Future directions for academic practice plans: thoughts on organization and management from Johns Hopkins University and the University of Pennsylvania.

Academic practice plans have been challenged in recent years by increasing pressures for productivity and financial performance. Most practice plans began as relatively loose affiliations among the clinical departments associated with their respective medical schools, and such approaches were adequate in an earlier era. However, this model is not well suited to deal with the current and future challenges that face the practice plans, hospitals, and medical schools that comprise our academic medical centers. The current clinical, financial, and regulatory environment requires highly effective business management, a shared commitment to common goals, and meticulous attention to regulatory compliance. In turn, the organizational structures, daily management, and overall governance of academic practice plans must be revised to address these new expectations. The business, clinical, and academic performance of the individual practices must be aligned to meet the diverse, and sometimes conflicting, needs of the academic health center. Both Johns Hopkins Medicine and the University of Pennsylvania (Penn Medicine) have been addressing these issues independently, but their approaches share many common principles. Among others, these principles include (a) organizational alignment, (b) strong practice plan business management, (c) shared resources and strategies, (d) accountability for performance in each practice based on credible data generated by the practice plan, (e) uniform audit and compliance standards, and (f) application of market strategy principles to assure the right mix of primary and specialist physicians, and appropriate incentive-based compensation for physicians. The application of these approaches at two academic health centers, and the rationale for these approaches, are discussed in detail.     

Parent satisfaction with the electronic medical record in an academic pediatric rheumatology practice

Background

Patient satisfaction has not been widely studied with respect to implementation of the electronic medical record (EMR). There are few reports of the impact of the EMR in pediatrics.

Objective

The objective of this study was to assess the impact of implementation of an electronic medical record system on families in an academic pediatric rheumatology practice.

Methods

Families were surveyed 1 month pre-EMR implementation and 3 months post-EMR implementation.

Results

Overall, EMR was well received by families. Compared with the paper chart, parents agreed the EMR improved the quality of doctor care (55% or 59/107 vs 26% or 26/99, P < .001). More parents indicated they would prefer their pediatric physicians to use an EMR (68% or 73/107 vs 51% or 50/99, P = .01).

Conclusions

Transitioning an academic pediatric rheumatology practice to an EMR can increase family satisfaction with the office visit.     

Correlation between academic motivation and professional identity in medical students in the Faculty of Medicine of the Universitas Gadjah Mada Indonesia

Background

Professionalism is a skills area that should be mastered by medical graduates. The period of formal education is essential for the formation of professionalism. The involvement of internal factors, such as academic motivation, and external factors, such as the learning environment, might play a role in the development and learning of professional identity.

Contribution of academic departments of general practice to undergraduate teaching, and their plans for curriculum development.

BACKGROUND. In 1991, the General Medical Council suggested the development of a new undergraduate curriculum, on a 'core plus electives' basis. The combination of National Health Service reforms and the rising profile of academic departments of general practice had led to a consideration of general practice as an alternative teaching environment. These departments now face escalating expectations from their medical schools of their ability to provide additional community based teaching. AIM. The aim of this study was to investigate the present contribution of academic departments of general practice to undergraduate teaching and their plans for curriculum development, including the introduction of community-based clinical skills teaching. METHOD. A questionnaire was circulated in June 1993 to all academic departments of general practice in the United Kingdom and Eire. RESULTS. Twenty seven out of 28 questionnaires were returned. Twenty two departments provided pre-clinical teaching and all provided a clinical practice attachment. Eight medical schools were organizing community-based clinical skills teaching, and in two this formed the basis for a community-based medical attachment. Eight planned to reduce the factual content of their curricula and introduce problem-based learning while nine were contemplating a 'core plus electives' option. Fourteen medical schools had primary care input in teaching basic clinical skills and an additional seven planned to introduce this. Problems encountered by the general practitioner tutors in teaching clinical skills included insufficient time and resources and poor self-esteem; they identified a need for good central and peripheral organization. CONCLUSION. Compared with a 1988 study, academic departments of general practice are increasingly involved in teaching both general practice and general medical skills at undergraduate level. Curriculum change is occurring rapidly, with an increasing trend towards community teaching; the implications for both academic departments and general practitioner tutors are discussed.     

Frequent attenders in general practice: medical, psychological and social characteristics

A group of frequent attenders at a general practice surgery have been studied by comparison with a group of age-and sex-matched controls. Frequent attenders are distinguished by a high predisposition to neurotic illness (as measured by the `N' score of the Eysenck personality questionnaire) and a high prevalence of affective neurosis. Poor past physical health was commonly found among the frequent attenders and comprised for the most part the common chronic physical illnesses. Of the social characteristics studied only marital breakdown was found significantly more often in frequent attenders than controls.     

Educating residents about managed care: a partnership between an academic medical center and a managed care organization.

Physicians are taught to think in terms of individual patients rather than in terms of the health of a population, a view typically reinforced by residency training. Managers of managed care organizations estimate that it takes between one and two years of additional post-residency experience to prepare graduates of U.S. residency programs to practice in managed care settings. The authors describe a two-week block rotation in managed care and health system change that is required of all third-year medical residents at New York-Presbyterian Hospital/ Weill Cornell Medical Center. The program was developed through a partnership between the Joan and Sanford I. Weill Medical College of Cornell University, the New York-Presbyterian Hospital, and Empire BlueCross BlueShield. The authors discuss the rationale, curriculum content, teaching methods, and evaluation of the program, which is designed not only to educate residents about managed care but also to enable them to think critically about the changing health care system. The results of the program have exceeded expectations. Residents' knowledge of health economics, managed care concepts, and health system change, as measured by pre- and post-rotation tests, has shown a steep learning curve. Further, the residents have consistently given the rotation the highest ratings, and some residents have changed their career plans as a result of their participation. The program, which continues to expand, has demonstrated the potential of collaboration between traditional adversaries, an academic medical center and a managed care insurance company, and provides a replicable model for similar partnerships.     

Non-cognitive characteristics predicting academic success among medical students in Sri Lanka

ABSTRACT: BACKGROUND: We aimed to identify socio-demographic and non-cognitive characteristics determining success or failure of Sri Lankan medical undergraduates. METHODS: A retrospective study conducted among ninety students of the Faculty of Medical Sciences, University of Sri Jayewardenepura. They were stratified in to two equal groups; Group 'A' ('High-achievers') included students who have obtained a honours degree at the final MBBS examination, while Group 'B' ('Low-achievers') included students who have referred in one or more subjects at the same examination. A revised version of the Non-cognitive Questionnaire (NQ) was the study instrument. RESULTS: Males were 56.7%. Mean age was 26.4+/-0.9 years. 'High-achievers' were significantly younger, from Colombo district, studies for GCE A/L at a National School and entered university at first attempt in comparison to 'Low-achievers' (p<0.05). The 'High-achievers' demonstrated a significantly higher mean score for the following non-cognitive domains; Positive self-concept and confidence, realistic self-appraisal, leadership, preference of long range goals and academic familiarity. The results of the binary logistic regression analysis indicates that age, being selected to university from Colombo district, residency at Western province, entering university from GCE A/L first attempt, obtaining a 'Distinction' for GCE A/L English subject, higher number of patient-oriented case discussions, positive self-concept and confidence, leadership qualities, preference of long range goals and academic familiarity all significantly increased the odds of obtaining a honours degree at the Final MBBS. CONCLUSION: Non-cognitive characteristics were important predictors of academic success. A combined system incorporating both past academic performance and non-cognitive characteristics might help improve the selection process and early recognition of strugglers.     

Changing environment and the academic medical center: the Johns Hopkins Hospital

Academic medical centers need strong patient bases and strong financial bases to educate and to support research. After careful delineation of its mission with regard to patient care, research, and education, the Johns Hopkins Hospital expanded its health care delivery capabilities and strengthened its position in the health care marketplace by acquisitions of and mergers with other hospitals and a health maintenance organization in the Baltimore area. The resulting conglomerate, operating under the direction of a holding company, the Johns Hopkins Health System, has achieved its goals of expanding patient care capabilities, broadening the patient base, and enlarging the asset base and cash flow. Half the medical residents at the Johns Hopkins School of Medicine receive training at nontraditional sites, and further expansion of teaching activities is being explored. Potential roles of traditional and nontraditional teachers in these activities are discussed.     

Structure of medical psychotherapy: program for academic formation

Starting from a general definition of psychoanalysis and with the aim of deepening our knowledge of the relationship between theory and practice, a scientific structure of psychotherapy is developed. The necessity of a training for doctors specialized in the field of psychotherapy has led us to design a training program consisting of three academic courses. This program, established by the Academy of Analytical Psychotherapy in a University Department of Psychiatry and Medical Psychology, introduces a new speciality in our country. In these three academic courses the theoretical aspects are covered (in a series of courses, seminars and lectures) as well as practical aspects (dealt with in sessions of individual and group psychoanalyses) and methods of evaluation at both individual and group levels. The model stated above can be considered the basis of a training program for doctors specializing in analytical psychotherapy.     

Faculty and staff teams: a tool for unifying the academic health center and improving mission performance.

The organizational structure of the academic health center (AHC) may present significant barriers to deep and lasting organizational change. The insular nature and structure often seen in academic departments and other units at AHCs result in competition for scarce resources, rather than in working together to add value to one another or to the organization as a whole. Successful unification around organizational performance goals is needed more than ever by AHCs as they struggle to meet their challenges. Over a five-year period (2000-2005) at the Penn State College of Medicine and Milton S. Hershey Medical Center, organizational inner cohesiveness was created through the use of teams that unified the clinical, academic, and research enterprises. Barriers that typically separate academic departments, such as a lack of understanding of the impact of organizational funds flow on each of the missions, were broken down. Traditional barriers between employees and management (e.g., poor communication, lack of clarity on organizational goals, and claims that neither side understood the other) were reduced. Problems that seemed to be intractable in the past such as an inequitable distribution of resources, responsibilities, and rewards, were solved through the implementation of a teams approach across departments and missions. The authors describe the creation and operation of these AHC-wide teams. The rationale for using teams is elucidated, the difference between teams and committees is defined, and data on five years of team performance are presented. The authors argue that the breadth of scope and comprehensiveness of the teams approach represents an effective model for implementing AHC-wide transformational change.     

Changing environment and the academic medical center: the Johns Hopkins School of Medicine

Both academic and economic goals must be served by the academic health center. In response to ongoing stresses on medicine, the Johns Hopkins School of Medicine and the Johns Hopkins Hospital rapidly developed and implemented an expanded system of medical care. Vertical integration included provision of both acute and chronic care facilities and both primary and specialty care, as well as insurance products, in particular a health maintenance organization. Horizontal integration was accomplished by acquisition of or affiliation with other hospitals. The realignment of medical resources and patients shifted the locus of medical education somewhat, from the traditional hospital setting to the ambulatory care setting (in which many students and residents will eventually practice anyway). In addition, many physicians in the new settings are not traditional Johns Hopkins faculty members. Results of educational efforts in these altered circumstances so far have been mixed, partly because the capacity of the individual center to train students and residents is necessarily limited, and the fragmentation of the system makes inevitable problems of quality control and management. These issues are being worked out. The drain on faculty resources for research imposed by the need to expand clinical practice has been offset by a system of awards for research to faculty members. Efforts are being made to sustain the excellence of the traditional Johns Hopkins faculty's reputation while assuring doctors newly affiliated with the Hopkins system that they are no less important to the system. Opportunities to learn and to teach more economical medicine while retaining quality are discussed.     

Pharmacogenetics and the future of medical practice

Pharmacogenetics is today widely proclaimed to be about to revolutionize the face of medicine. In a more realistic assessment, the implementation of molecular genetics and biology will continue to provide us, as it has done already, with better ways to diagnose and treat illnesses, but it will do so at a stepwise and evolutionary pace, based on an improved understanding of the nature of disease, allowing more specific treatments, better risk prediction, and the implementation of preventive strategies. As such, future progress in biomedicine will travel the same well-trodden paths of improved differential diagnosis and risk prediction along which it has advanced in the past decades and centuries. Thus, while meaningful biomedical research today by and large depends on the use of the newly developed tools of genetics and genomics and the insights that we gain through them, it is unlikely fundamentally to change the direction of medical progress.