Opinion
VIEWPOINT
Donald M. Berwick, MD, MPP Institute for Healthcare Improvement, Cambridge, Massachusetts.
Corresponding Author: Donald M. Berwick, MD, MPP, President Emeritus and Senior Fellow, Institute for Healthcare Improvement, 20 University Rd, 7th Floor, Cambridge, MA 02138 (donberwick @gmail.com).
Postgraduate Education of Physicians Professional Self-regulation and External Accountability have little or no accountability to the public at large for how they spend those funds. The recent Institute of Medicine report on the financing and governance of graduate medical education (GME) (from a committee that I cochaired) called for an entirely new level of accountability, with goals for GME more directly aligned with the workforce needs of a new health care system.3 Much of the educational community greeted this report with alarm, concerned that the proposed “accountability” was code for “bureaucracy” and an entryway into damaging reduction in funding. A struggle exists between the romance of professional self-regulation, on the one hand, and duty, on the other hand, of professionals in all their roles, including professional educators, to keep track of and respond to information on what society thinks of and wants from their work. A temperate view will honor both sides of that struggle. After all, who would not want a physician to have a profound sense of personal duty and individual commitment to patients? And, after all, who would not want professionals overseeing one-seventh of the US economy to ask continually how well they are meeting society’s needs? From that viewpoint, it is crucial to ask what “society’s needs” are from health professional education today. One important need is for educators to help build a new system of delivery of care, with properties not emphasized enough in most traditional postgraduate medical eduNeither patients nor physicians are well cation. The new care—“Triple Aim” care—will produce better outcomes for served on a battleground between people in care, better health for popuprofessional self-regulation and lations, and lower per capita costs. 4 Here are a few examples of its properexternal accountability. ties: the steady replacement of visits, reached a multibillion–dollar size and shows no hint admissions, and face-to-face encounters with other of abatement. Physician morale, according to some, is forms of help and interaction (such as telemedicine at unprecedented low levels, in part as the romantic and telephone care) when these are superior; the shift image of a physician’s self-reliance and accountability of agendas from professionally controlled priorities to to self has wilted under the hot glare of regulatory shared decision making and “what matters to the patient” medicine5; the extensive use of personalized surveillance.2 The education of physicians has been strangely ex- medicine and evidence-based care at the individual empt from this trend. Professional societies and their for- level; extraordinarily high priority for team-based care mal commissions and boards have retained strong con- and coordinated services; explicit and unapologetic trol over determining the criteria necessary to become stewardship of resources, without rationing but also and remain a physician and certifying who has made the without waste; and crystal-clear expectations about grade. The funding of postgraduate medical training— the unacceptability of disruptive and disrespectful residencies and fellowships—remains largely a nearly behaviors. Today, in this new era of person-centered, teamunchanged flow of what now amounts to more than $13 billion per year of Medicare and Medicaid funds into based innovative care, graduate medical education the coffers of teaching hospitals, whose administrators should inculcate in physicians personal responsibility,
For most physicians, training inculcates a professional identity in which self-reliance and accountability to self are bedrock. “This is your patient,” is the message, “and you are responsible for your patient. Period!” Those words connect to the very definition of profession as articulated in 1970 by Freidson: “A profession is a work group that retains to itself the right to judge the quality of its own work.”1 Society cedes that right to the profession on the basis of 3 assumptions: (1) that the profession commits to putting the interests of those it serves before its own interests; (2) that the profession has technical knowledge and capacity not accessible to laypeople; and (3) that the profession will regulate itself. Actually, Freidson had some doubts about the social contract, at one point suggesting, “So far as terms of work go, professions differ from trade unions only in their sanctimoniousness.”1(p367) Numerous trends suggest that much of the public today shares those doubts, at least as the policies of their officials reflects the public’s will. The history of health care regulation over the past 30 years is a steady march toward external accountability, transparent measurement, and incentive-based payment more associated with piecework and employment than with self-regulation. The price has been high. The health care measurement industry alone has
jama.com
(Reprinted) JAMA May 12, 2015 Volume 313, Number 18
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a New York University User on 05/17/2015
1803
Opinion Viewpoint
of course. But it should convey this message too: “Remember, you are part of a noble enterprise much bigger than yourself, and among the most important questions you can ask yourself every single day is not, ‘What do I do?’ but rather, ‘What am I part of?’” To be sure, the self-regulating physician preparation systems have a legacy to be proud of. Highly credible bodies oversee the inspection, certification, and monitoring of educational programs of all medical schools and residency programs, most specialized fellowships, and much of continuing medical education (CME). But staid, respected, and formal systems with long histories may lack, or resist, dynamism in pursuit of needed changes. Physicians for the future need to be different in important ways from physicians of the past. How can regulation and certification best accelerate toward that end, without the slightest compromise in the diligence of oversight or physicians’ pride and sense of responsibility? Some answers may lie in reorganizing the oversight of physician education. The design principles for governance and conduct of that oversight should parallel the design principles that ought to guide much of health care delivery reform, such as integration, strengthened patient voice, teamwork, cost reduction, and modern forms of simplification in work streams.6,7 The unprecedented cooperation that the future of health care needs might become more likely if the standards and oversight of physician education in the United States were brought under the aegis of a single governing body, from undergraduate requirements through CME. That model deserves thorough consideration now, making certain to preserve latitude and energy for innovation and experimentation, such as being led recently (as the “Next Accreditation System”) by the Accreditation Council for Graduate Medical Education. Existing oversight bodies for the various phases of physician training and retraining would become subsidiary structures under this single oversight body. Educational goals for physician preparation should be aligned with the systemic needs for better care, better health, and lower cost through improvement. In addition, it is high time to revise premedical course requirements in light of these new educational goals. ARTICLE INFORMATION Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Berwick reports that he has served as the cochair of the Institute of Medicine Committee on the Governance and Financing of Graduate Medical Education, whose report is cited in the manuscript.
1804
“Person-centered care” will be a hallmark of the new delivery system, with stronger patient voice throughout. So it should be for physician training. All governing bodies for the oversight of physician preparation at all stages should include lay members and patient representatives on their boards of directors. Teamwork in care is more essential now than ever before. Physicians-in-training should participate in coordinated programming with nursing and other professions, especially around processes for safety and coordinated care of chronic illness. Curricula should include specific instruction and practice in what makes effective teams, the properties of high-reliability organizations, designs for proper handoffs of information and responsibility, conflict resolution, and human factors in design. Fragmentation and needless variation add cost and risk to care. Simplifying care processes often helps. Similarly, physician licensure and relicensure in the United States should be simplified; it should be national, not state by state, although state-based oversight of physician misbehavior and malpractice continues to make sense. Neither patients nor physicians are well served on a battleground between professional self-regulation and external accountability. Better for both is alignment between the norms the insiders cherish and the needs of the population for new, better, and more affordable care. Restructuring the oversight of education can help, if, like health care, it becomes more integrated, cooperative, and holistic in its mission and design. These proposed changes are tough hills for the current power structure to climb. Each of the separate bodies now guarding its piece of care, with its own jurisdiction and history, may well believe that only it can effectively discharge its local responsibilities. They may believe, as it were, “This is my part of professional development, and I am responsible for it. Period!” However, that principle now serves physician education no better than it now serves patients. From a struggle for local control, health care needs to emerge into an era of wholeness—shared and respectful stewardship. So does the system that prepares physicians for that future.
2. Berwick DM. The epitaph of profession. Br J Gen Pract. 2009;59(559):128-131. 3. Committee on the Governance and Financing of Graduate Medical Education, Board on Health Care Services, Institute of Medicine. Graduate Medical Education That Meets the Nation’s Health Needs. Washington, DC: National Academies Press; 2015.
REFERENCES
4. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759-769.
1. Freidson E. Profession of Medicine: A Study of the Sociology of Applied Knowledge. Chicago, IL: University of Chicago Press; 1970.
5. Bisognano M. Foreword. In: Barnsteiner J, Disch J, Walton MK. Person and Family Centered Care. Indianapolis, IN: Sigma Theta Tau International; 2014.
6. Kenney C. Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience. Boca Raton, FL: CRC Press; 2011. 7. Gabow PA, Goodman PL. The Lean Prescription: Powerful Medicine for Our Ailing Healthcare System. Boca Raton, FL: CRC Press; 2015.
JAMA May 12, 2015 Volume 313, Number 18 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a New York University User on 05/17/2015
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VIEWPOINT
Donald M. Berwick, MD, MPP Institute for Healthcare Improvement, Cambridge, Massachusetts.
Corresponding Author: Donald M. Berwick, MD, MPP, President Emeritus and Senior Fellow, Institute for Healthcare Improvement, 20 University Rd, 7th Floor, Cambridge, MA 02138 (donberwick @gmail.com).
Postgraduate Education of Physicians Professional Self-regulation and External Accountability have little or no accountability to the public at large for how they spend those funds. The recent Institute of Medicine report on the financing and governance of graduate medical education (GME) (from a committee that I cochaired) called for an entirely new level of accountability, with goals for GME more directly aligned with the workforce needs of a new health care system.3 Much of the educational community greeted this report with alarm, concerned that the proposed “accountability” was code for “bureaucracy” and an entryway into damaging reduction in funding. A struggle exists between the romance of professional self-regulation, on the one hand, and duty, on the other hand, of professionals in all their roles, including professional educators, to keep track of and respond to information on what society thinks of and wants from their work. A temperate view will honor both sides of that struggle. After all, who would not want a physician to have a profound sense of personal duty and individual commitment to patients? And, after all, who would not want professionals overseeing one-seventh of the US economy to ask continually how well they are meeting society’s needs? From that viewpoint, it is crucial to ask what “society’s needs” are from health professional education today. One important need is for educators to help build a new system of delivery of care, with properties not emphasized enough in most traditional postgraduate medical eduNeither patients nor physicians are well cation. The new care—“Triple Aim” care—will produce better outcomes for served on a battleground between people in care, better health for popuprofessional self-regulation and lations, and lower per capita costs. 4 Here are a few examples of its properexternal accountability. ties: the steady replacement of visits, reached a multibillion–dollar size and shows no hint admissions, and face-to-face encounters with other of abatement. Physician morale, according to some, is forms of help and interaction (such as telemedicine at unprecedented low levels, in part as the romantic and telephone care) when these are superior; the shift image of a physician’s self-reliance and accountability of agendas from professionally controlled priorities to to self has wilted under the hot glare of regulatory shared decision making and “what matters to the patient” medicine5; the extensive use of personalized surveillance.2 The education of physicians has been strangely ex- medicine and evidence-based care at the individual empt from this trend. Professional societies and their for- level; extraordinarily high priority for team-based care mal commissions and boards have retained strong con- and coordinated services; explicit and unapologetic trol over determining the criteria necessary to become stewardship of resources, without rationing but also and remain a physician and certifying who has made the without waste; and crystal-clear expectations about grade. The funding of postgraduate medical training— the unacceptability of disruptive and disrespectful residencies and fellowships—remains largely a nearly behaviors. Today, in this new era of person-centered, teamunchanged flow of what now amounts to more than $13 billion per year of Medicare and Medicaid funds into based innovative care, graduate medical education the coffers of teaching hospitals, whose administrators should inculcate in physicians personal responsibility,
For most physicians, training inculcates a professional identity in which self-reliance and accountability to self are bedrock. “This is your patient,” is the message, “and you are responsible for your patient. Period!” Those words connect to the very definition of profession as articulated in 1970 by Freidson: “A profession is a work group that retains to itself the right to judge the quality of its own work.”1 Society cedes that right to the profession on the basis of 3 assumptions: (1) that the profession commits to putting the interests of those it serves before its own interests; (2) that the profession has technical knowledge and capacity not accessible to laypeople; and (3) that the profession will regulate itself. Actually, Freidson had some doubts about the social contract, at one point suggesting, “So far as terms of work go, professions differ from trade unions only in their sanctimoniousness.”1(p367) Numerous trends suggest that much of the public today shares those doubts, at least as the policies of their officials reflects the public’s will. The history of health care regulation over the past 30 years is a steady march toward external accountability, transparent measurement, and incentive-based payment more associated with piecework and employment than with self-regulation. The price has been high. The health care measurement industry alone has
jama.com
(Reprinted) JAMA May 12, 2015 Volume 313, Number 18
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a New York University User on 05/17/2015
1803
Opinion Viewpoint
of course. But it should convey this message too: “Remember, you are part of a noble enterprise much bigger than yourself, and among the most important questions you can ask yourself every single day is not, ‘What do I do?’ but rather, ‘What am I part of?’” To be sure, the self-regulating physician preparation systems have a legacy to be proud of. Highly credible bodies oversee the inspection, certification, and monitoring of educational programs of all medical schools and residency programs, most specialized fellowships, and much of continuing medical education (CME). But staid, respected, and formal systems with long histories may lack, or resist, dynamism in pursuit of needed changes. Physicians for the future need to be different in important ways from physicians of the past. How can regulation and certification best accelerate toward that end, without the slightest compromise in the diligence of oversight or physicians’ pride and sense of responsibility? Some answers may lie in reorganizing the oversight of physician education. The design principles for governance and conduct of that oversight should parallel the design principles that ought to guide much of health care delivery reform, such as integration, strengthened patient voice, teamwork, cost reduction, and modern forms of simplification in work streams.6,7 The unprecedented cooperation that the future of health care needs might become more likely if the standards and oversight of physician education in the United States were brought under the aegis of a single governing body, from undergraduate requirements through CME. That model deserves thorough consideration now, making certain to preserve latitude and energy for innovation and experimentation, such as being led recently (as the “Next Accreditation System”) by the Accreditation Council for Graduate Medical Education. Existing oversight bodies for the various phases of physician training and retraining would become subsidiary structures under this single oversight body. Educational goals for physician preparation should be aligned with the systemic needs for better care, better health, and lower cost through improvement. In addition, it is high time to revise premedical course requirements in light of these new educational goals. ARTICLE INFORMATION Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Berwick reports that he has served as the cochair of the Institute of Medicine Committee on the Governance and Financing of Graduate Medical Education, whose report is cited in the manuscript.
1804
“Person-centered care” will be a hallmark of the new delivery system, with stronger patient voice throughout. So it should be for physician training. All governing bodies for the oversight of physician preparation at all stages should include lay members and patient representatives on their boards of directors. Teamwork in care is more essential now than ever before. Physicians-in-training should participate in coordinated programming with nursing and other professions, especially around processes for safety and coordinated care of chronic illness. Curricula should include specific instruction and practice in what makes effective teams, the properties of high-reliability organizations, designs for proper handoffs of information and responsibility, conflict resolution, and human factors in design. Fragmentation and needless variation add cost and risk to care. Simplifying care processes often helps. Similarly, physician licensure and relicensure in the United States should be simplified; it should be national, not state by state, although state-based oversight of physician misbehavior and malpractice continues to make sense. Neither patients nor physicians are well served on a battleground between professional self-regulation and external accountability. Better for both is alignment between the norms the insiders cherish and the needs of the population for new, better, and more affordable care. Restructuring the oversight of education can help, if, like health care, it becomes more integrated, cooperative, and holistic in its mission and design. These proposed changes are tough hills for the current power structure to climb. Each of the separate bodies now guarding its piece of care, with its own jurisdiction and history, may well believe that only it can effectively discharge its local responsibilities. They may believe, as it were, “This is my part of professional development, and I am responsible for it. Period!” However, that principle now serves physician education no better than it now serves patients. From a struggle for local control, health care needs to emerge into an era of wholeness—shared and respectful stewardship. So does the system that prepares physicians for that future.
2. Berwick DM. The epitaph of profession. Br J Gen Pract. 2009;59(559):128-131. 3. Committee on the Governance and Financing of Graduate Medical Education, Board on Health Care Services, Institute of Medicine. Graduate Medical Education That Meets the Nation’s Health Needs. Washington, DC: National Academies Press; 2015.
REFERENCES
4. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759-769.
1. Freidson E. Profession of Medicine: A Study of the Sociology of Applied Knowledge. Chicago, IL: University of Chicago Press; 1970.
5. Bisognano M. Foreword. In: Barnsteiner J, Disch J, Walton MK. Person and Family Centered Care. Indianapolis, IN: Sigma Theta Tau International; 2014.
6. Kenney C. Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience. Boca Raton, FL: CRC Press; 2011. 7. Gabow PA, Goodman PL. The Lean Prescription: Powerful Medicine for Our Ailing Healthcare System. Boca Raton, FL: CRC Press; 2015.
JAMA May 12, 2015 Volume 313, Number 18 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a New York University User on 05/17/2015
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