Healthcare is not about health.

Initiatives designed to reduce the disease burden and improve the health of the US population that focus on increasing access to health care have been disappointing. Progress requires multifaceted change. We must first acknowledge that the healthcare system is focused on reversing or modifying disease, not enhancing health. Our conceptualization of the development of ill health and disease must also change. Scientific advances are clarifying the complex interactions among the development of ill health and disease and an individual's behaviors, their microbiota, and their physical, social, and emotional environments. A person's genetic makeup predisposes them to a wide array of disease conditions but is rarely deterministic in and of itself. Factors extrinsic to the individual, including the social determinants of health, play a major role in disease development, often decades later. The complexity of health and disease requires a "team" accountable for the health of our populations, and these teams must be expanded beyond the medical professions. Governmental officials, architects, business leaders, civic organizations, social and neighborhood groups are among the key stakeholders on the health side of the equation. If and when disease does become manifest, then the care part of the healthcare system assumes the larger role. This has major implications for the education of our clinically focused health science students, but also of professional disciplines previously deemed peripheral to health. Simply redoubling our efforts and focusing on our current healthcare system is insufficient to make progress in the health of the populace. One example of a multipronged approach in Allentown, PA is explored in depth.

Teaching artificial intelligence as a fundamental toolset of medicine.

Artificial intelligence (AI) is transforming the practice of medicine. Systems assessing chest radiographs, pathology slides, and early warning systems embedded in electronic health records (EHRs) are becoming ubiquitous in medical practice. Despite this, medical students have minimal exposure to the concepts necessary to utilize and evaluate AI systems, leaving them under prepared for future clinical practice. We must work quickly to bolster undergraduate medical education around AI to remedy this. In this commentary, we propose that medical educators treat AI as a critical component of medical practice that is introduced early and integrated with the other core components of medical school curricula. Equipping graduating medical students with this knowledge will ensure they have the skills to solve challenges arising at the confluence of AI and medicine.

Machine Learning: The Next Paradigm Shift in Medical Education.

Machine learning (ML) algorithms are powerful prediction tools with immense potential in the clinical setting. There are a number of existing clinical tools that use ML, and many more are in development. Physicians are important stakeholders in the health care system, but most are not equipped to make informed decisions regarding deployment and application of ML technologies in patient care. It is of paramount importance that ML concepts are integrated into medical curricula to position physicians to become informed consumers of the emerging tools employing ML. This paradigm shift is similar to the evidence-based medicine (EBM) movement of the 1990s. At that time, EBM was a novel concept; now, EBM is considered an essential component of medical curricula and critical to the provision of high-quality patient care. ML has the potential to have a similar, if not greater, impact on the practice of medicine. As this technology continues its inexorable march forward, educators must continue to evaluate medical curricula to ensure that physicians are trained to be informed stakeholders in the health care of tomorrow.

Making sense out of the world: Expanding our mental model of health and disease.

We make sense of the world through our mental representations or models. They allow us to identify and categorize objects and ideas and shape our views of the world determining what we consider relevant and valid. Mental models enable reasoning, including clinical reasoning in regard to diagnosis and therapy. Scientific advances in understanding of biologic processes in health and disease have begun to reveal their complexity. Systems biology has embraced this complexity and is recognized as complementary to the reductionist approach to science. The mental models educators impart in their students create the boundaries for what is deemed relevant scientifically and clinically. The successes emanating from the prevailing Western mental model of health and disease focusing on the individual and the reductionist approach to scientific inquiry is unquestioned. However, as our understanding of biologic processes has grown, the necessity of a new mental model that encompasses factors external to the individual is evident. The author proposes that a mental model, akin to an ecosystem, with the individual residing at the confluence of their genetic, behavioral, environmental, and microbiota factors be consciously developed in students. Embracing the complexity and interactions of biologic processes within and external to the individual is necessary to continue to advance science and medicine.

Beyond the COVID Pandemic, Telemedicine, and Health Care.

This article reviews the current experience and the flaws encountered in the rush to deploy telemedicine as a substitute for in-person care in response to the raging coronavirus (COVID-19) pandemic; the preceding fault lines in the U.S. health care system that exacerbated the problem; and the importance of emerging from this calamity with a clear vision for necessary health care reforms. It starts with the premise that the precursors of catastrophes of this magnitude provide a valid basis for planning corrective measures, improved preparedness, and ultimately serious health reform. Such reform should include standardized protocols for proper deployment of telemedicine to triage patients to the appropriate level and source of care at the point of need, proper use of relevant technological innovations to deliver precision medicine, and the development of regional networks to coordinate and improve access to care while streamlining the care process. The other essential element is a universal payment system that puts the United States at par with the rest of the industrialized countries, regardless of variation among them. The ultimate goal is creating an efficient, effective, accessible, and equitable system of care. Although timing is uncertain, the pandemic will be brought under control. The path to a better future after the pandemic offers some consolation for the massive loss of life and treasure during this pandemic.

Innovation in Response to the COVID-19 Pandemic Crisis.

The COVID-19 pandemic has disrupted all aspects of academic medical center missions. The number and rapidity of innovative responses to the crisis are extraordinary. When the pandemic has subsided, the world of academic medicine will have changed. The author of this Invited Commentary anticipates that at least some of these innovations will become part of academic medicine's everyday clinical and educational operations. Here, he considers the implications of exemplary innovations-virtual care, hospital at home, advances in diagnosis and therapy, virtual learning, and virtual clinical learning-for regulators, academic medical centers, faculty, and students.

Competency Committees in Undergraduate Medical Education: Approaching Tensions Using a Polarity Management Framework.

Implementing competency-based medical education in undergraduate medical education (UME) poses similar and unique challenges to doing so in graduate medical education (GME). To ensure that all medical students achieve competency, educators must make certain that the structures and processes to assess that competency are systematic and rigorous. In GME, one such key structure is the clinical competency committee. In this Perspective, the authors describe the University of Michigan Medical School's (UMMS's) experience with the development of a UME competency committee, based on the clinical competency committee model from GME, and the first year of implementation of that committee for a single cohort of matriculating medical students in 2016-2017.The UMMS competency committee encountered a number of inter dependent but opposing tensions that did not have a correct solution; they were "both/and" problems to be managed rather than "either/or" decisions to be made. These tensions included determining the approach of the committee (problem identification versus developmental); committee membership (curricular experts versus broad-based membership); student cohort makeup (phase-based versus longitudinal); data analyzed (limited assessments versus programmatic assessment); and judgments made (grading versus developmental competency assessment).The authors applied the Polarity Management framework to navigate these tensions, leveraging the strengths of each while minimizing the weaknesses. They describe this framework as a strategy for others to use to develop locally relevant and feasible approaches to competency assessment in UME.

THE ELECTRONIC HEALTH RECORD AND DEVELOPMENT OF MEDICAL STUDENTS' MENTAL PATIENT MODELS.

Medical practitioners routinely use dual process clinical reasoning: pattern recognition, termed system 1 thinking, and system 2 thinking or analytic reasoning. System 1 thinking, a hallmark of expertise developed through experience with multiple similar patients and deliberate practice, is rapid and automatic. For decades, the structured written medical write-up and progress notes served an educational as well as a patient care role. The introduction of electronic health records (EHRs) potentially hinders the development of the cognitive models upon which system 1 thinking is predicated. Using a vignette-based extended matching chief complaint examination, we investigated the effects of introducing an inpatient EHR on three classes of third-year medical students before and after the EHR implementation. While some subsection scores were significantly different, there was no overall change in performance. Based on this assessment, the development of cognitive models of patient presentations is not impeded by the introduction of an EHR.

Assessing Residents' Competency at Baseline: How Much Does the Medical School Matter?

BACKGROUND: Although there is some consensus about the competencies needed to enter residency, the actual skills of graduating medical students may not meet expectations. In addition, little is known about the association between undergraduate medical education and clinical performance at entry into and during residency. OBJECTIVE: We explored the association between medical school of origin and clinical performance using a multi-station objective structured clinical examination for incoming residents at the University of Michigan Health System. METHODS: Prior to assuming clinical duties, all first-year residents at the University of Michigan Health System participate in the Postgraduate Orientation Assessment (POA). This assesses competencies needed during the first months of residency. Performance data for 1795 residents were collected between 2002 and 2012. We estimated POA variance by medical school using linear mixed models. RESULTS: Medical school predicted the following amounts of variance in performance-data gathering scores: 1.67% (95% confidence interval [CI] 0.36-2.93); assessment scores: 4.93% (95% CI 1.84-6.00); teamwork scores: 0.80% (95% CI 0.00-1.82); communication scores: 2.37% (95% CI 0.66-3.83); and overall POA scores: 4.19% (95% CI 1.59-5.35). CONCLUSIONS: The results show that residents' medical school of origin is weakly associated with clinical competency, highlighting a potential source of variability in undergraduate medical education. The practical significance of these findings needs further evaluation.

Collaboration Platforms in China for Translational and Clinical Research: The Partnership Between Peking University Health Science Center and the University of Michigan Medical School.

PROBLEM: Clinical and translational research is increasing in China, attracting faculty-to-faculty collaborations between U.S. and Chinese researchers. However, examples of successful institution-to-institution collaborations to facilitate this research are limited. The authors describe a partnership between Peking University Health Science Center (PUHSC) and the University of Michigan Medical School (UMMS) designed to enable faculty-initiated joint translational and clinical research projects. APPROACH: In 2009, UMMS leadership identified PUHSC as the most appropriate institutional partner, and the Joint Institute for Translational and Clinical Research was established in 2010. Each contributed $7 million for joint research projects in areas of mutual interest. A shared governance structure, four thematic programs (pulmonary, cardiovascular, liver, and renal diseases), three joint research-enabling cores, and processes for awarding funding have been established along with methods for collaborating and mechanisms to share data and biomaterials. OUTCOMES: As of November 2015, 52 joint faculty proposals have been submitted, and 25 have been funded. These projects have involved more than 100,000 patients in the United States and China and have generated 13 peer-reviewed publications. Pilot data have been leveraged to secure $3.3 million of U.S. extramural funding. Faculty and trainee exchanges take place regularly (including an annual symposium), and mechanisms exist to link faculty seeking collaborations. Critical determinants of success include having co-ownership at all levels with coinvestment of resources. NEXT STEPS: Each institution is committed to continuing its support with a repeat $7 million investment. Next steps include initiating studies in new clinical areas and pursuing large clinical intervention trials.

Gender Disparities in Academic Practice.

BACKGROUND: In academia, women remain underrepresented. The authors' sought to examine differences in faculty position and professional satisfaction among academic physicians by gender. METHODS: From 2008 to 2012, academic faculty members at a single institution were surveyed (2008, n = 737; 2010, n = 1151; and 2012, n = 971) regarding current position, choice of position, professional satisfaction, and desire for leaving. Logistic regression was performed to compare aspects of professional satisfaction by gender. RESULTS: Men more often held tenure track positions compared with women (2008, 45 percent versus 20 percent; 2010, 47 percent versus 20 percent; and 2012, 49 percent versus 20 percent; p < 0.001). Women were more likely to engage in only clinical activities compared with men (2008, 31 percent versus 18 percent; 2010, 28 percent versus 14 percent; and 2012, 33 percent versus 13 percent; p < 0.001) and less likely to participate in research. Women chose tracks to accommodate work-life balance [2008, OR, 1.9 (95 percent CI, 1.29 to 2.76); 2010, OR, 2.0 (95 percent CI, 1.38 to 2.76); and 2012, OR, 2.1 (95 percent CI, 1.40 to 3.00)], rather than the opportunity of tenure [2008, OR, 0.4 (95 percent CI, 0.23 to 0.75); 2010, OR, 0.5 (95 percent CI, 0.35 to 0.85); and 2012, OR, 0.5 (95 percent CI, 0.29 to 0.76) compared with men. Men reported higher professional satisfaction compared with women (2008, 5.7 versus 5.4, p < 0.009; 2012, 5.3 versus 5.0, p < 0.03). Men were more likely to leave because of leadership opportunities (14.4 percent versus 9.2 percent, p < 0.03) and compensation (14.2 percent versus 9.2 percent, p < 0.03) compared with women. CONCLUSIONS: Women report lower levels of professional satisfaction in academic practice compared with men. Given the increasing pressures of academic practice, efforts to align work-life balance and professional goals could potentially improve faculty satisfaction and retention.

GME Innovations Grant Program at the University of Michigan Health System-Fostering Changes in Education and Clinical Care.

BACKGROUND: Changes in graduate medical education (GME) have resulted in curricula, goals and objectives, and assessment methods becoming more formal, yet there is little financial support for the educational research required to develop better teaching approaches and assessment tools. OBJECTIVE: We sought to encourage the development of new educational tools and assessment methods to improve the overall conduct of GME at the University of Michigan. INTERVENTION: The University of Michigan Health System has recently established a new educational grant that is designed to foster innovative educational research in GME. We describe the experience with a new and robust internal educational grant, including the source of funding, mechanisms for reviewing and assessing the proposals, the types of proposals that have currently been funded, and the effect and results of these studies on GME at the University of Michigan Health System. OUTCOMES: Projects funded by the grant have changed the curriculum in the involved programs, and many have resulted in sustained changes, including new methodologies in the simulation center, the development of an "academy" of faculty physicians with significant teaching expertise, and the creation of web-based teaching and assessment tools for "just in time" learning, and have been disseminated at national meetings and in peer-reviewed journals. CONCLUSIONS: The GME Innovations Grant Program at the University of Michigan Health System has been successful to date, funding 11 proposals during the course of 6 years. Some of these proposals have resulted in permanent changes and additions to residency training programs.

Predictors of job satisfaction among academic faculty members: do instructional and clinical staff differ?

OBJECTIVES: This study aimed to identify and compare predictors of job satisfaction between instructional and clinical faculty members. METHODS: A 61-item faculty job satisfaction survey was distributed to 1898 academic faculty members at the University of Michigan Medical School. The anonymous survey was web-based. Questions covered topics on departmental organisation, research, clinical and teaching support, compensation, mentorship, and promotion. Levels of satisfaction were contrasted between faculty members on the two tracks, and predictors of job satisfaction were identified using linear regression models. RESULTS: Response rates for the instructional and clinical faculty groups were 43.1% and 46.7%, respectively. Clinical faculty members reported being less satisfied with how they were mentored and fewer reported understanding the process for promotion. There was no significant difference in overall job satisfaction between the two faculty groups. Surprisingly, clinical faculty members with mentors were significantly less satisfied with how they were mentored and with career advancement, and were significantly less likely to choose an academic career if they had to do it all over again compared with instructional faculty mentees. Additionally, senior-level clinical faculty members were significantly less satisfied with their opportunities to mentor junior faculty members compared with senior-level instructional faculty staff. Significant predictors of job satisfaction for both groups included areas of autonomy, meeting career expectations, work-life balance, and departmental leadership. In the clinical track only, compensation and career advancement variables also emerged as significant predictors of overall job satisfaction. CONCLUSIONS: Greater emphasis must be placed on faculty members' well-being at both the institutional level and the level of departmental leadership. Efforts to enhance job satisfaction and improve retention are more likely to succeed if they are directed by locally designed assessments involving department chairs and are specifically aimed at fostering more effective mentoring relationships and increasing the opportunities available for career advancement activities such as research work. Our findings show that these strategies can have significant impacts on job satisfaction and the retention of clinical track faculty members.