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Stephen C. Shannon, DO, MPH

By Stephen C. Shannon, DO, MPH
President and CEO, AACOM

While the economic stimulus efforts of the Administration and Congress are dominating the news these days, health care reform is both a prominent part of that discussion and a priority in its own right. This emphasis is clear when one listens to those in a position to define these priorities and move this agenda forward. And, increasingly, medical education is recognized as part of the larger agenda.

In the meetings I have attended recently, hearing from such policy makers as President Obama’s top advisor on health policy Jean Lambrew (Deputy Director, White House Office of Health Reform), Senator Max Baucus (Chair of the Senate Finance Committee and author of one prominent proposal under consideration), and key staff members of the relevant committees

in both houses, it is clear that both the Congress and the Administration intend to move health care reform quickly in this session of Congress, once the economic stimulus package has been resolved.

There are common elements in nearly all proposals that directly and indirectly impact medical education. Universal access, quality, and cost-efficiency are the underlying themes in the reform efforts under discussion. And when these are discussed, there is a clear focus on the need for a primary care-focused system that relies on prevention and evidence- and team-based care to achieve these results. Where evidence is lacking, clinical effectiveness research is seen as a means to develop the evidence. And the universal adaptation of electronic medical records is proposed as a tool to enable efficiency and quality by supporting evidence-based decision making, patient record access, ease of communication, minimization of medical errors, and a population-based approach to prevention and disease management.

While the regulations and financing mechanism changes are the ‘devil-in-the-details’ issues by which health care reform is proposed to be implemented, the details themselves have major implications for medical education. If the efforts underway are successful, and clearly something along these themes will emerge given the broad-based, bipartisan and business community support, then our students will be practicing in a world different from the one in which they are being trained to practice today. In recent years, our schools have been assessing and changing their curricula to prepare students to be self-directed learners, use technology, and incorporate evidence-based clinical decision making. But often the education changes run up against the real world of clinical training and practice. Such areas as prevention-focused interprofessional team-based care are often isolated programs that exist amidst a larger world of uninsured populations utilizing episodic care. And the current economic situation seems likely to make this worse.

Elements of interprofessional, team-based care have long been used in geriatrics, pediatrics, chronic disease management, and the military. It is also an important element of the ‘Medical Home’ model being proposed by a wide variety of professional and policy-making organizations as a mechanism to implement a truly integrated health care system[1]. But, today, interprofessional team-based care is more of an idea than a reality. While clear evidence exists as to the quality of care that can be provided in team-based care models, there is little evidence regarding cost-effectiveness or how best to train health professionals to practice in this model. And the definition of the ‘team’ means different things to different disciplines, with the underlying scope-of-practice issue often dominating the debate on a state-by-state basis.

Nevertheless there are a wide variety of initiatives underway to improve the selection and education of our students and residents for interprofessional team-based practice. Formal requirements in this regard have been implemented, with standards adopted for the competency-driven curricula of our colleges and the residency programs in the basic core competencies of (note highlighted):

  • Osteopathic philosophy and osteopathic manipulative medicine
  • Medical knowledge
  • Patient care
  • Interprofessional and communication skills
  • Professionalism
  • Practice-based learning and improvement
  • System-based practice[2] [3]

Curriculum re-design has focused on these issues, and innovations in interprofessional clinical training and practice are underway in a variety of settings (see, among others, the new curriculum being implemented at Western University of Health Sciences/College of Osteopathic Medicine of the Pacific; the interdisciplinary clinic at Arizona College of Osteopathic Medicine of Midwestern University; and A.T. Still University/Kirksville College of Osteopathic Medicine's interprofessional curriculum with Truman University's nursing program).

Whatever happens with health care reform on a national level, the issues driving attempts at many levels to improve quality, access, and cost-effectiveness of health care for our population will be prominent in the changes ahead. AACOM will be working on several levels to forward these issues by advocating at the federal level for resources that will allow our colleges to implement and evaluate innovations; working with other health professions education associations to create new resources for and focus on these issues; highlighting the innovations and best practices of our colleges; reporting on reform developments; and helping to develop the resources and the research needed to improve our nations system of medical education as it relates to our changing health care system.

February 2009

 


[1] See, for example, "Joint Principles of the Patient-Centered Medical Home," March 2007, American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), and American Osteopathic Association (AOA); "AAMC Adopts Position on 'Medical Home' System of Care," March 25, 2008 press release of the Association of American Medical Colleges; and "A 2020 Vision of Patient-Centered Primary Care," Karen Davis, PhD, Stephen C. Schoenbaum, MD, Anne-Marie J. Audet, MD, Journal of General Internal Medicine, October 2005, 20 (10).

[2] “Colleges of Osteopathic Medicine Accreditation Standards and Procedures—2008,” Commission on Osteopathic College Accreditation.

[3] “Accreditation Document of Osteopathic Postdoctoral Training Institutions and The Basic Documents for Postdoctoral Training Programs--2008,” American Osteopathic Association.