NEW CHALLENGES IN INTERNAL MEDICINE
0025-7125/92 $0.00
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GRADUATE EDUCATION IN THE MULTISPECIALTY GROUP Donald T. Erwin, MD
Like most other things, the nature of graduate medical education takes different forms depending on the local resources. A graduate education program in an institution with a large faculty and a small patient population will most likely stress "faculty involvement and experienced supervision," whereas a program with a large patient population and small faculty will stress "independent management" in their various brochures. Thanks to the Residency Review Committee's (RRC) requirements and vigilance, the fundamentals of most graduate education programs are similar. There probably are some differences in the ethos of programs depending on the nature of their birth. The medical school with a primary mission of education has accepted the responsibility to provide service in this process of education. And, in recent years, more and more medical schools have felt the need to provide funding through practice income and therefore have made faculty commitments to increasing patient care. Graduate education traditionally has had different reasons for being in the multispecialty clinic. Practitioners in the multispecialty clinics have learned that the best way to ensure high quality patient care is with a graduate education program. There are several reasons that this is so: 1. House staff provide comprehensive care directly. 2. House staff stimulate the staff to "keep up" and teach as well as learn. 3. Recruitment of high quality staff is greatly aided when there is an opportunity to participate in a first-rate training program. From the Department of Medicine, Ochsner Medical Institutions, New Orleans, Louisiana THE MEDICAL CLINICS OF NORTH AMERICA VOLUME 76· NUMBER 5· SEPTEMBER 1992
1021
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ERWIN
In many cases, because the development of graduate education programs in multispecialty clinics is the result of study and strategic direction, the blueprint to follow and an understanding of the resources involved are more clearly defined in the setting where education is undertaken by choice after faculty, staff, and patients are already established. This feeling of developing graduate education by choice and of underwriting part of its development creates a different attitude and decreased tolerance for "bureaucracy" or resistance to change simply based on an historical precedent that is embodied in the thinking, "That's the way we've always done it." If pressed to make generalizations about graduate education in a multispecialty setting, I would submit the following features for consideration as being the product of education in a multispecialty setting. PATIENT ORIENTATION
Education in the multispecialty center is patient centered as opposed to student centered. The patient's rights, desires, input, and response to their care are always very evident. This focus helps the institution maintain consistent supervision and provides continuing feedback from the patient. This has a definite direct benefit on focusing areas such as outcome of care, patient satisfaction, and meeting the patient's demand for high quality care. There are other, more subtle benefits since the patient in this setting is more apt to teach young physicians that medicine is interactive. The patient does not unquestionably accept bland explanations and is more likely to remind the young and older physician alike on a daily basis that patient/doctor communication represents interaction between adult equals. While many long for the "good old days when physicians weren't challenged," patients in a multispecialty clinic (regardless of payor status) recognize they are in an environment where questions are encouraged and patients are expected to assume responsibility for informed decisions to be made about their care. PATIENT CARE
High quality care is a "must." Many of the multispecialty institutions expend significant resources in order to participate in graduate education. Unlike medical schools where teaching is expected and the time usually is negotiated, the physicians in a multispecialty clinic recognize in advance that they must pay to teach. This payment takes the direct form of underwriting part of the graduate education costs as well as an indirect form with loss of income opportunity. Time out of practice to teach, make rounds, do clinical research projects, and so forth, impacts not only the individual but the entire group income. Physicians in multispecialty groups accept this as part of the overall
GRADUATE EDUCATION IN THE MULTISPECIALTY GROUP
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cost of graduate education if they choose to develop education programs. These costs can be quite significant-in our case, attending rounds, clinic supervision, and consultation rounds cost the Ochsner Clinic 6 to 7 million dollars in the years 1977 through 1990 for activities at one state hospital where we have provided the housestaff and part of the teaching faculty. Moreover, this is only but one of several hospitals where we have attending responsibility. By and large, medical schools would negotiate for the hospital to reimburse faculty time as well as housestaff. The physician in practice or the multispecialty clinic practitioners rarely can do so. Even though Medicare reimbursement pays the hospitals for residents' salaries, there are still significant costs to the multispecialty group that must come from practice revenues, philanthropy, or nonprofit foundation support. In order to provide the revenue to underwrite education (and research), the multispecialty clinic must be successful in recruiting and maintaining its patient base. This is only accomplished by the patients' belief that they receive the highest quality care available. While this usually involves a degree of high technology, it also involves the type of professional communication that leaves the patient understanding and satisfied with his or her care, along with efficient business systems for promotion, patient access, reimbursement, and socioeconomic support. In a real sense then, multispecialty clinics must guarantee their own survival and success by developing a trusted reputation and a loyal following. In today's highly competitive medical environment, purchasers of health care have developed yardsticks to separate window dressing from bonafide high quality. Clearly, the multispecialty clinic must "do well" in order to "do good." HEALTH CARE ADAPTABILITY
The multispecialty clinic probably adapts quicker to forces directing change. These forces are familiar to us all but include societal concerns about health care cost, access, and results. Each and all of these factors require fundamental change in the manner of medical practice and, therefore, affect what is taught. New models of health care delivery (HMO, PPO, and managed care of various sorts), therefore, may be easier to develop in a setting where the decision-making process is usually more streamlined and allows flexibility to change. Without sizable endowments, the multispecialty clinic must be more sensitive to major changes in medicine brought on by these societal pressures; failure to do so may have serious financial consequences. In this regard, many of the directives of the RRC regarding ambulatory care may be better accomplished in the multispecialty clinic. The multispecialty clinic usually has ample outpatient space because it must provide prompt access to physicians. Additionally, the multispecialty faculty likely has direct experience with the practice of ambulatory medicine and usually includes a large physician staff whose major
1024
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interest is the practice of medicine rather than research or administrative duties. Similarly, continuity of care is likely to be a hallmark of multispecialty clinic care as the systems to provide it usually are in place. CURRENT MODES OF PRACTICE
Practice in the multispecialty clinic may more closely represent what the practice of medicine is on a day-to-day basis. Many authors have commented on the change in nature of the medical school internal medicine clerkship to the point that it is characterized as having a patient population of the chronically ill, critically ill, and those hospitalized for procedures. If this experience is coupled with an ambulatory experience that is poorly organized, poorly managed, or poorly equipped, then there seems little to draw students into the broad field of internal medicine. The multispecialty clinic may offer a more enticing picture. We believe that we should aggressively seek to recruit medical students for electives. It is our hope that our institution can offer satisfying rotations where thoughtful and efficient care are rendered in a patient-centered system. We hope to provide emphasis on how judgments are made rather than just the most recent technology. We further strive to provide an ambulatory experience that is well organized, efficient, user friendly and where the house officer and student alike are able to develop personal relationships with their patients and teaching colleagues. In this setting, we hope the house officer develops a view of the internist as a personal physician able to provide advanced health care for complex problems by leading the patient management team. Many of the multispecialty clinics have this type of internist in abundant supply to function as preceptors and role models. We believe this is more likely the role of the future internist, and we think that conveying the excitement and gratification of the practice of internal medicine is more likely done by individuals who remain genuinely excited and gratified about their own practice. It seems that it is the nature of multispecialty groups to allow physician differentiation on the one hand and empowerment of the primary care physician as the patient management leader on the other. We therefore believe that this form of training contributes diversity, realism, and richness to the overall clinical and learning experience of the medical resident and medical student. Address reprint requests to Donald T. Erwin, MD Department of Medicine Ochsner Medical Institutions 1514 Jefferson Highway New Orleans, LA 70121
0025-7125/92 $0.00
+ .20
GRADUATE EDUCATION IN THE MULTISPECIALTY GROUP Donald T. Erwin, MD
Like most other things, the nature of graduate medical education takes different forms depending on the local resources. A graduate education program in an institution with a large faculty and a small patient population will most likely stress "faculty involvement and experienced supervision," whereas a program with a large patient population and small faculty will stress "independent management" in their various brochures. Thanks to the Residency Review Committee's (RRC) requirements and vigilance, the fundamentals of most graduate education programs are similar. There probably are some differences in the ethos of programs depending on the nature of their birth. The medical school with a primary mission of education has accepted the responsibility to provide service in this process of education. And, in recent years, more and more medical schools have felt the need to provide funding through practice income and therefore have made faculty commitments to increasing patient care. Graduate education traditionally has had different reasons for being in the multispecialty clinic. Practitioners in the multispecialty clinics have learned that the best way to ensure high quality patient care is with a graduate education program. There are several reasons that this is so: 1. House staff provide comprehensive care directly. 2. House staff stimulate the staff to "keep up" and teach as well as learn. 3. Recruitment of high quality staff is greatly aided when there is an opportunity to participate in a first-rate training program. From the Department of Medicine, Ochsner Medical Institutions, New Orleans, Louisiana THE MEDICAL CLINICS OF NORTH AMERICA VOLUME 76· NUMBER 5· SEPTEMBER 1992
1021
1022
ERWIN
In many cases, because the development of graduate education programs in multispecialty clinics is the result of study and strategic direction, the blueprint to follow and an understanding of the resources involved are more clearly defined in the setting where education is undertaken by choice after faculty, staff, and patients are already established. This feeling of developing graduate education by choice and of underwriting part of its development creates a different attitude and decreased tolerance for "bureaucracy" or resistance to change simply based on an historical precedent that is embodied in the thinking, "That's the way we've always done it." If pressed to make generalizations about graduate education in a multispecialty setting, I would submit the following features for consideration as being the product of education in a multispecialty setting. PATIENT ORIENTATION
Education in the multispecialty center is patient centered as opposed to student centered. The patient's rights, desires, input, and response to their care are always very evident. This focus helps the institution maintain consistent supervision and provides continuing feedback from the patient. This has a definite direct benefit on focusing areas such as outcome of care, patient satisfaction, and meeting the patient's demand for high quality care. There are other, more subtle benefits since the patient in this setting is more apt to teach young physicians that medicine is interactive. The patient does not unquestionably accept bland explanations and is more likely to remind the young and older physician alike on a daily basis that patient/doctor communication represents interaction between adult equals. While many long for the "good old days when physicians weren't challenged," patients in a multispecialty clinic (regardless of payor status) recognize they are in an environment where questions are encouraged and patients are expected to assume responsibility for informed decisions to be made about their care. PATIENT CARE
High quality care is a "must." Many of the multispecialty institutions expend significant resources in order to participate in graduate education. Unlike medical schools where teaching is expected and the time usually is negotiated, the physicians in a multispecialty clinic recognize in advance that they must pay to teach. This payment takes the direct form of underwriting part of the graduate education costs as well as an indirect form with loss of income opportunity. Time out of practice to teach, make rounds, do clinical research projects, and so forth, impacts not only the individual but the entire group income. Physicians in multispecialty groups accept this as part of the overall
GRADUATE EDUCATION IN THE MULTISPECIALTY GROUP
1023
cost of graduate education if they choose to develop education programs. These costs can be quite significant-in our case, attending rounds, clinic supervision, and consultation rounds cost the Ochsner Clinic 6 to 7 million dollars in the years 1977 through 1990 for activities at one state hospital where we have provided the housestaff and part of the teaching faculty. Moreover, this is only but one of several hospitals where we have attending responsibility. By and large, medical schools would negotiate for the hospital to reimburse faculty time as well as housestaff. The physician in practice or the multispecialty clinic practitioners rarely can do so. Even though Medicare reimbursement pays the hospitals for residents' salaries, there are still significant costs to the multispecialty group that must come from practice revenues, philanthropy, or nonprofit foundation support. In order to provide the revenue to underwrite education (and research), the multispecialty clinic must be successful in recruiting and maintaining its patient base. This is only accomplished by the patients' belief that they receive the highest quality care available. While this usually involves a degree of high technology, it also involves the type of professional communication that leaves the patient understanding and satisfied with his or her care, along with efficient business systems for promotion, patient access, reimbursement, and socioeconomic support. In a real sense then, multispecialty clinics must guarantee their own survival and success by developing a trusted reputation and a loyal following. In today's highly competitive medical environment, purchasers of health care have developed yardsticks to separate window dressing from bonafide high quality. Clearly, the multispecialty clinic must "do well" in order to "do good." HEALTH CARE ADAPTABILITY
The multispecialty clinic probably adapts quicker to forces directing change. These forces are familiar to us all but include societal concerns about health care cost, access, and results. Each and all of these factors require fundamental change in the manner of medical practice and, therefore, affect what is taught. New models of health care delivery (HMO, PPO, and managed care of various sorts), therefore, may be easier to develop in a setting where the decision-making process is usually more streamlined and allows flexibility to change. Without sizable endowments, the multispecialty clinic must be more sensitive to major changes in medicine brought on by these societal pressures; failure to do so may have serious financial consequences. In this regard, many of the directives of the RRC regarding ambulatory care may be better accomplished in the multispecialty clinic. The multispecialty clinic usually has ample outpatient space because it must provide prompt access to physicians. Additionally, the multispecialty faculty likely has direct experience with the practice of ambulatory medicine and usually includes a large physician staff whose major
1024
ERWIN
interest is the practice of medicine rather than research or administrative duties. Similarly, continuity of care is likely to be a hallmark of multispecialty clinic care as the systems to provide it usually are in place. CURRENT MODES OF PRACTICE
Practice in the multispecialty clinic may more closely represent what the practice of medicine is on a day-to-day basis. Many authors have commented on the change in nature of the medical school internal medicine clerkship to the point that it is characterized as having a patient population of the chronically ill, critically ill, and those hospitalized for procedures. If this experience is coupled with an ambulatory experience that is poorly organized, poorly managed, or poorly equipped, then there seems little to draw students into the broad field of internal medicine. The multispecialty clinic may offer a more enticing picture. We believe that we should aggressively seek to recruit medical students for electives. It is our hope that our institution can offer satisfying rotations where thoughtful and efficient care are rendered in a patient-centered system. We hope to provide emphasis on how judgments are made rather than just the most recent technology. We further strive to provide an ambulatory experience that is well organized, efficient, user friendly and where the house officer and student alike are able to develop personal relationships with their patients and teaching colleagues. In this setting, we hope the house officer develops a view of the internist as a personal physician able to provide advanced health care for complex problems by leading the patient management team. Many of the multispecialty clinics have this type of internist in abundant supply to function as preceptors and role models. We believe this is more likely the role of the future internist, and we think that conveying the excitement and gratification of the practice of internal medicine is more likely done by individuals who remain genuinely excited and gratified about their own practice. It seems that it is the nature of multispecialty groups to allow physician differentiation on the one hand and empowerment of the primary care physician as the patient management leader on the other. We therefore believe that this form of training contributes diversity, realism, and richness to the overall clinical and learning experience of the medical resident and medical student. Address reprint requests to Donald T. Erwin, MD Department of Medicine Ochsner Medical Institutions 1514 Jefferson Highway New Orleans, LA 70121
