider the personal time and effort involved in teaching asa to the Cooperative is a difficult decision.

dollar quantified opportunity cost However, the reciprocal relationship

between cut-back in patient load and personal time and effort involved in teaching is clear.

In the present analysis, the 10% objective cost figure has been used

and the associated increased cost in personal time and effort has been treated as a subjective cost.

The 35% time spent by residents on spenalty rotation annually is equivalent to 4,2 resident years.

Thus 4.2 specialist years are subjected to the estimated

10% productivity loss.

If the cost of physician time with the attendant nursing

services and overhead is estimated at $70,000 per physician year, this por ion of the residency experience costs approximately 4.2 x 0.1 x $70,000,or,529,400 In addition, there is the cost of the resident's time, calculated at 4.2 x or $43,848 for a total Of $73,248.

c. Thettina The third majer setting-considered was that of Coverage, time during which.the resident is on call in the hospital in internal medicine, obstetrics, pediai or emergency departments. Residents spend approximately 25% of their time, or three resident years per year, in these settings. Thus, the first cost is residentime which may:be-calculated as 3 x $10,440 or $31,320.

There is no productivity.. loss in this setting, for the residental presence has not resulted in an increase in staff required for coverage purposes. On the other hand, there has been, no evident increase in productivity attributable to the presence of the residents, as there has been no decrease in staff required for coverage. Thus, it would seem to be justified to interpret that there has been neither a cost in productivi_y:, loss nor a benefit through'increased productivity in this setting. Specialists in Internal Medicine, Pediatrics and Emergency Departments perceived resident coverage/teaching as an even trade-off through decreased

servicedme but increased teaching time. The Obstetrical coverage situation may have been an exeption which realized a net saving. Group Health presently experiences approximately eightbirths per day and during off-hours these are- covered by an on-call obstetrician. The

notorious variability of workload in labor and delivery frequently requires the obstetric an-on-call to call in the second obstetrician on-call or back-up obstetrician from home. Since the institution of residency coverage, rvely has this been necessary. It may be estimated that this decrease in manpower .requirement represents one-quarter of one physician; however, this decrease has not been directly translated into hiring or staffing policy changes. Without consideration of the rendered obstetricalservices, the,total cost of the Coverage Setting is $31,320 in resident time or $2,610 per resident year. Most residencies do not include significantly long rotations in specialist offices. Traditional residencies in other than primary care are comprised atmost entirely of Coverage Settings which is presumably a much less costly mode, espeCially where the presence of a resident is not in addition to, but is in lieu of a -staff physician. Most primary care residencies teach skeialty material in the Coverage-. Setting, without teaching in the context of the, daily practice of specialists.

,In

view ofthe high cost of the Specialty Rotation as constituted in the Group Health Cooperat ve Residency, the alternative offered:by other residencies deserves

consideration as a cost reduction measure unless clear and valuable learning

outcomes or other benefits are documented. d.

Classroom and 0

-Cam u

Settin s

The fourth setting of the residency is the non-clinical teaching which takes place outside of the clinical setting such as classroom instruction and teaching taking place off campus.

The cost of on-campus overhead for this instruction

has not been evaluated because it is small in comparison to other costs, and therefore has played a relatively-small role in management decision making.

Otherwise, the costs of classroom and off-campus teaching are summarized as follows:

$3,000

Consultant teaching fees Audiovisual equipment

1,000

Travel and tuition for offcampus courses

5,000 $9,000

Total

Cost per resident year 3.

Mann n

121L'LSLy2port_S stem" Settin

Planning -and administration costs 25

and Adminjstration

of a physician's time ($10,000),

75% of a medical educator°stime ($12,125), and 100% of a. secretary's'time

08,400), $1,350 in overhead, and $900 in equipment.

The total of these is

$32,775 peryear, yielding an administrative cost of $2,731 per resident year. A.

Total Objective Costs of the Residency- Some Considerations The total of the above objective costs is $180,153; per year, yielding a

cost per resident:year of 15,013

(Table V-6).

The importance of this total objettive cost figure lies not in its absolute

value but in its relative magnitude and in the relative contributions of the various settings to the total cost.

It has been observed that the Specialty

Rotation, which accounts for 35% of resident time, arrounts for a disproportionate amount of the cost.

By contrast with the Specialty Rotation Setting, there is

-the relatively low cost and high yield of training

in the Family Practice Unit.

Thus, the simple expedient of substituting coverage situations for Specialty Rotations, as most residencies do, would reduce the total cost to

$!'-

and

the cost per resident year to $12,563.

It can be seen how manipulation of settings may substantially costs.

:Tsidency

Similar examples could be elaborated for the effect of various veriables

on cost, including the level of attainment of the learner, educational objectives, space provided for education,- And preceptor and preceptee roles;- all of which

ultimately be an arbitrary assignment of value by the administration. The data revealed that the critical cost determinant was th'e preceptor's perception of role.

How much time was felt should be devoted to teaching studen.s?Fromi6ence should come the Ome devoted to teaching? Should it come from decreases in volume of delivered patient care or from reallocations of personal time? Costs such as supgilies, nurses' time, laboratory requests and space were trivial in comparison to the cost of the preceptor's time. However, the issue of space for medical student teaching was felt to be a potentially significant cost'Source, though it was not so here due to the available facilities. Ultimate dollar costs ascribed were $79.80 per student day for second year interviewing and physical examination training and $5320 per student day for third year interviewing, advanced diagnostic examination and initial patient management training under the current curriculum. From this portion of the study a major outcome was the rec_gnition by faculty and administrators at both institutions, as well as recognition by involved consumers at Group Health, of certaih cost and benefit factors involved with medical student teaching at the Cooperative. These groups also came to realiie that the factors were to varying degrees both quantifiable and controllable. Among the factors and constructs now appreciated by these groups are: -Most cost/benefit apportionments are often difficult at best, and medical education in a health care delivery setting is,joiht production, which makes valid cost opportionment even more of a problem. However, there are analytical methods which can be used to assign to educational activities reasonable values which can then be used for planning purposes by the University and Group Health. -A major factor influencing the-preceptor's time consumption in given educational activities is role perception. One can clarify and monitor role, expectations and thereby gain a measure of control over time spent for educational purposes. -Through use of the strategy of monitor dollar equivalent costs.

patient visit monitoring,it may be possible to-

Where fluctuations are noted concomitant

to the students'

appearance 'in clinics for teaching purposes, cost allocation with compensation can be made. -There are subjective costs and benefits such as enhancement in patient and staff satisfaction with Group Health, prestige associated with being a medical education institution, or decreases in morale due to increases in effort or disruption of systems. These can be studied and assigned values which may be useful to managers. in chm

.

Leo,.

.

TAB E V-5

Cost Per Fami y Practice Visit

Overall Residency Cost

326,000

Annual Residency Visits

Residency

21,000

Overall HMO

Labor

Physician Nurse

Ex enses

Overhead

7.45

8.77

.5.72

2.31

.36

2.00 15.53

.33

-sti a

d

2.51

13.92

Expenses exclude lab, X-ray, presc iptions-these are treated as fixed costs for the HMO.

TABLE V-6

Residency Program

Residency - Objective Costs Total

Teaching Site Family Practice Setting - Actual cost per visit (teaching) Equivalent cost per nonteaching

Net Cost/visiL Number of visits/ year Net Cost/Year Number of residents

Per Resident

15.53

13,92 1.61

21,000

33,810 12

Net cost/yr/resident

2,818

Speciality Setting Labor plus Overhead

29,400

Resident's Labor

43,848

Total

73,248

6,104

31,320

2,610

Coverage Setting

Resident Labor

Classroom setting

Consultation

3,000

Audiovisual

1,000

Travel

5,000 9,000

Total

Support System

Labor

HMO as a Whole

(Cost Beyond Service Produced)

480

32,775

2,731

0

0

180,153

15013

are controllable by the program administration. 5.

Sub'ective Costs a d Ben

-.

A Mana-ement Con

As mentioned in the introduction, there are costs and benefits which are neither easily measured, nor readily cast into dollar values. Such variablesinclude education of medical staff which may diffuse from a residency program, increases or decreases in staff morale assOciated with the Presence of an educational program, or increases or decreases in consumer demand for membership in the Cooperative contingent upon the public's perception of the educational program's value. Traditional economic analysis would demand the quantification of such variables in dollars. Even the most cursory glance at some of these variables, such as morale, staff and membership recruitment, and education,.leads to the inference that cost of objectifyinc7 measures of these variables could be some multiple of the annual joudget for the residency itselfand the resultant dollar imputations might remain subject to accusations of arbitrariness. Nevertheless, in the absence of such objective measures, Group Health is faced with management decisions regarding fts edOcational program. Thus, estimates here are based on the common managment technique of listing and subjectively evaluating the intangible costs and benefits. While the Group Health administrator employing such a technique may not be able to ascribe a rigorous dollar value to changes in consumer demand secondary to the presence of tbe educational program, from a practical standpoint, he maY discover all that is necessary for the deCision-making process. Being confident that the relatively miniscule size of thetaching program has afforded no appreciable impact on the overall Group Health subscription or attrition rate, and that those consumers directly involvefl in the teaching program are usually satisfied at or

above the level

of uninvolved consumersmey be sufficient. Such costs, or benefits, may not be labeled objective as they cannot be readily converted into dollars, or will not be converted because costs of rigorous measurement and conversion cannot be justified by the benefit of having the information. Even.so, it may be a very real cost or benefit of which management must have some reasonable estimate as the basis for reasonable decision making.

J- pursuing these managment objectives, the list of variables outlined in Appendix L, Table 1 has been assembled. Each represents a potential cost or bene-. fit, depending on the dirction of change. Often a givern variable,may have been examined with respect to both Group Health employees and members. of these variables from a managerial point of view follows.

48i

Oiscussiem

6.

.aTE9171_2f Subjective Costs

a.Effort and Enjoyment Effort may be divided into the devotion of personal time and the subjective sense of effort during the working day.

Interviews with the medical staff

reveal that for preceptors there is increased effort associated with teaching while carrying a full clinical load without the benefit of cut-backs.

For

some preceptors, the reported concomitant increase in enjoyment is so great as to subjectively balance or outweigh the increase in. effort.

However, even

in such cases, it is perceived that the increased effort could not be sustained throughout the year without a substantial negative effect.

For medical staff

members whose increased effort is not offset by increased enjoyment the "cost" is evident and may be critical.

The dollar values which might be attached to

this effort change are subject to negotiation and have not been quantified%

Further, as certain portions of the cost in effort may be offset by a benefit in morale, effort alone cannot be a sufficient base from which to make decisions regarding an educational program.

It is'also clear that it would be

unwise to choose preceptors whose personal effort is.not perceived as being somewhat balanced by the increased enjoyment they associated with teaching.

Nursing staff employees reported no marked changes in effort as a funct on of the residency teaching situation.

However, some have reported a benefit of

increased enjoyment associated with professional education. In Coverage situations, with the exception of Obstetrics which has been

discussed above, the interview results indicate an approximate balance between the increased effort of teaching and decreased effort expended in service, There was also increaied enjoyment for about half the surveyed staff associated with teaching.

Internists indicated that should such resident coverage be ex-

panded, the balance would shift toward a net benefit resulting from a decreased service effort.

It is obvious that for a systematic effort reduction to occur

to the extent that it affords an objective benefit (as obstetrical coverage does the coverage delivered by residents must-be pervasive and consistent.

Nursing

staff reported no significant changes in effort or enjoyment in coveraoe situations

with the exceptions of the Emergency Department, where workine with residents was sometimes perceived as requiring increased effort due to slower work rates and variations in levels of ability; and ward coverage, where .the availability of an

on-call resident when ward problems arose was perceived as decreasing nursing stress.

4

2

The consumers' sense of effort and enjoyment seems adequately balanced. ,

-Effort, in the sense of personal time expended, is often increased in all three clinical settings - Family Practice, Specialty Rotation, and Coverage,But it is either perceived as a negligible cost or it is associated with appreciation and/

or enjoyment of the attention.Rejection of the attentions of the resident has been an infrequent problem which is easily handled in its rare occUrence. b,

Consumer-Related.Factors

The effect of the retidency on demand for membership is considered trivial. Indeed, the presence of the relatively small residency is not widely known to the public.

Consumer satisfaction with residency-related services is felt by

the staff to be at Or above the average level so that a negative impact on demand would not be expected unless the residency format were drastically changed. Dissatisfaction with house staff-provided services in other programs is often associated

with settings in which the house staff is preponderant and is

not adequately "leavened" by experienced staff.

This isclearly not the case

at Group Health.

Health Care Delivered

The staff did not feel the availability, accessibility, and acceptability of the health care delivery were significantly affected by the residency program.

Occasionally the long hair or casual dress of a resident was mentioned regarding acceptability, but a significantrejection by consumers has not been noted.

Alsc

mentioned was the fact that residents build their practices partly of difficult patients and patients uncommitted to any one physician-this may be interpreted as an increase in availability and accessibility, but in any case, is expressly appreciated by the more senior medical staff.

Adequate outcome measures of effectiveness have not been devised for Group tlealth as a whole, much less for the residency alone.

Regarding quality

as measured by process, it is the general opinion of the staff that sub-standard care- has been eliminated in the Family Practice Unit.

Some staff report that in

preceptor situations they are more careful to insure that process adheres to formal ciriteria, and this behavior may lead to an increased quality of care. d

Recruitment

It is generally believed that the residency has a moderate positive effect

on recruiting but not enough to induce any great stress were the residency to be 'eliminated. .

Recruitment is affected in a number of ways.

Approximately, balf

of the residency-graduates themselves are recruited onto the Group Health staff.

483

In addition, each year two hundred applicants for four residency positions are exposed Lo the Cooperative. There may be some increased recruitment and/o decreased turn-over associated with recruits who prefer an institution committed to teaching. Finally, the presence of the residency itself may

induce modifications in the style of GroupHealth practice designed to make it more attraCtive to current residents which also mAkes it more attractive to residency graduates.

e, Morale The general morale of the staff seems mildly increased by the,presence of the residency. There are exceptions, but those who express displeasure

are only mildly affected and are not those directly associated with the residency. Morale of those teaching seems moderately increased, which is to be expected since they have chosen to teach.

Morale is a complex function, dependent upon effort, enjoyment, educati n, a perceived need to teach, and a perception of increased institutional or individual prestige derived from teaching. will not be elaborated.

These ramifications of relationships

Morale is most positively affected where coverage

situations are associated with a large decrease in effort expended in service. As discussed above, such a situation obtains in Obstetrics, and, potentially., in Internal Medicine and other direct coverage settings. f,

Continuing Education

The continuing education of the medical staff, especially the Family Practice Staff, s considered to be moderately augmented by the presence of the residency. Residents conduct one-third of the family practice educational conferences.

Further,

there is the difficult-to-measure, but important diffusion of learning by random contact by staff with the residents or their preceptors to bring new ideas, information, approaches and challenges to the staff.

This diffusion is maximized

in coverage situations, although unfortunately there is no coverage situation which consistently exposes the residents to the.full family practice staff. There is also the stimulation'of preceptors to independently further their own education through extra reading or participation in more formal learning experiences, which effect is perceived to be moderately positive. It has also been noted that some nurses in preceptor situations appreciate a moderate educational benefit.

Overall Outcome

The overall outcome of the residency cost study was parallel to that of the medical student course cost study.

Methodologies were developed and piloted

which generated cost data regarding the training of residents in a health maintenance organization.

Further, where it was demonstrated that certain parameters

could be readily quantified, there were others for which the cost of objectifying would have exceeded the potential value of information obtained.

Even for these,

,r:- :

however, subjective evaluations of relative cost

,

benefit

and impact could-be

made whlch could be of use to decision makers within the University and the Cooperative.

Resource Paper No. 16

MEASURING THE COST OF PRIMARY CARE RESIDENCY TRAINING *

From Pa t III of the Harvard UniversityFinal Report, December 1975. Project to Develop Curriculum for Physician Training in HMOs.

486

MEASURING THE COSTS or PRIMARY CARE RESIDENCY TRAINING

The Harvard affiliated hospitals, like teaching hospitals throughout the United States, have planned and developed residency programs in response to the service needs of the institutions and in conformity with accreditation requirements of specialty boards. The response to service needs has permitted program directors to assign direct costs of the residencies to the hospital. Thus, residents' stipends, fringe benefits, laundry, health insurance, and more recently, malpractice insurance, have become part of the operating costs of the hospital. In this capacity the direct costs are included in the day rate along with nursing services, dietary, housekeeping, and so on. The amount of these direct costs have been determined by the laws of supply and demand with pressures to increase wages coming from house officer associations, comparison, shopping by senior medical students and the attendant fears of losing qualified applicants to better-paying training programs. Negative pressure on wage levels has come predominantly from the ability of prestigiouS:training programs to recruit good house officers while offering low wages, and from peer pressure among other teaching hospitals to hold the line on escalating wages. The indirect costs of inpatient training in the form of faculty time required for teaching rounds and didactic sessions, administrative costs for interviewing applicants and going through the selection process, unnecessary laboratory -tests and x-rays, and longer hospital stays are more difficult to measure. .These costs are partially allocated to the day rate and to research grants and- donated time of clinical faculty.

The development of primary care training programs has shifted part of the teaching from the inpatient service with its economic buffering capacity of the day rate and research grants to the ambulatory setting with its more stringent requirements for economic accountability. In fee-for-service ambulatory settings, reimbursement formulas still lag behind those negotiated with third party payors for hospital-based care, and few research grant-funded faculty have been eager to teach ambulatory medicine - to say nothing about their appropriateness had they been willing. This contrast in the financing of educational programs in the two settings is further heightened by the nature of patient flow. The inpatient occupancy rate - and thus, reimbursement rate,is scarcely influenced by the time devoted to teaching, As noted above, the influence is in the direction of prolonging hospital stay and hence increasing . occupancy rate. This added cost is then borne by society at large but mayactually be viewed by hospital administrators as a positive financial benefit. However, in the ambulatory setting, a patient not seen because of a teaching conference or preceptorial discussion is a patient fee lost to the practice. In a pre-paid practice this loss is expressed as a decrease in staff productivity which would require a larger staff to provide the same benefit package to the subscriber. As part of the A.A.M.C. curriculum project at Harvard Medical School, we have attempted to measure the cost of residency training in the HMO setting of the Harvard Community Health Plan (HCHP) and the Harvard Trimary Care Program. )

The UM is a pre-pai& group practice with a membership of 50,000 enrolled in two centers. The Kenmore Center serves 35,000 members in Boston and is affiliated with the Beth Israel and Peter Bent Brigham Hospitals, the Children's Hospital Medical Center, and the Boston Hospital for Women. The Cambridge Center opened in 1973 after receiving a grant flom the Robert Wood Johnson Foundation which -was given in part to create a site for the training of primary care physicians. The Cambridge Center is affiliated with the Cambridge Hospital and currently serves 15,000 members with a projected goal of 35,000 members in full enrollment.

.

The Harva -d Primary Care Program began in 1973 with a group of six internal medicine residents at the Massachusetts General Hospital (2), the Bet:11 Israel Hospital (2) and the Peter Bent Brigham Hospital (2). The program was expanded to eleven residency positions in 1974 with the help of a grant from the Robert Wood ohnson Foundation and matching Oands from Harvard Medical School. in July 1975, the adult primary care residency further expanded to include the Mount Auburn Hospital and Cambridge Hospitals and the Cambridge Center of the HCHP, with a total of 23 residency positions in all sites. A track in primary care pediatrics was initiated at Children's Hospital Medical Center and nurse-practitioner training has been integrated with the adult primary care residency at the Massachusetts General Hospital. Funding for the program is guaranteed only through June 1977. Thus, from the very beginning we have been aware of the need to document the costs of training residents in ambulatory settings in order to make appropriate cost-saving modincations in the program which would have minimal impact on the educational content of the curriculum and to be more persuasive in negotiating reimbursement rates with third party payors and continuing support from medical school funds and foundation grants. In a larger sense, we hope that our efforts and those or other groups examining the costs of primary care training will influence the federal manpower legislation in a realistic and positive way.

11.om the outset it was obvious that certain costs and benefits of the residemy program would be difficult to measure and others would be unfeasible or impossible without resorting to elaborate accounting systems, some of which immediately raised the question, "is the juice worth the squeeze?" The impact of the residency program on marketing the HMO is one such example. For some prospective members the presence of a resident might be_a deterrent because the prospective members expects to receive care from a fully-trained_ professional in return for paying the premium. Or the residency program might be perceived as linking the HMO with all of the negative features of the teaching hospital OPD. On the other hand, some people vould be attracted to an HMO with residents in training because of the desire to have a personal physician who is also a teacher. This view has in fact been expressed by several members of As important as these costs might be to the 11MO, we are not attempting to measure them at this ;time.

We are focusing on the costs related to physician productivity in the Data is collected for management purposes on all visits to the Kenmore and Cambridge Centers or RAW. These encounters are recorded as number of single visits (15 minutes), complete check-ups (30 minutes) and long returns (30 minutes) on a monthly basis. The total number of encounters are then converted to the number of 15 minute equivalents in order to calculate the average number of equivalent visits each provider had per session. The full-time physicians have eight sessions of four hours each per week at the HMO.

488

Kenmore Center while the Cambridge physicians have nine sessions of three and a half hours each if they are full-time. To achieve comparable rates, the Cambridge physicians' productivity is calculated on the basis of adjusted equivalent visits per four hour session. Similar calculations are made for the nurse practitioners and 15 minute slots were filled primary care residents at each site. If all by the appointment clerk, each physician see the equivalent of 16 patient should visits per session. The Harvard Primary Program reimburses HCHP for 307 of Care a staff physician's salary for each fulltime equivalent resident. The 30% reduction in patient load,to for precepting the resident allow time would be equivalent of 4.8 visits per session, reducing the staff physician's productivity to 11.2 visits Several factors make this direct per session. translation erroneous. First, the primary care curriculum includes a series of didactic sessions covering the important topics in ambulatory medicine. varying amounts of time dependingPreparation for these sessions consumes on the instructors with the topic, his or her previous familiarity interest in the subject the presentation. matter, and the format of Secondly, only four sessions per week of the resident's time is devoted to internal medicine. The other four sessions at Kenmore (five at Cambridge) are spent in dermatology, office gynecology, minor orthopedics, ENT, ophthalmology, and psychitry. In most of these areas, the resident works with less independence than in internal medicine fewer patients who are not and sees also seen by the staff physlcian. to the system is shifted toward Thus, the cost the non-internal medicine disciplines the preceptor spends more where supervisory-teaching time with the resident and the resident "produces" fewer net patient latter area where we are experiencing visits for the system. It is in this the greatest difficulty in quantifying the impact which the resident has On the number ef patients which can see per session. the specialist For the internal medicine encounters during July 1975 Center, the average staff physician at the Kenmore had 12,5 equivalent visits per session with a range of 9.8 to 17,3. The physician averaging 17.3 visits 6 sessions during the month, and only worked it is likely that he "over-booked" to see some of his in order returns before leaving on vacation. worked an average of 17.2 sessions The 15 staff internists during this vacation month. Six primary care residents each worked an average of six sessions during this with a 7.1 equivalent visit same period per session productivity. If the three senior residents who had spent six months or the previous year at Kenmore and now returning for their one session were week followup are analyzed separately, we find that they had an average of per 8,3 equivalent visits three junior residents, at HCHP per session. The for their first rotation, averaged 6.3 visits. Data for the Cambridge Center for the month or June, 1975 (the month without primary care residents) last are as follows: Six internists an average of 25.2 sessions had working an average of 13.0 equivalent visits session. The four adult.nurse per practitioners worked an average of 31.7 seeing 8,1 equivalent patient visits sessions, per session. Part of the between average number of sessions discrepancy aith the internists at the Cambridgeworked by the nurse practitioners compare Center is accounted for by the fact that three of the four nurses work full-time and the fouith ith administrative combined clinical responsibilities, whereas only three of the ;chedule seven or more six internists clinical sessions per week. The remainder of their -ime is devoted to administration, hospital-based practice or home responsibilities.

When analyzed separitely, the full-time physicians averaged 12.8 equivalent visits per session and the part-time physicians averaged-13.6 visits. One might argue on ihebasis of these findings that productivity increases_ as number or sessions per week decreases. If this observation were to hold up over time and with larger numbers of physicians involved, one might then argue that decreasing a staff internists' number of sessions to create time for teaching might actually increase unit productivity for the remaining sessions.

If we assume that all other factors at the two centers have equal impact on physician productivity, the presence of residents at Kenmore can be said to have lowered the per session equivalent visits from 13.0 to 12.5. There were 258 staff sessions at Kenmore during this period which translates to a loss of 129 equivalent visits for the month. Against this cost must be balanced the equivalent visits provided by the residents. During their 36 sessions at 7.1 visits per session, the residents provided care for 256 equivalent visits for a net gain or 127 visits for the month. If we further assume that a full-time resident with four internal medicine sessions per week averaging 16 sessions per month, at 7.1 visits per session, will generate 114 visits per month, this can be compared with the staff internists productivity. The full-time internists working 32 sessions per month at 12.5 visils per session will provide 400 equivalent visits. As pointed out earlier, the remainder of the resident's week is devoted to more purely educational activities so far as HCHP is concerned, and the resident's contribution in terms or added patients cared for is minimized ir present at all. Therefore, we can use the equivalent visits in adult medicine alone to compare productivity with a fully trained internist. The 114 resident visits are 28.5% of the staff physician encounters If we include the 0.5 equivalent visits, per session difference between the center with (Kenmore) and the center without residents (Cambridge), the resident's net productivity decreases to 27.4% of a staff internist. In our budget calculations for this fiscal year, the average staff salary was 000 and the average resident stipend $12,000, with fringe benefit costs being slightly greater for the staff plician.. Based on these salary figuri7 alone, the resident would have to produce 33 1/3% as many encounterd to equal the staff physician's output on a cost-equivalent basis. The 5.9% short-fall (33.= - 27.4%' would then be the net cost to HCHP of the training program. for each nAll-time equivalent resident this mnounts to n net- cost of $2124 plus fringe benefits per year. Having said all of thi.s, what is wrong with out method of calculating costs? first, assuming that the above data are reliable,we have not included the cost of space. in order for HCHP to deliver equivalent services to its

enrollees, two residents are required to replace each staff physician (7.1 equivalent visits per resident session is 57% of the 12.5 visits per internist). This figure, rather than the 28.5% value, is used for space costs because we are here concerned only with the internal medicine space needs. Stated in cost terms, each resident requires twiee as much space as a staffphysician. With the decreased productivity per unit space, the total enrollment in a facility using residents will have to be curtailed. During the stait-up period in the Cambridge Center, ample space is available because the member ship of 15,000 is cared for in a facility designed for 35,000. The space co t now is nullified by the benefit to HCHP of having additional staff to increase the capacity to keep a physician - nurse practitioner - resident team open to

new members. This ability to avoid closing a team to new members is mainly thought to be a marketing asset, and as such is very difficult to quantify.

Administrative costs are comparable to space costs. For each new or additional person required to deliver the benefit package tc subscribers, there are additional administrative costs, i.e. processing the forms for salary, fringe benefit and tax purposes, orienting new employees to the center, planning appointment schedules, making space assignments. A major administrative cost for HCHP during the past year or two has been the staff time required for planning the residency itself and in discussing the method of presenting the program to membership followed by the actual presentation.

A potential cost of the residency is the possibility of a higher rate of hospitalizations, more frequent return visits, and more frequent use of laboratory and x-ray examinations among patients seen by residents. We have no data yet to shed light on this question. Several confounding variables make it unlikely that we will ever have accurate data in these areas. First, the preceptor is actively involved in such major decisions as when to hospitalize a patient, what laboratory studies are most appropriate, what consultations should be requested, and how soon should the patient return. But as anyone familiar with the decision-making process on in-patient teaching services can attest, learning clinical management occurs in direct relationrship with the amount of reaponsibility allowed. The second variable is the conscious pre-selection of difficult clinical problems for the resident to follow. In order to fulfill the objectives of the primary care curriculum, this referring of complicated patients to the resident's panel will continue. Some of the benefits for HCHP of having primary care residents in training have already been mentioned. An important one is the increased ability of the Plan to attract staff physicians be,-ause of the opportunities to teach. At the present time of steady growth in Plan membership, a significant amount of administrative and proCessional time is devoted to recruiting new physicians. The historical precedent of Group Health of Puget Sound has not been lost on MEP, which views the preparation of future staff physicians as an important result of the residency program. Anything which serves to limit the amount of time spent in recruitment activities by the highest-pail physicians in the HMO is a very real financial gain for the practice. Hiring a physician who has been a resident the practice also tends to minimize the risk involved whenever new employees are brought into the group. Again, however, all or these factors themsejves involve multiple variables, and it is doubtful that any reliable value can be affixed to these personnoT costs and benefits. Finally, there is the benefit to society at large in having physicians trained to provide primary care services. If this benefit is perceived as a justification for public support of primary care residency programs, the HMO may benefit directly by receiving public funds for educational purposes. HCHP is already receiving generous private support from the Robert Wood Johnson Foundation because of the view that society will benefit from the special training of physicians for primary care functions.

In summary, we have outlined an approach to measuring costs involved in training primary care residents in a health maintenance organization. Among the many different costs and benefits which have impact on primary

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care residency training,physician productivity emerges as the central factor. it is also the gasiest factor to measure quantitatively. Preliminary results from the Harvard Primary Care Program and the Harvard Community Health Plan suggest that residents,at the end of their second year of training, who devote only half of their time in the HMO to internal medicine patients, are capable of seeing 7.1 equivalent visits compared with 12.5 for the staff internist. When factors of different salary levels between resident and staff physician, and the need for the resident to rotate through other specialties to acquire primary care skills are factored in, the cost to the HMO of training the primary care resident is approximately *MOO per year. As we gather additional data, the validity of this figure will be tested.

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Primary Care Education in Health Maintenance Organizations

DOCUMENT RESUME HE 008 515 ED 132 943 AUTHOR TITLE INSTITUTION Infeld, Marcel D. Primary Care Education in Health Maintenance Organizations: Curric...

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