Practicing effectively in today's health system: teaching systems-based care.

BACKGROUND AND OBJECTIVES: The Institute of Medicine and the new Accreditation Council for Graduate Medical Education General Essentials have focused attention on the Undergraduate Medical Education for the 21st Century (UME-21) core content area of systems-based care. Through teaching systems-based care, medical students can learn how physicians effectively deliver and coordinate care within the health system. While medical students can be introduced to the organization, financing, and delivery of the health care system through lectures, the principles and practice of systems-based care must be reinforced through structured learning experiences during the clinical (ie, third and fourth) years. The purpose of this article is to define the undergraduate clinical content and experiences in systems-based care offered by the eight UME-21 partner schools. METHODS: The eight partner UME-21 schools exposed third- and fourth-year medical students to a variety of clinical experiences outside the traditional teaching hospital in such settings as physician offices, skilled nursing facilities, the patient's home, hospice, and public health departments. They also taught systems-based care skills such as care coordination, performance assessment, and quality improvement. RESULTS: Based on surveys of graduating students, the UME-21 programs were successful in exposing students to the aforementioned topics, though there was variability among schools. DISCUSSION: The experiences of the UME-21 schools in teaching about systems-based care, as discussed in this paper, may be useful to those involved in medical school curricula planning.

A curriculum in systems-based care: experiential learning changes in student knowledge and attitudes.

BACKGROUND: To provide efficient, quality patient care, physicians must have a fundamental understanding of how the health care delivery system functions and how to appropriately use the various components of this system. As part of the Undergraduate Medical Education for the 21st Century (UME-21) initiative, the University of Miami in partnership with AvMed Health Plans, a nonprofit managed care organization (MCO) developed a longitudinal educational program that prepares all students for medical practice in emerging systems of care. METHODS: The program, which spans the 4-year undergraduate curriculum, incorporates didactic sessions and practical experiences to teach about the clinical, managerial, financial, and ethical aspects of systems-based care. During the third year of medical school, students visit the administrative offices of AvMed Health Plans for a day-long series of presentation-discussions and experiential tours through the various administrative departments. There, they experience first-hand all facets of a systems-based approach to care using evidence-based practice guidelines, utilization review, quality measurement and improvement, and chronic disease management. RESULTS: An attitudinal survey, constructed to evaluate general attitudes toward managing care and MCOs, was administered to students at the beginning of their first, second, and third year and immediately before and after their visit to AvMed during their third year. Using factor analysis, there were no significant differences in students' attitudes at the beginning of the first, second, or third year nor immediately before the seminar day at the MCO. However, the day-long seminar at AvMed did have a favorable effect on attitudes toward systems of care and MCOs in general. In addition, students performed well on post-evaluation knowledge assessments addressing fundamental concepts of systems of care and the function of an MCO in managing the care of its members. The visit to the MCOs (AvMed) offices and the day-long curriculum was replicated at another medical school, with similar effects on students' attitudes. CONCLUSIONS: Medical students have neutral-to-negative opinions of systems of care and MCOs. Early educational experiences such as classroom lectures and panels that address managing care issues have minimal effect on these opinions. However, bringing medical students to an MCO's administrative offices, seeing first-hand how systems of care operate, and having an open dialogue with physician administrators does effect a positive change in medical student opinions of a system in which care is managed. In addition, medical students can gain new knowledge about effective systems-based practice.

The hypertension management program: identifying opportunities for improvement.

To date, relatively few programs have been evaluated that were designed to affect the clinical practice patterns of primary care physicians who treat patients with hypertension. In particular, studies that have evaluated blood pressure control as a clinical outcome before and after an intervention are lacking. The Hypertension Management Program, developed by Applied Health Outcomes, is a quality improvement program designed to improve the medical management of hypertension in population-based health care settings. This program is in the process of continuing to collect baseline data from health maintenance organizations, conducting physician-focused interventions designed for improving clinical care, and collecting postintervention data between 6 and 12 months after the intervention is completed to determine its effect. The authors present the rationale for conducting large-scale hypertension management programs that measure outcomes, as well as preliminary baseline and postintervention data from the Hypertension Management Program, based on a current database of more than 1.9 million individuals enrolled in eight health care plans.