June 2008

Grant Results

SUMMARY

From 2000 to 2004, staff of the Stanford Faculty Development Center designed, pilot-tested and revised the Professionalism in Contemporary Practice curriculum, a series of 10 seminars covering key topics in 21st-century medicine, including evidence-based medicine, patient safety and quality improvement.

The seminars consist of a "train-the-trainer" approach in which center staff select medical faculty from around the country and, in a month-long training program, teach them how to deliver the seminars to other physicians, residents and medical students at their home institutions.

Key Results

  • During the project period, a pilot group of 15 physicians received training in the curriculum and, in fall 2004, project staff began delivering the final version of the curriculum to other faculty and students at their home institutions.

Funding
The Robert Wood Johnson Foundation (RWJF) supported this project through a grant of $739,900 to Stanford University School of Medicine.

 See Grant Detail & Contact Information
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THE PROBLEM

Medical school training falls short of preparing new physicians to face the difficulties of contemporary medical practice, according to staff of the Stanford Faculty Development Center, a physician training center at Stanford University.

Today's physicians face rising expectations from patients and payers, more constrained resources, new layers of interference between doctor and patient, and increased administrative hassles.

New strategies, such as a greater emphasis on evidence-based medicine, use of clinical practice guidelines, and explicit quality improvement initiatives, have the potential to cut costs, increase quality of care and preserve physicians' sense of autonomy and satisfaction. Established medical faculty, however, need training in these approaches so that they can restructure their own professional lives and teach faculty, physicians, medical residents and other health professionals the skills needed for contemporary medical practice.

The Stanford Faculty Development Program at Stanford University, Palo Alto, Calif., has previously developed curricula in five areas relevant to primary care practice:

  1. Medical decision-making.
  2. Clinical teaching.
  3. Geriatrics in primary care.
  4. Preventive medicine.
  5. End-of-life care (see Grant Results on ID# 035017 that supported the end-of-life care curricula development).

The center uses a train-the-trainer approach, in which selected faculty members participate in a one-month facilitator-training course at Stanford. Following the training, these faculty members return to their home institutions able to deliver a series of seminars in one of the program content areas for fellow faculty and residents. Trained facilitators also serve as regional and national resources, coming together in teams to conduct workshops for larger groups of faculty or residents.

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RWJF STRATEGY

RWJF is also supporting Partnerships for Quality Education, a national program to develop new models for training primary care residents and nurse practitioners in managing care and working in collaborative interdisciplinary practices (for more information see Grant Results).

Although this grant was made by RWJF's Human Capital team, it also relates to RWJF's interest in quality care. RWJF is pursuing a four-pronged approach to improve the quality of care for chronic disease in outpatient settings. This approach includes: standardizing the measurement of quality; engaging consumers and purchasers in demanding quality; demonstrating that when providers, purchasers and patients are aligned around a common set of quality standards, better care is possible; and evaluating progress toward higher quality.

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THE PROJECT

Under this grant, staff of the Stanford Faculty Development Center designed, pilot-tested and revised the Professionalism in Contemporary Practice curriculum, a series of 10 seminars covering key topics in 21st-century medicine.

The purpose was to train physician faculty in key concepts and issues and prepare them to transfer their newly acquired knowledge and attitudes to peers, residents and students in their home institutions. The Contemporary Practice curriculum builds directly on the Stanford center's previously developed curriculum on medical decision-making, which outlines the basic concepts and tools physicians need to make decisions in the uncertain climate of contemporary medicine.

To help guide the design of the new curriculum, the Stanford team assembled an Advisory Group of faculty from medical schools around the country (see Appendix 1). The Advisory Group included Gordon Moore, M.D., National Program Director of Partnerships for Quality Education.

The Stanford team also gathered input into the curriculum design by surveying a group of 58 physician faculty members who had been trained as facilitators in the Medical Decision-Making curriculum between 1986 and 1999. Thirty-six (62 percent) of these physician "alumni" responded to a four-item survey, which asked them to recommend and rate topics for inclusion in the new curriculum.

Alumni said the most important topics included in the previous course were: cost-effectiveness analysis, probability assessment and evaluating test performance. For the new curriculum, they recommended that it also cover critical appraisal skills, finding evidence, basic biostatistics, research designs, clinical practice guidelines and policy issues. Twenty-five of the alumni indicated interest in participating in a two-week pilot-training session to become facilitators in the new Professionalism in Contemporary Practice curriculum.

To help select curriculum topics, the project team also conducted a review of the literature on contemporary medical practice and competencies for physicians in the 21st century.

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RESULTS

  • The project team created the Stanford Faculty Development Center's Professionalism in Contemporary Practice curriculum. The curriculum consists of 10 50-minute modules, which are designed to fit into one-hour seminars facilitated by trained physician-educators. The topics include:
    • The Current Health Care Environment
    • Evidence-Based Medicine
    • Patient Safety
    • Quality Improvement for Individuals
    • Quality Improvement for Systems of Care
    • Shared Decision-Making: For Individuals
    • Shared Decision-Making: For Systems of Care
    • Facilitating Change: On a Local Level (Part A)
    • Facilitating Change: On a Local level (Part B)
    • Facilitating Change: On a System Level
  • From 2002 through 2004, center staff trained 15 physicians from 14 institutions as facilitators of the Professionalism in Contemporary Practice curriculum. Training activities include instruction in the curriculum, review of background literature, training in teaching skills, delivery of practice seminars to Stanford University faculty, and sessions on home-site implementation and data collection for program evaluation. The first group of facilitators, trained in 2002, included 10 physician "alumni" who had completed the Medical Decision-Making curriculum. In 2004, five new faculty members received training. (See Appendix 2 for a list of the home institutions of faculty members trained.)
  • The 15 trained facilitators received the final version of the Contemporary Practice curriculum and began to deliver the seminars to faculty members and medical residents at their home institutions in fall 2004. According to the Stanford project team, the trained facilitators are teaching the seminars to physicians as well as to multidisciplinary groups. One of the facilitators has reported using teleconferencing technology to disseminate the curriculum to other institutions. (The project team has not tracked how many faculty members have completed the seminars thus far.)
  • Stanford faculty conducted a two-day retreat to train 24 health professionals at the Veterans Affairs Palo Alto Health Care System in key components of the Professionalism in Contemporary Practice curriculum. The purpose of the October 2003 retreat was to examine which of the curriculum components were most relevant to groups of physicians, administrators, nurse practitioners, nurses, pharmacists and medical clerical staff working together in a real-world clinical setting. Two multidisciplinary teams participated in the retreat, one from an inpatient setting (an intensive care unit) and one from an outpatient setting (a general medical clinic). Both teams designed quality improvement projects that they could implement following training. The intensive care unit team worked on ensuring that physicians adequately communicate to nurses both their short-term and long-term plans for patients. The medical clinic group worked on a plan designed to ensure that patients understand and implement clinic discharge and follow-up plans.

    The Stanford team found that physicians and residents have different training needs than do members of multidisciplinary teams. The physician's initial focus is typically on the individual patient and clinical concerns, whereas multidisciplinary team members often play administrative roles that require their attention to more system-level issues. In addition, physicians and residents' pre-existing knowledge about key concepts, such as medical decision-making and evidence-based medicine, differs from that of the administrative team members. Based on the experience of training both groups, the Stanford project staff revised the Professionalism in Contemporary Practice curriculum to include one version for physician faculty and residents and another for multidisciplinary teams of health professionals working together in clinical settings. Stanford then trained the physician facilitators to work with both kinds of groups.
  • The Stanford project team created the Professionalism in Contemporary Practice Literature Database. The database contains more than 1200 articles and books on issues in 21st-century medical practice. The database materials complement the on-site training in contemporary practice received by the physician facilitators.

Communications

The project team disseminated information about the Professionalism in Contemporary Practice curriculum through workshops and presentations at the annual meetings of the Society of General Internal Medicine in 2003 and 2004. A description of the curriculum appears on the Web site of the Stanford Faculty Development Center. The curriculum modules are listed in Bibliography.

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LESSONS LEARNED

  1. Physicians who have been trained in one curriculum may have difficulty shifting to a new area where they feel they have less expertise. Physician faculty trained as facilitators using the Medical Decision-Making curriculum felt comfortable teaching with those materials and did not feel the same commitment and confidence with the new Professionalism in Contemporary Practice curriculum. (Project Director)

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AFTER THE GRANT

In October 2004, the American College of Physicians funded a two-day workshop for 10 chief residents from five institutions in northern California. In April 2005, the team presented a workshop on the Professionalism in Contemporary Practice curriculum, entitled Reflection and Institutional Change, to members of the California Regional Society of General Internal Medicine.

Also in 2005, project staff received a three-year, $750,000 grant from the Josiah Macy, Jr., Foundation to continue training medical faculty. During the grant period, project staff trained 15 additional facilitators from participating institutions in areas relevant to teaching the curriculum.

By March 2008, the 25 facilitators trained from 2002 to 2006 had disseminated the curriculum to approximately 75 faculty and residents at their home sites, and to another 125 at presentations made at regional and national meetings. The five facilitators from the 2007 session plan to train at least 35 medical teachers in 2008.

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GRANT DETAILS & CONTACT INFORMATION

Project

Medical Decision-Making for Contemporary Practice: A National Faculty Development Program

Grantee

Stanford University School of Medicine (Palo Alto,  CA)

  • Amount: $ 739,900
    Dates: July 2000 to June 2004
    ID#:  037961

Contact

Kelley M. Skeff, M.D., Ph.D.
(650) 725-8802
skeff@stanford.edu

Web Site

http://sfdc.stanford.edu

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APPENDICES


Appendix 1

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Advisory Group for Medical Decision-Making in Contemporary Practice

Daniel Kent, M.D.
Milliman and Robertson, Inc.
Seattle, Wash.

Gordon Moore, M.D., M.P.H.
Director, National Program Office
Partnerships for Quality Education
Brookline, Mass.

Sunita Mutha, M.D.
Director, California Managed Care Education and Research NetworkCenter for the Health Professions
University of California, San Francisco
San Francisco, Calif.

Harold Sox, M.D.
Chair of Medicine
Dartmouth School of Medicine
Hanover, N.H.


Appendix 2

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Home Institutions of Faculty Trained in the Professionalism in Contemporary Practice Curriculum: 2002, 2004

2002
Kettering Medical Center
Kettering, Ohio

National Yang-Ming University
Taipei, Taiwan

Stanford University
Stanford, Calif.

Uniformed Services University of the Health Sciences
Bethesda, Md.

University of Alabama
Birmingham, Ala.

University of California, Davis
Davis, Calif.

University of California, San Diego
San Diego, Calif.

University of Chicago
Chicago, Ill.

University of Iowa
Iowa City, Iowa

2004
Alameda County Medical Center
Oakland, Calif.

Howard University
Washington, D.C.

Mayo Clinic
Rochester, Minn.

Mount Sinai Medical School
New York, N.Y.

Northwestern University
Chicago, Ill.

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Reports

Braddock C and Bergen M. Module 6: Shared Decision-Making: For Individuals. Contemporary Practice Curriculum. Palo Alto, Calif.: Stanford Faculty Development Center, 2004.

Braddock C and Bergen M. Module 6: Shared Decision-Making: For Systems of Care. Contemporary Practice Curriculum. Palo Alto, Calif.: Stanford Faculty Development Center, 2004.

Dembitzer A and Bergen M. Module 2: Evidence-Based Care. Contemporary Practice Curriculum. Palo Alto, Calif.: Stanford Faculty Development Center, 2004.

Dembitzer A and Bergen M. Module 3: Patient Safety. Contemporary Practice Curriculum. Palo Alto, Calif.: Stanford Faculty Development Center, 2004.

Holmboe E and Bergen M. Module 4: Quality Improvement: For Individuals. Contemporary Practice Curriculum. Palo Alto, Calif.: Stanford Faculty Development Center, 2004.

Holmboe E and Bergen M. Module 5: Quality Improvement: For Systems of Care. Contemporary Practice Curriculum. Palo Alto, Calif.: Stanford Faculty Development Center, 2004.

Rudd P and Bergen M. Module 1: The Current Health Care Environment. Contemporary Practice Curriculum. Palo Alto, Calif.: Stanford Faculty Development Center, 2004.

Rudd P and Bergen M. Module 8: Facilitating Change: On the Local Level-A. Contemporary Practice Curriculum. Palo Alto, Calif.: Stanford Faculty Development Center, 2004.

Rudd P and Bergen M. Module 8: Facilitating Change: On the Local Level-B. Contemporary Practice Curriculum. Palo Alto, Calif.: Stanford Faculty Development Center, 2004.

Rudd P and Bergen M. Module 8: Facilitating Change: On the System Level. Contemporary Practice Curriculum. Palo Alto, Calif.: Stanford Faculty Development Center, 2004.

Audio-Visuals and Computer Software

Stanford Faculty Development Program for Contemporary Practice EndNote Bibliographic Database on CD-ROM, February 2004. The database is available online; purchase of EndNote software is required to access the articles in the database.

World Wide Web Sites

http://sfdc.stanford.edu. The Web site of the Stanford Faculty Development Center contains a description of the center's program objectives, dissemination model, training methods, program evaluation methods and results, and a list of previous participating institutions, a list of project staff and background information on each of the four courses offered, including the Professionalism in Contemporary Practice course.

Presentations and Testimony

Peter Rudd, Anne Dembitzer, Lars Osterberg and Christopher Sharp. "Getting Started on a Continuous Quality Improvement Project," at the 26th Annual Meeting of the Society of General Internal Medicine, May 1, 2003, Vancouver, British Columbia, Canada.

Merlynn Bergen, Clarence Braddock, Anne Dembitzer, Eric Holmboe, Lars Osterberg, Peter Rudd and Christopher Sharp. "Getting Started in Continuous Quality Improvement (a precourse)," at the 27th Annual Meeting of the Society of General Internal Medicine, May 12, 2004, Chicago. (Abstract available online; requires registration in Community of Science.)

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Report prepared by: Jayme Hannay
Reviewed by: Richard Camer
Reviewed by: Molly McKaughan
Program Officer: Susan Hassmiller