The cost of medical education in an ambulatory neurology clinic

Decreased revenue from clinical services has required academic hospitals and physicians to improve productivity. Medical student education may be a significant hindrance to increased productivity and income. This study quantifies the amount of time spent by faculty members teaching medical students in an ambulatory neurology clinic as well as the amount of time students occupied rooms when seeing patients on their own. Over a three-week period in an ambulatory neurology clinic, an observer noted these quantities of time, and the opportunity costs of both amounts of time were determined. Attending physicians spent an average of 19.6 minutes per medical student per half-day teaching, which translates to an average cost of $20.78 per half-day clinic. Students spent an average of 49.9 minutes per half-day seeing patients in the absence of an attending physician, an opportunity cost to the clinic of $142.50 per student per half-day.     

Teaching clinical medicine in the ambulatory setting. An idea whose time may have finally come

A resurgence of general interest in teaching clinical medicine in ambulatory-care settings has occurred for several reasons, including changes in the case mix in teaching hospitals, the new responsibilities of house officers and attending physicians brought about by the current payment systems for health care, the increased expectations of patients that medical care will be "personal," the progressive limitations imposed on the education of medical students by the shorter lengths of stay sought by hospitals under the diagnosis-related-groups system of payment, and the growing need for well-trained primary care physicians that has resulted from the increase in medical care organizations. In this paper, I review earlier attempts to emphasize ambulatory care, to identify the pitfalls that new efforts in this direction should avoid. I also compare inpatient and ambulatory-care teaching to provide a basis for understanding the educational goals that can be achieved more easily in each setting. In addition, I suggest major changes in the flow and use of clinical-practice funds and hospital payments so that they can become possible sources of the financing and organization of an expanded effort to teach clinical medicine in ambulatory-care settings.     

Rediscovering the medical school.

Medical schools, once devoted primarily to educating medical students, have evolved into complex academic medical centers (AMCs), some of which place a greater emphasis on research and the clinical business than on educating future physicians. This occurred primarily as the result of outside forces, specifically the available revenue streams that have fostered growth. Discipline-based departments have been at the center of the governance structure of medical schools, but many AMCs now have research institutes and centers to enhance research productivity, and faculty group practices to maximize clinical revenue. Although AMCs have been successful in making scientific discoveries, developing new technologies, and providing state-of-the-art clinical care, their successes have not always been favorable to the education mission. Furthermore, the roles of departments and their chairs have not always been carefully considered; a mismatch between organizational and governance structures is occurring. In this article several suggestions are offered to help medical schools rediscover their unique reason for existence and better distinguish core missions from core businesses. Mission-based management and mission-based budgeting provide the framework for maximum success of all the missions. Specific suggestions include (1) organizing a national task force to consider optimal organizational and governance structures of modern AMCs, (2) establishing a core teaching faculty, (3) creating a matrix letter of assignment that aligns salary rates with assigned activities, (4) linking education to the provision of health care to the underinsured, and (5) forming education centers to effectively centralize governance of the education mission.     

Financing graduate medical education.

The direct costs of residency training in the United States are over $1 billion per year. These educational programs have been organized predominantly around hospital services and supported by hospital revenues. Pressure has been increasing to reduce the rate of increase in hospital expenditures or costs or both. This article describes alternative methods for financing graduate medical education. Debate over the current sources of financing reveals several troublesome issues: the presence of residents allegedly decreases the productivity of professionals and leads to overusage of ancillary services, proposed methods to pay for faculty salaries and services have created confusion and concern, and the financing of ambulatory-care training has been insufficient and poorly coordinated. The medical-education community must resolve these professional and educational problems so that financing issues can be debated and properly defended.     

An assessment of the clinical skills of fourth-year students at four New England medical schools

This paper describes a collaborative effort among five New England medical schools to assess important clinical skills of fourth-year medical students graduating in the class of 1988; results are presented from the four schools that provided sufficient data. Faculty from each school developed 36 patient cases representing a variety of common ambulatory-care problems. Over the course of a day, each student, on average, interacted with 16 different standardized patients, who were nonphysicians trained to accurately and consistently portray a patient in a simulated clinical setting. The students obtained focused histories, performed relevant physical examinations, and provided the patients with education and counseling. At each school, the performance of a small number of the students fell below standards set by the faculty. These deficiencies were not detected with the evaluation strategies currently being used. Although the use of standardized patients should not substitute for the process of faculty observing students as they interact with real patients, it appears that standardized patients can provide faculty with important information, not readily available from other sources, about students' performances of essential clinical activities and the levels of their clinical skills.     

Overcoming a perfect storm: an academic cardiology section's story of survival.

Increasingly, academic institutions are grappling with financial pressures that threaten the academic mission. The author presents an actual case history in which a section of cardiology in an academic health center was confronted with huge projected deficits that had to be eliminated within the fiscal year. The section used eight principles to shift from deficit to profitability (i.e., having revenue exceed costs). These principles included confronting the brutal facts, managing costs and revenue cycles, setting expectations for faculty, and quality improvement. The section accomplished deficit reduction through reducing faculty salaries (nearly $2 million) and nonfaculty salaries ($1.3 million) and reducing operational costs while maintaining revenues by increasing individual faculty productivity and reducing accounts receivable. In the face of these reductions, clinical revenues were maintained, but research revenue and productivity fell (but research is being fostered now that clinical services are profitable again). These principles can be used to stabilize the financial position of clinical practices in academic settings that are facing financial challenges.     

Community preceptors' views of their identities as teachers.

PURPOSE: Community physicians are increasingly being recruited to teach medical students and residents, yet there has been little research about how they think of themselves as teachers or what factors contribute to "teacher identity." Physicians who think of themselves as teachers may be more likely to enjoy teaching, to teach more, and to be recognized by students and other faculty as good teachers. Identifying factors that enhance teacher identity may be helpful for the recruitment and retention of high-quality community faculty. METHOD: Thirty-five experienced community preceptors were audiotaped in five structured focus groups in April 2001, answering a series of questions about their teacher identity. Responses were qualitatively analyzed for evidence of themes. RESULTS: "Feeling intrinsic satisfaction" was the most common theme that emerged from the tapes. Preceptors also identified that "having knowledge and skill about teaching" and "belonging to a group of teacher" enhanced their roles as teachers. "Being a physician means being a teacher," "feeling a responsibility to teach medicine," and "sharing clinical expertise" also emerged as important themes. Although a group of participants were interested in "receiving rewards for teaching," rewards did not need to be financial compensation. For some, genuine recognition for their efforts by the medical school, particularly in the form of faculty development opportunities, constituted reward and recognition for teaching. CONCLUSIONS: Community physicians described a variety of factors that contribute to their identity as teachers. Faculty development programs offer opportunities to strengthen teacher identity and foster relationships between teaching programs and community-based faculty.     

The educational value of community preceptorships in surgery

Increasing class size provided the impetus to send students on the core surgery course at the Medical University of South Carolina College of Medicine into the community hospitals with members of the clinical faculty. Each student was assigned to a surgeon and accompanied this preceptor on rounds, in the operating room, and in the office. To determine whether the students' learning was affected by being outside the university, the authors looked at the experience from 1977 to 1986 with 683 surgery students who took community preceptorships and 696 surgery students who took only university-based rotations. The two groups were compared in regard to age, sex, basic science grade-point average, class rank at the end of the first two years in medical school, ward evaluations, grades on departmental final examinations, and National Board of Medical Examiners "mini-examination" scores and Part II surgery scores. No differences were found. Choices of specialty for the first postgraduate year and evaluations of program directors were reviewed for 1982, 1985, and 1986, and were similar for all three years. The preceptorship program has been popular with students, who stated that they valued the one-to-one relationship with surgeons who liked to teach. The program has relieved pressure on the university hospital system and provided a good learning experience for students.     

The procedural skills of medical students: expectations and experiences

The procedural skills that medical students should learn were identified by a survey of faculty and residents at the University of North Carolina at Chapel Hill School of Medicine in 1985. Those who responded indicated that it was important for students to have exposure to all 52 procedures listed on the questionnaire. Only a small number of procedures were identified by 75% or more of those who responded as being important for students to perform with proficiency (11 procedures identified by the faculty, nine by the residents). On another questionnaire, the graduating medical students indicated that, for the most part, they had experience performing these important procedures. To ensure clinical competency, expectations regarding these skills should be communicated to students, faculty, and residents and, ideally, a system should be established to assess these skills.     

What we say and what we do: self-reported teaching behavior versus performances in written simulations among medical school faculty.

Much of the research in medical education is performed through the use of self-reporting questionnaires. Although this can be a valid way to conduct research, little effort has been made to examine the fit between what teachers self-report and what they actually do. In an attempt to investigate this, the authors interviewed 47 preclinical faculty members at two large medical schools in 1990. The faculty members were initially given a questionnaire asking them to self-report in four categories: interactive skills; knowledge or abilities they considered important for students to develop; factors that influenced their curriculum development; and sources from which they sought pedagogical assistance. This was followed by four written simulations that examined four areas of teaching: small-group discussions, course design, lecturing, and test construction. In addition, the authors specifically sought to identify any differences in teaching philosophy and practice between those preclinical faculty who were physicians and those who were not, as well as any interinstitutional differences. Although in certain instances there was a strong correlation between self-reporting and performance as measured by a simulated teaching scenario, in most instances the correlation was quite low. Consequently, the authors suggest that researchers must be careful in their use of self-reporting as a means of assessing teaching behavior, and that whenever possible, researchers should observe the teachers they are studying.     

Evolution of clinical ethics teaching at the University of Pittsburgh

The authors explain that several years of effort, by many faculty from a variety of disciplines, were required to expand medical ethics teaching at the University of Pittsburgh School of Medicine beyond the preclinical years. Since 1986, faculty associated with the school's Center for Medical Ethics have begun a comprehensive ethics teaching program for all four years and the residency period; they also are attempting to develop an ethics consultation service. The authors describe the program, its promise and plans, and the significant difficulties involved in establishing and maintaining it, not only problems of long-term funding but of the uninformed and negative attitudes of some students and faculty toward ethics teaching, especially in the clinical setting. Also discussed are the pros and cons of using cases in ethics teaching and the program's approaches to evaluation and to training clinical faculty in clinical ethics issues.     

Using faculty consensus to develop and implement a medical ethics course.

This report describes the development and implementation of a new required course in medical ethics for second-year medical students at the Cornell University Medical College, 1988-89 and 1989-90. The course was specifically designed to teach students who had not yet started their clinical clerkships to think critically and systematically about ethical issues faced by practicing physicians. The goals, structure, and content of the course were developed using an innovative technique, a planning model involving faculty consensus. The faculty members found the planning sessions intellectually challenging and enjoyable, and reported that the sessions added greatly to their teaching of the course. The students' evaluations over the first two years of the course (with 188 of the 201 students--94%--responding) documented the students' satisfaction with the content and the structure of the course, and their belief that the course had achieved its goals. The authors conclude that the faculty's participation in the planning process was crucial to the success of the course.     

Using a productivity-based physician compensation program at an academic health center: a case study.

PURPOSE: With increased budget constraints, academic health centers (AHCs) have turned their focus on physician compensation. While many AHCs are concerned that compensation programs driven primarily by revenue generation will have a negative impact on their academic mission, little information is available to support this. The authors examined the effects on teaching and clinical productivity of an innovative compensation program for pediatrics primary care faculty at an AHC and related those effects to national standards for productivity. METHOD: A baseline productivity and compensation assessment was conducted for a group of 35 academic general pediatricians. The data were compared with Medical Group Management Association (MGMA) figures for general pediatricians. A productivity-based faculty compensation program using the work component of the relative-value unit (RVU) as the measure of productivity was designed and implemented. Productivity and compensation were measured after the first year of the program and compared with the baseline assessment. The numbers of hours precepting students and residents and the students' evaluations of their clinical experiences before and after implementation of the program were compared. RESULTS: The baseline assessment showed that over half of the faculty had productivity that fell below the MGMA 25th percentile, while the majority had compensation that exceeded this percentile. After implementation of the compensation program, 89% of the faculty increased their clinical productivity. The times faculty spent precepting and students' evaluations before and after program implementation were unchanged. CONCLUSIONS: Successful productivity-based physician compensation programs can be developed for AHCs.     

How do physicians teach empathy in the primary care setting?

To explore how primary care clinician-teachers actually attempt to convey empathy to medical students and residents, the author carried out a qualitative study in 1999-2000 in which 12 primary care physicians reflected on their views of empathy, how they demonstrated empathy to patients, and how they went about teaching empathy to learners. Interview data were triangulated with observations of actual teaching sessions and informal questioning of students and residents who had been taught by the faculty participants. Grounded theory was used to interpret the data. The faculty had clear conceptualizations of what empathy meant in clinical practice, but differed as to whether it was primarily a measurable, behavioral skill or a global attitude. Respondents stressed the centrality of role modeling in teaching, and most used debriefing strategies, as well as both learner- and patient-centered approaches, in instructing learners about empathy. Findings suggest that limiting the teaching of empathy to a skill-based approach does not reflect the richness of what actually occurs in the clinical setting, and that it is important to teach empathy comprehensively, acknowledging both behavioral and attitudinal tools.     

Economical laboratory support system for influenza virus surveillance.

When increases in influenzalike illnesses were first detected during the 1984 to 1985 and 1985 to 1986 influenza seasons, throat swab specimens were mailed by physicians across the United States to one hospital laboratory, and each specimen was inoculated into a single tube of cell culture. Of 165 specimens, 52 (32%) were positive for influenza A or B virus within 3 days of receipt when tested by fluorescence microscopy, permitting positive results to be received by the physicians within 1 week on the average. Approximate direct cost was $16 per specimen.     

Promoting fundamental clinical skills: a competency-based college approach at the University of Washington.

The focus on fundamental clinical skills in undergraduate medical education has declined over the last several decades. Dramatic growth in the number of faculty involved in teaching and increasing clinical and research commitments have contributed to depersonalization and declining individual attention to students. In contrast to the close teaching and mentoring relationship between faculty and students 50 years ago, today's medical students may interact with hundreds of faculty members without the benefit of a focused program of teaching and evaluating clinical skills to form the core of their four-year curriculum. Bedside teaching has also declined, which may negatively affect clinical skills development. In response to these and other concerns, the University of Washington School of Medicine has created an integrated developmental curriculum that emphasizes bedside teaching and role modeling, focuses on enhancing fundamental clinical skills and professionalism, and implements these goals via a new administrative structure, the College system, which consists of a core of clinical teachers who spend substantial time teaching and mentoring medical students. Each medical student is assigned a faculty mentor within a College for the duration of his or her medical school career. Mentors continuously teach and reflect with students on clinical skills development and professionalism and, during the second year, work intensively with them at the bedside. They also provide an ongoing personal faculty contact. Competency domains and benchmarks define skill areas in which deepening, progressive attention is focused throughout medical school. This educational model places primary focus on the student.     

Enhancing behavioral science education at the Ohio State University College of Medicine.

The social and behavioral sciences play key roles in patient health outcomes. Given this reality, successful development of social and behavioral science curricula in medical education is critically important to the quality of patients' lives and the effectiveness of health care delivery systems. The Institute of Medicine, in a recent report, recommended that medical schools enhance their curricula in these areas and identified four institutions as "exemplars" of social and behavioral science education. The authors describe an ongoing curriculum development and improvement process that produced one such exemplary program at The Ohio State University College of Medicine.The authors provide a historical perspective on behavioral science education, discuss issues that led to curricular change, and describe the principles and processes used to implement reform. Critical factors underlying positive change are addressed: increase active learning, recruit a core group of small-group facilitators who are primary care physicians, diversify teaching methods, support student-directed educational initiatives, enhance student-teacher relationships, centralize course administration, obtain funding, implement a faculty development program, and apply curriculum quality improvement methods. Outcome data from evaluations completed by both students and small-group physician faculty are presented, and future directions regarding further revision are outlined. The authors believe that the strategies they describe can be applied at other institutions and assist behavioral science educators who may experience the challenges typically encountered in this important field of medical education.     

Stability of medical specialty selection at the University of Kentucky.

In the fall of 1989, all graduates of a 30-year-old medical college were surveyed by questionnaire concerning their motivations for their original selections of specialties, motivations for changing their specialties when such changes had occurred, and factors involved in their current choices of specialties. The 723 respondents were grouped by specialty response into one of three groups (primary care plus medicine and pediatrics subspecialties; surgery; or controllable lifestyle), and responses were statistically analyzed. The most important factors influencing initial specialty selection were perceived match of personality and specialty; technology and methodology characteristic of the specialty; and time for family activities, in that order. The ratings of the 175 respondents who stated that they had changed specialties indicated that time for avocational pursuits and time for family activities were the most important reasons for change. The reasons for selecting a different specialty varied. This study's findings suggest that a student's likelihood of making an inappropriate specialty choice may be reduced by a broad undergraduate medical education with realistic experiences in clinical activity. Students' lack of awareness of the lifestyle of a particular specialty may be a significant factor in the flow of physicians from noncontrollable lifestyle specialty areas. Those who counsel medical students need to be aware of the increasing importance of controllable lifestyle features, changing attitudes, faculty role-modeling, and mentors as strong influences on students' choices of specialties.     

The new face of gross anatomy

The nature of anatomy education has changed substantially over the past decade due to both a new generation of students who learn differently from those of past years and the enormity of advances in anatomical imaging and viewing. At Mount Sinai School of Medicine, our anatomy courses have been designed to meld classic dissection with the tools physicians and surgeons will use tomorrow. We introduce students to the newest technologies available for viewing the body, such as minimally invasive approaches, ultrasonography, three-dimensional visualizations, multi-axial computerized image reconstructions, multi-planar magnetic resonance imaging, and plastinated prosections. Students are given a hands-on, team-building experience operating laparoscopes in the laboratory. A great strength of our program is the important and active participation by faculty from 15 different basic and clinical departments, including several chairs and voluntary faculty. This interdisciplinary approach brings to our students direct, one-on-one encounters or presentations by our finest physicians and surgeons and our core anatomy faculty. In addition, the presence of many teaching assistants drawn from upper classmen and advanced graduate students adds an additional, vibrant dimension. Our anatomy programs for medical/graduate students and postgraduates are structured around three simple principles: (1) it is a privilege to teach, (2) we enlist only passionate teachers, and (3) it is our role to instill appreciation and respect for human form.