Connecting with Passion to Solve Community Problems: A Transformative Care Model

As a new class of students progresses through the Transformative Care Continuum (TCC), an innovative family medicine education and training program, the American Association of Colleges of Osteopathic Medicine (AACOM) spoke with Dr. Leanne Chrisman-Khawam, assistant professor of social medicine at the Ohio University Heritage College of Osteopathic Medicine (OU-HCOM) and TCC director, about the program’s benefits not only to students, but to educators, patients, health professionals and communities.

The TCC program is a partnership between OU-HCOM and the Cleveland Clinic to educate and train family medicine physicians with an emphasis on community health. Dr. Chrisman-Khawam was recently honored with a Celebrating Achievements and Recognizing Excellence award, a formal employee recognition program at OU-HCOM.

The answers below have been edited for brevity and clarity.

Q: Last June, we interviewed Dr. Sandra Snyder, program director for the family medicine residency program at Cleveland Clinic and fellow TCC director, about the TCC program from the graduate medical education (GME) perspective. From an undergraduate medical education (UME) perspective, what are the tangible benefits you have seen so far from the TCC’s unique education and training model?

Dr. Chrisman-Khawam: There are many tangible benefits to this type of program. It harkens back to the old concept of apprenticeship. Our students are integrated into the care team right from the beginning, which creates great mentorship opportunities. Very early on students interact with various individuals in the health team, which is useful for developing their professional identities and will have a downstream impact on their quality improvement projects. Students will be able to better avoid bottlenecks by being more intimately aware of interprofessional team members’ roles and identities.

Another central piece is the opportunity to fail. That sounds horrible, doesn't it, the opportunity to fail? But it's critical. In medicine, we have such an aversion to failure, which takes away learning opportunities. Humans learn best when they fail. I think of this much the same way I thought about raising my teenagers—sending them out into the world with a huge safety net underneath them. I want them to fail while I’m still there to catch them. In our program, students start working with patients so early that they can't possibly know all the medicine yet, so they have all this opportunity to fail and learn from that failure. This is unique because medical education in general has almost zero tolerance for failure and I think that’s a mistake. I think it's part of what leads to burnout.

Q: What has it been like to see your first graduating class of TCC students become residents this July?

Dr. Chrisman-Khawam: In that regard I am a very proud mama. I have birthed this program from so much of my own lived experience, as well as academic and training experience, and I've spent all this time trying to make medical education better. I knew very early on that my experience in graduate education was kind of a disappointment. I went to this amazing undergraduate institution that looked carefully at how we learned and was very supportive, and offered amazing give and take with our professors, and then I got to graduate school and thought, this is graduate school? This is awful! I didn't feel like I was being molded into a position. I felt like I was literally sipping at the fire hydrant. I knew I wanted to make it better.

I grew up in a poor town in a family that didn't have a lot. My family doctor was the difference between us making it or not. He brought me into his clinic to help cover all the positions in the office over the summer, so when people went on vacation, I would be the secretary, or I’d be the accountant, the nurse, the medical assistant, and so on. I learned all the roles in the office. That experience had a huge influence on the TCC program’s framework. I understood the health system differently than others did. I understood how to come up with a differential as a medical student. There's something about this process of mentorship and seeing and learning from others that's important and we don't do it enough in medical education. We have all this information and then we transition and have all this clinical opportunity, but those should not be disconnected. They should be a continuous, single piece. The brilliant thing has been watching these TCC graduates. They function so incredibly well in the clinic. They're self-assured. They have this sense of why they're doing what they're doing, and when they don't know, they aren’t afraid to ask for help because they know that's part of the process. At both of our sites I’ve had faculty come to me and say these are not just the best interns of the class, they're some of the best residents that we have ever had, so watching them graduate and do this work is gratifying but seeing them excel and achieve and be able to impact health outcomes and their own residency health systems is priceless. I mean, it's been an incredible, incredible experience.

Q: This year, like last year, we continue to face challenges from the COVID-19 pandemic. How is your newest class of students adjusting amid these ongoing concerns?

Dr. Chrisman-Khawam: The transition in and out of virtual learning has been a real difficulty. I mean, I think people are struggling just to resume social behavior right now and it's no different for very stressed-out medical students. The interesting thing is that with the TCC, we're recruiting for resilience and flexibility, and we augment those skills with resilience builders. We also build a compact together about what students expect from me and from us as a school, and what they expect from each other, and how they're going to respond when that compact gets broken. Every year, students get just a little better at this, or maybe I’m getting better at framing the activity, but I dare say this year was the best, and part of it may be that this year’s students understand very clearly that life is uncertain. Responding to that uncertainty has been very valuable. So, while the pandemic has been horrible in some ways it's offered us opportunity that I don't think we would have seen otherwise.

Q: As an MD working to educate osteopathic medical students, what is your perspective on the value of continuous osteopathic medical education and training from UME through GME that the TCC provides, and how does the TCC model support the osteopathic learning environment?

Dr. Chrisman-Khawam: That's a great question and one I always feel obligated to answer. I am an allopathic physician, but I am also a family physician, and family medicine has a very similar viewpoint as the osteopathic principles of function and structure. Just like I spent my college summers working in that family doctor's office, I also worked in an osteopathic hospital and probably would have become a DO if I had been trained today. However, there were not as many osteopathic schools back when I was studying medicine, and they were all far away from where I lived. I also thought I’d never leave Oregon, go figure! In the TCC program, we promote the sanctity of the structure and function relationship and of the body's ability to heal itself. We're constantly looking at the patient, how the patient is in their environment and the environmental factors altering someone’s ability to self-heal. Similarly, we look at the healthcare system as a patient, and the system is very sick right now. We're spending more and more money for less and less value. Our outcomes are decreasing but the cost keeps going up. Part of the reason for this is a defocus on the osteopathic tradition. The country needs to refocus on the basis of healthcare, which isn't even family medicine, it's public health and community. It's our environment, our food, our lived experience, our communities of support. All of those are lacking right now. The TCC program connects those things intimately. We believe that medicine and the community must be integrated. We believe that medicine and the community must be integrated. We believe that the health system has the ability to heal itself, just like a patient, which is an osteopathic approach to changing the health system. Market forces, the desire for good outcomes, all of these are pressures on the system, but so are the people in the system who want to do good work. We're all in it for the right reasons. However, it requires leadership and a vision of unification and this understanding that there is structure and function, and we need to get those in the right order.

Q: How does your background in social medicine inform the TCC, and do you have any plans to expand the TCC’s approach to fields beyond family medicine, such as social medicine, that might also benefit from such a strong focus on community?

Dr. Chrisman-Khawam: Great question! Social medicine is a collection of educational trainings that lead towards a unified whole. Our social medicine department consists of psychologists, historians, philosophers, finance people, economics people, epidemiologists and anthropologists. We're a very eclectic crew. Being a family physician in that social medicine team is an interesting and novel thing. They brought me in and accepted me as part of the department, and I was very drawn to it because of my lived experience. Again, there were things outside of medicine that were pushing on health, and I found that behavioral health was necessary to family medicine success. Adverse childhood experiences are detrimental to people’s ability to heal themselves. If they are left untreated, healing isn’t possible. Similarly, I found that systemic racism is a barrier to self-healing. If we don’t address systemic racism, we are essentially plucking people out of a burning building, treating the burns and then sending them right back into the fire. You can’t do that and expect the sanctity of the unit to heal itself. If we're not going to become a part of the community and help heal the community then we're not osteopathic at all. We can’t ignore the pressures that are causing ongoing injury. So, we have to think about health differently. We’re not just teaching through this sense of, oh there's a problem, because I think education too often does that. We're giving students the skills to respond to the problem and asking them to figure out how they can partner with the community to try to build a bridge to heal. That's really the goal of the program, to help folks be able to support not just the body unit but the community unit, the medical education unit and the health system unit because those are all out of whack. Just like osteopathic medicine, the idea is to try to get back to homeostasis. We're not there yet, but I always say there's no shortage of work to do and we don't have to do everything individually. We just have to do something and when we all do something together it builds to that whole.

Q: When we spoke with Dr. Snyder, she referred to the TCC as her “immunity to burnout” because of the important work its students and residents do for the community. What have been the most inspiring community projects TCC students worked on this year?

Dr. Chrisman-Khawam: I just want to comment in general on immunity to burnout because I think it's an important concept for those who are listening. I’m sure many have experienced this passion to make things better and to heal and that's what brought them to medicine. The enormous moral injury caused by the revisions to medicine in the 80s and 90s that tried to decrease costs took away a lot of autonomy and control from physicians. That led to this incredible moral injury that is absolutely unsustainable, causing people to feel like they don't want to do this job anymore. So, as Dr. Snyder noted, we're teaching these young minds how to create projects based on their passions. Originally, our institutions wanted us to create our own projects and plug students into them, which is not the concept of the TCC, because that doesn't get to what burns inside of you, that thing that drives you to do good. Our students’ ideas are so much better than anything we could come up with because they come from their passion and their desire to give autonomy and control back to their patients. Part of what we teach our students is to be patient centered, which has led to these amazing projects.

For instance, we have a young woman in Akron, Ohio who noted that the rates of obesity and diabetes were dramatically higher in some of the counties where she practices than the rest of the state. She discovered there was a huge lack of healthy grocery stores in these areas. It was mostly a food desert. There were lots of fast-food restaurants and a few convenience stores, but no stores that sold regular, natural, whole food. So, she partnered with an imperfect produce maker, the Akron city food bank, the nutrition department at the hospital and Kent State University's education and media department, and the partnership developed into a very interesting economic driving force in Akron with a little coffee shop and a commercial kitchen where they bring people in to help them start businesses. This student also made videos to educate people on how to prepare the food and now she has a Caregiver Catalyst Grant to create disease-specific food boxes to accompany the videos that can be sent to those in need who receive Supplemental Nutrition Assistance Program benefits. She’s created this very complex, amazing project with multiple community partners that addresses the burning building. She's creating something sustainable, something that people can eventually buy at their local convenience store. I mean, what a brilliant idea! I would never in a million years have thought of this. It comes from her own ideas and passion, which is key when you talk about immunity to burnout.

Q: TCC is a truly innovative program that is part of the American Medical Association’s Accelerating Change in Medical Education initiative. Do you see this type of program potentially transforming medical education in the future? Why or why not?

Dr. Chrisman-Khawam: Absolutely. We need to do this kind of work throughout the country, and we need to realign the needs of the country to enhance public health. This need was very clearly demonstrated by the pandemic. There were not enough educators distributed equally and when you don't have a robust public health system and something like a pandemic happens, people are sucked into all these rabbit holes on the Internet for information rather than having experts on the ground who can provide answers and guidance. We absolutely need to change the health system and we need to alter medical education. I think we've become very obsessed with knowing everything because it's scary dealing with ambiguity and uncertainty, which humans are not hardwired for. We’re actually hardwired against this for our own safety and protection. The problem is that medical knowledge is doubling every 70 something odd days and soon it will be less than that, so it really isn't about knowing everything. We can't cram everything there is to know into a medical student. This is going to have to be the future of medical education because if medical education or medical knowledge is turning over every two months you can't possibly keep up with that. What you can keep up with is knowing how to deal with that information and then how to process and share that information. That's another burning building, because we can't possibly know it all when it comes to evidence-based medicine, and there needs to be this blanket of public health and primary care across the country for the health system to be successful. Until we make that decision we're not going to do better. It’s also a mistake to try to crush medical education into a smaller packet. We are not doing that. We're not crushing more medical school into less time. We’re transforming the way that students use information and I think that is the far more important skill. We need to give students tasks that help them fail and then correct those failures. These tasks can also help students demonstrate their competency. You know, I look at our students who have these projects up and running as interns, and I've never seen interns with projects like these ever in my 30 years of doing this. So now, suddenly, we have students who have $100,000 grants who are changing food deserts in their family medicine residencies in their first year. That's dramatic! The important thing now is to spread this concept.

Q: What have been some key lessons learned and what advice would you give to other UME and GME programs interested in pursuing a similar partnership?

Dr. Chrisman-Khawam: Find your friends. Another immunity booster is doing this work with people who are like-minded, who want to grow together and who want to build together. Doug Harley, DO, and Sandy Snyder, DO, are two people who have changed my life. Elliot Davidson, MD, and Carl Tyler, MD, these folks have put their heart and soul into this program. I so appreciate them allowing me to have an impact at their residency sites and that doesn't happen if you don't have friends. You really want to find where you are alike and sit down and have a meal together and discuss what things you can bring to each other's places. I think this is going to have a huge impact on these residencies. They've changed the way that they look at how to get better outcomes. The community has become integral. Community health and population health aren’t just being paid lip service. And it works for all of us—students, faculty and interprofessional team members—in terms of immunity to burnout. I would just say that there is a cost, so plan for the cost up front and know you're going to get a downstream benefit in terms of value to patients and a positive change to the healthcare system. One of the things we did not do well was that we're big ships moving in the ocean, and you know how big ships are, they don't turn very fast. Our learning management systems, our computers, the way we talk to each other, the firewalls, all of these seem like such simple things, but boy do they get in the way of good work. So, think about how your systems work and how you communicate and make sure you can integrate everything, just in terms of practical advice.

For more information about the TCC program, please read AACOM’s interview with Dr. Snyder published on June 10, 2021 or view this webinar presented on October 30, 2020 by Dr. Snyder, Dr. Chrisman-Khawam and Dr. Harley.