Family Medicine Education: Supporting Healthcare

Transformation Jeffrey Borkan, MD, PhD

Assistant Dean for Primary Care – Population Medicine Professor and Chair of Family Medicine

Alpert Medical School of Brown University

The Evolution of Family Medicine Education to Support Healthcare Transformation

• Intellectual basis of Family Medicine• Health Systems Science – the third Science• Family Medicine for America’s Health• Strategic directions led by CAFM• Medical school exemplars in healthcare

transformation education

The Intellectual Basis of Family Practice J Fam Pract. 1975 2(6):423-8

• Patient management is the quintessential skill of clinical practice and the unique field of knowledge of family physicians

• The sine qua non of family practice is the knowledge and skill which allow the family physician to confront relatively large numbers of unselected patients with unselected conditions and to carry on therapeutic relationships with patients over time.

G. Gayle Stephens, MD

The Need for a New Medical Model: a Challenge for Biomedicine. Science.1977;196:129–136.

George Engel , MD

The Case for Primary Care

• There is now good evidence, from a variety of studies at national, state, regional, local, and individual levels that good primary care is associated with better health outcomes (on average), lower costs (robustly and consistently), and greater equity in health.

Barbara Starfield, MD, MPH

The Core of Family Medicine and Public Health

Health Systems Science

• Goal better prepare our students to succeed in our evolving healthcare systems

– Third Science of Medicine– Third Science of Medical Education

7

Health Systems Science

What is the Goal of the Third Science?

• Preparing students for 21st Century practice in the broader context of patient’s lives and population health

• Seamlessly integrating with the First Science and the Second Science

Health Systems Science

Health Systems Science Definition

• Principles, methods, and practice of improving quality, outcomes, and costs of healthcare delivery for patients and populations within systems of medical care

• Conceptualized as factors that impact the health outcomes for individual patients and populations of patients beyond the basic and clinical sciences

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Health Systems Science

Population Health

Policy

Informatics

Quality

Health Determinants

OtherPractice Improvement

High-Value CareTeamwork

Domains for Curriculum Design

Core Strategies:1. Ensure every person will have a personal relationship

with a trusted family physician or other primary care professional, in the context of a medical home

2. Increase the value of primary care3. Reduce health care disparities4. Lead the continued evolution of the patient-centered

medical home5. Ensure a well-trained primary care workforce6. Improve payment for primary care by moving away

from fee for service and towards comprehensive primary care payment

• Reforms are needed across the entire educational continuum, including how we recruit, train, and help practicing family physicians refresh their skills

Transforming Training to Build the Family Physician Workforce Our Country NeedsHughes, et. al. Family Medicine 2015;47(8):620-7.)

Must provide opportunities to:• acquire skills needed in new practice and payment

environments• incorporate new educational standards that reflect

the public’s expectations of family physicians• collaborate with our primary care colleagues• develop effective interprofessional training, and to

design educational programs that are socially accountable to the patients, families, and communities we serve

Family Medicine Residency Innovations Task Force• What is our intention, now? • What do we know so far? • What do we still need to learn? • What assumptions do we need to test or challenge? • What's emerging from the current efforts that

should inform what we do next?

Medical School Exemplars in Training for Healthcare Transformation

• University of New Mexico: health extension services

• School of Community Medicine at the University of Oklahoma-Tulsa: health of the community

• Duke University: Primary Care Leadership Track

• Penn State: health system science including a navigator program

• Mayo Clinic: Science of Health Care Delivery

• Brown: Primary Care –Population Medicine Program

Health Extension Rural Offices (HERO) in New Mexico: An Academic Health Center and the Social

Determinants of Disease

Mayo Medical School

• Innovative Science of Health Care Delivery curriculum, in which students learn how health care systems work

• Students earn a certificate in the Science of Health Care Delivery upon graduation

The New Primary Care-Population

Medicine Program at Alpert Medical School

A Vision for the ProgramA bold and innovative scholarly program that trains “clinicians-plus” with a primary care and population medicine focus

– 4-year program– dual degree MD-ScM– Research requirement in primary care, population

medicine, and health policy – Interdisciplinary and leadership training– Methods for integrated, active learning – Up to 24 students per class

Readies students for leadership roles in health care on the local, state, or national level ranging in areas from:

• Primary Care Clinical Service• Population Health• Research• Education• Health Policy

Basic Science, Clinical Medicine & Population Medicine

Active Learning/Flexibility/Creativity/Scholarship

The Four Year Continuum:

Basic Sciences and Population Medicine

Clinical Sciences andPopulation Medicine

Specific Curricular Elements

Longitudinal Integrated Clerkship (LIC)• 32 weeks of LIC with weekly

outpatient (Pediatrics, IM, FM, OB-GYN, Surgery, Psychiatry/ Neurology) sessions

• Inpatient experiences based on curricular needs (total 12 weeks starting with a 6 week Med-Surg immersion)

• Students in groups that meet for tailored didactics, morning reports, and special activities (e.g., homeless and incarceration medicine)

ScM in Population Medicine• 9 course integrated curriculum• Special journal club and group

activities • Scholarly work related to PC-PM

with thesis requirement • 5th Year (research fellow status), if

needed

Aug Sept Oct Nov Jan Feb Mar Apr May JuneDec

Scientific Foundations of Med

Histology

Human Anatomy

Gen Path

Brain Sciences

Head/Neck Anatomy

Micro/IDSS

Doctoring I Doctoring II (with extension into summer)

Year 1

IMS I IMS II

Population Medicine I Population Medicine II (semester), III, IV, V (summer)

SS Anat.

Aug Sept Oct Nov Jan Feb Mar Apr May JuneDec

Cardio

Doctoring III Doctoring IV

Renal HR Heme GIPulm

Clin

ical

Ski

lls

Cle

rksh

ip

HR, Human Reproduction; End, Endocrine

USMLE Step 1

IMS III IMS IV

All blocks integrate systemic physiology, pathophysiology, pathology and pharmacologywith relevant nutrition and genetics.

Population Medicine VI

End

Begi

n Cl

erks

hips

Year 2

April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May

Quarter 1 Quarter 2 Quarter 3 Quarter 4

Longitudinal Integrated Clerkship

Year 3

• Internal Medicine • Surgery • Pediatrics • Obstetrics & Gynecology • Psychiatry/Neurology• Family Medicine

Population Medicine VI and VII

Inpatient

June July Aug Sept Oct Nov Dec Jan Feb Mar April MayMay

Residency Interviews

Subinternship(s) / Electives/ICU

Year 4

Population Medicine IX

Thesis Completion

In Year 4, students will participate in elective rotations and a sub-internship offered at Alpert Medical School and complete their thesis

Expected Products of the Program• Primary Care “clinicians plus”• Halo effects – on faculty and mentors, physician

groups, hospitals, and healthcare systems• Diffusion of innovations to the categorical program• Improvements in the outcomes, quality, and cost

and the organization of healthcare in Rhode Island• Strengthening of the bonds between the Medical

School and the State• Fostering further research in primary care,

population medicine, and health policy• Enhancements to Brown’s reputation

What’s Next?

• The healthcare system is transforming more rapidly than medical education – how do we prepare students for the context in which they will work, and prepare them to adapt to and ideally lead the change?