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
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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?