Assignment: Medical Education and the Changing Practice of Medicine Medical Education

Assignment: Medical Education and the Changing Practice of Medicine Medical Education ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Assignment: Medical Education and the Changing Practice of Medicine Medical Education Chapter 6 Medical Education and the Changing Practice of Medicine Medical Education: Colonial America to the 19th Century • No medical schools • Sick were treated with medicinal herbs and anecdotal information in their homes • Few university-trained European physicians emigrated to America; trained colonial “medical students” in apprenticeships • No formal methods of testing new physicians; practiced without regulation of any kind Medical Education: Colonial America to the 19th Century • Apprenticeship training with mentors continued until hospitals founded in mid1700s • First medical school established in 1756 (College of Philadelphia), 2nd at King’s College, 1768 (later Columbia Univ.) • 1800: only four U.S. medical schools added; each had a few faculty members teaching all courses Flexner Report and Medical School Reforms • 1904, AMA developed – Council on Medical Education: address needed educational improvements and standards – JAMA: published medical school state licensing failure statistics and group schools by failure rates, demanding poor schools to improve or resign the association Flexner Report and Medical School Reforms • 1905: Support for AMA reforms by Carnegie Foundation for the Advancement of Teaching; examine all 155 US & Canadian schools’ entrance requirements, faculty, laboratories & hospital relationships • Schools’ cooperated believing that review would lead to Carnegie Foundation support Flexner Report and Medical School Reforms • “Medical Education in the U.S. and Canada” – Lauded some schools: Harvard, Western Reserve, McGill, U of Toronto, Johns Hopkins (cited as a “model for medical education”) – Stimulated support from foundations & wealthy; University affiliated schools w/favorable ratings were primary recipients establishing future influence over future directions – Licensing legislation pursued; new standards for training duration, labs & other facilities Graduate Medical Education Consortia • Formal associations of medical schools, teaching hospitals, other organizations involved in residency training to improve organization, governance, MD supply and distribution through local coordination. • MD: allopathic physicians (138 schools); DO (Doctor of osteopathy- 29 schools); degrees are equivalent • No national licenses; state medical boards license with specific requirements; 3-7 yr. residency accredited by Accreditation Council for Graduate Medical Education (ACGME) required. Graduate Medical Education Consortia • ACGME: not-for-profit independent organization dedicated to quality of residents’ training – Accredits ~ 9,000 U.S. residency programs; also addresses MD distribution and supply – 2012 transition to outcomes-based evaluation system to measure competencies. – ACA: redistribute specific resident training slots to needed specialties and areas with Medicare reimbursement flexibility Delineation and Growth of Medical Specialties • AMA concerns began in mid 1800s: – Fragmented care (not treating “whole patient”). Assignment: Medical Education and the Changing Practice of Medicine Medical Education • AMA slow response prompted specialists to form their own societies – Late 1800s: specialty associations formed in ophthalmology, otology, obstetrics & gynecology, pediatrics Delineation and Growth of Medical Specialties • Deficient training of medical specialists – At 1910 Flexner Report, huge variations in specialty training duration & quality; virtually any physician could call themselves a “specialist.” – 1917 WWI army recruitment revealed shocking “unfit” to practice as “specialist” MDs and some overall “unfit” – American College of Surgeons est. oversight & practice standards for certifying surgeons in 1917 Delineation and Growth of Medical Specialties • Deficient training of medical specialists, cont’d – 1924: AMA Council on Medical Education began approving hospitals for residency specialty training programs; for next 40+ years, poorly conducted programs persisted – AMA: Citizens Committee on GME, chaired by John Mills; 1966 report eliminated independent internships, awarding residency accreditation to institutions, not hospital departments; report led to current residency requirements Delineation and Growth of Medical Specialties • Deficient training of medical specialists, cont’d – 1970: “internship” dropped; AMA endorsed first year graduate training in a program approved by a “residency review committee (RRC);” by 1980 AMA issued training recommendations for the first postdoctoral year. – Current curriculum for specialization: well defined & standardized: medical school graduation-> approved residency program-> pass qualifying examination(s). Specialty Boards & Resident Performance • Hospitalists – Growing field outside of formal specialty training; sole responsibility caring for hospitalized patients; 30,000 in practice in 70% of U.S. hospitals – Most trained in internal medicine or pediatrics – Hospitalist benefits: expedite & improve coordination of hospital care, reduce costs, enable continuity, improve patient satisfaction – Current initiatives to “certify” role in relevant specialties Physician Workforce Supply and Distribution • Mid 1960s: Government predicted national MD shortage; policies to increase no. of MDs – Medical schools increased by 50%: students by 100% • 1980-2000: MDs increased from 467,679-> 813,770 (74%): 2012: 834,769 active U.S. physicians, median of 244/100,000 population • Issues: U.S. lacks national methodology to predict supply/demand Physician Workforce Supply and Distribution • Wide variations in practice locations not actual supply, e.g. Massachusetts- 415/100,000; 176/100,000 in Mississippi; rural and inner-cities chronically plagued by undersupply • International Medical Graduates (IMGs) fill residency gaps in shortfall of U.S. graduates; about 6000 per year. Physician Workforce Supply and Distribution • Ratios of Generalist to Specialist Physicians and the Changing Demand – Primary care physicians (PMDs): family medicine, pediatrics, general internal medicine (sometimes obstetrics & gynecology included); historically, numbers considered deficient with concerns about specialists contributing to rising costs – 1990s’ managed care growth -> federal & state policies increasing primary care physician supply Physician Workforce Supply and Distribution • Ratios of Generalist to Specialist Physicians and the Changing Demand, cont’d – 2012 Annals of Family Medicine study- 52,000 more PMDs needed by 2025; 33,000 for sheer population growth, 10,000 for aging, 8,000 for newly insured.Assignment: Medical Education and the Changing Practice of Medicine Medical Education – ACA & ARRA provisions include supports for increasing PMD supply – Specialist to generalist ratio: 67:33 Physician Workforce Supply and Distribution • Ratios of Generalist to Specialist Physicians and the Changing Demand, cont’d – Demand for specialists is strong: growth in general population and aging population – Medical students’ career choices influenced by training role models’ values, skills; major income differentials between primary care & specialties; experience in clinical training sites; educational emphasis on specialty practice Changing Physician-Hospital Relationships • Historically, unique, interdependent relationship based on patient admissions; MDs paid fee-forservice, hospital for costs incurred; medical staff organization carried out responsibilities to ensure quality care; MDs sole decision-makers about admissions, lengths of stay, resource use & referrals. • System changes: hospital fiscal penalties for lengths of stay; admissions require payer approval; readmissions carry penalties; health plans select hospitals based on cost-effectiveness Changing Physician-Hospital Relationships • Technology advancements allow MDs to compete with hospitals for outpatient services (diagnostic, surgical, etc.) • Hospital MD employment increase of 32% since 2000. – MDs leaving private practices due to: flat reimbursement, complex insurance, HIT requirements, desire for work-life balance Changing Physician-Hospital Relationships – Hospitals desire MD employment to secure market share, use of diagnostic & outpatient services, referrals to high-revenue specialty services, ACO development • AMA concerns in 2012: conflicts between MD loyalty to employer-hospital and patient best interests; MDs should inform patients about financial incentives related to treatment options Evidence-based Clinical Practice Guidelines • Clinical practice guidelines: protocols based on scientific evidence from rigorous review & synthesis of published medical literature – Evolved from data showing wide variations of medical procedures in different geographic regions and use of questionable services that added costs • AHRQ created by Congress in 1989 to develop guidelines; taken up by many professional & scientific organizations and evaluated by AHRQ Evidence-based Clinical Practice Guidelines – 14,000+ guidelines in online AHRQ National Guideline Clearinghouse • Evidence-based guidelines now considered most objective, least biased standards: help prevent use of unnecessary treatments, avoid errors with patient safety & consistent care priorities Health Information Technology and Physician Practice • HIT supported by ARRA, HITECH Act, ACA to incentivize EHR use, educate MDs in e-information collection, transfer & use • Medical schools, hospitals provide medical informatics training on spectrum of subjects, e.g. patient management, EHRs, e-Rx, research. • ABMS now certifies a MD subspecialty in “clinical informatics” within existing medical specialties. Health Information Technology and Physician Practice • HITECH: focus on EHR adoption among MDs, other professionals, hospitals through financial incentives for “meaningful use” paid through Medicare & Medicaid. – “Eligible providers” categories specified under Medicare & Medicaid; incentives paid on demonstrating highly specific “meaningful use” criteria by 1st stage deadline dates. Health Information Technology and Physician Practice – 2nd stage “meaningful use” criteria require demonstrating active consumer engagement in communication with providers – Participation rates to date have met expectations • HIT applications expected to transition medical care to new norms of computerized decision support systems, evidence-based practice, Assignment: Medical Education and the Changing Practice of Medicine Medical Education EHR use, computerized physician order entry and eprescribing Ethical Issues • Two areas of major physician concerns in the changing health care system 1. Medical care use: insurers’ efforts to manage costs, quality, access, subject physicians to numerous cost-avoidance parameters prompting issues of patient risk; traditional fee-for service practice yielding unnecessary procedures, ineffective treatments, fragmented care Ethical Issues 2. Technology advancements: life prolonging capabilities lack accompanying standard procedures for making terminal care decisions that must be dealt with by physicians, families, hospital ethics committees; gene manipulation and therapies present formidable use/abuse potential, e.g. genetic “blueprints” predicting future disease/treatment Future Perspectives • Physicians will transition from piece-meal feefor-service (volume-driven) to population health (value-driven) focus by participating in PCMHs & ACOs that align financial incentives with desired population health, i.e. public health outcomes • Public reporting on physician quality will increase overall quality and empower consumers Future Perspectives • Medical schools will enhance public & population health curriculum content and include content in national licensing examinations. • In the reformed system, medicine will seize opportunities to improve population health status through collaborations with other health & community-serving professionals, citizens & elected officials to ensure a coherent, effective and efficient delivery system for all Americans • Modified by ECPI University 2015 Chapter 7 The Healthcare Workforce Introduction & Health Professions • One of largest U.S. employers; 16.4 million, 11.4% U.S. workforce • 200+ occupations & professions; At 35% of workforce, hospitals are major employers (Fig. 7-1) • New vocations result from system changes, ~5.6 M new jobs in next decade, more than any other industry Introduction & Health Professions • Employment growth highest among health plans, ambulatory clinics, home health, offices of practitioners • Specialized positions result from medical advances, but reduce flexibility & increases costs – Growing acceptance of multi-skilled professionals, esp. in hospitals combining roles in related fields. Credentialing, Regulating Health Care Professionals • Government regulation necessary to protect citizens from incompetent, unethical practitioners. States are primary regulators; variations from state-to-state • ~50 occupations regulated by: 1. State licensure 2. Certification 3. Registration Credentialing, Regulating Health Care Professionals • The “downsides” of regulation – Restrictions limit health care organizations’ use of personnel and abilities to innovate in patient care – Restrictions influence professional educational programs to tailor curricula to testing requirements • States revising credentialing to provide more flexibility to fast-changing technology State Licensure • Most restrictive type of regulation; restricts entry into fields of practice • State laws define practice scope, education and testing requirements. • Prevents use of professional titles without meeting predetermined qualifications • Licensure boards: concern for setting standards, assessing competence for entry to fields of practice; power to censure, warn, revoke State Licensure: Shortcomings • Assesses only qualifications on entry to field • Does little to assess continuing competence; only continuing education courses Assignment: Medical Education and the Changing Practice of Medicine Medical Education. • Lax discipline; rarely censure or revoke licenses Physicians • 137 U.S. Medical Schools – 17,364- 2011 graduates • 26 Colleges of Osteopathy – 4,200 annual graduates – 7% of all U.S. physicians (63,000) • MDs, DOs share same privileges • Medical students ~49% female, ~38% minority Physicians • Post-graduate training – Most states require at least one year for licensing; professional standards require a minimum of 3 years of residency training to practice a specialty – Residency may range up to 8+ years; – Fellowships required for certification in subspecialty areas Physicians • Gap of 5,000 1st year residents filled by graduates of foreign medical schools – 6,000 foreign nationals enter U.S. practice per year – 25% of U.S. practicing physicians • ~1300 U.S. citizens attend foreign medical schools & return to U.S. each year • 35% of 700,000 practicing U.S. physicians are primary care: Internal medicine; Family practice; Pediatrics Nursing • Early U.S. Nursing • First professional training program: 1861, Philadelphia Women’s Hospital • Pre-WWI, 3 domains: public health, private duty, hospital – Public health elite: TB & infant care • 1920: 70% worked private duty, half in homes and half for private patients in hospitals; few employed in hospitals Nursing: Post WWI • Hospital care & training emphasized; hospitalbased schools of nursing proliferated to provide sources of low-cost labor; social & public health aspects were subjugated to image as symbols of national sacrifice & efficiency, deferential to physicians • Nursing leaders promoted high-quality nursing schools, preferably associated with universities Nursing: Training & Education-RNs • 2 yr. associate degree • 2-3 yr. hospital diploma programs –now defunct • 4-5 yr. bachelor degree at university/college • Specialization followed medicine starting in 1950s: By 1960s, masters and doctoral level preparation for teaching, advanced practice fields; clinical nurse specialists Nursing: Employment & Education Trends-RNs • 2010 report: 3 M+ RNs; 84.8% actively employed; increase of 1.5 M 1980-2008; 1/3 of increase due to importation of foreign-born graduates • Hospitals are primary employers, followed by ambulatory care and Community/public health (Table 7-2) Nursing: Employment & Education Trends-RNs • ~90% receive basic education in an institution of higher education (often ADN) from community colleges compared with 20% in 1960; graduate- degreed nurses now comprise 13.2% of all RNs, twice the percent reported in 1988. – > 180 schools offer doctoral programs: DNP, DNS, DNSc, DSN and PhD. Nursing: Employment & Education Trends-RNs • Hospital consolidations, fiscal pressures created hospital nursing stressors: sicker patients, higher nurse-to-patient ratios, supervision of lesser-skilled staff • Average RN age of 46 years leveled off in 2008 with recent increases in new graduates • Innovations of RWJF, sign-on bonuses, accelerated programs to address shortages Licensed Practical Nurses • Under supervision of RN or MD • One-year training in ~1,100 approved technical schools, vocational schools, community colleges, including classroom & supervised clinical practice • State license exam required • Hospital positions decreasing; other settings, e.g. nursing homes, residential care increasing.Assignment: Medical Education and the Changing Practice of Medicine Medical Education • Overall employment expected increase of 22% by 2020. Nurse Practitioners • RNs with advanced education, clinical experience; origins in 1960s due to MD shortage • Most have master’s degrees; national certification required; states prescribe scope of practice: 400 accredited masters & 100 accredited post masters programs • Specialize: e.g. neonatal, pediatric, school, adult, family, psychiatric, geriatric, obstetric, surgical, emergency • Cost effective, highly regarded; growing demand Clinical Nurse Specialist • Developed in response to highly specialized medicine • Focus on highly complex, sickest patients • 200+ masters programs for specialist preparation Dentistry • Early practice by barbers, blacksmiths & MDs • First school chartered in 1840 with 2-year program; by 1884, 28 schools, most privately owned; by 1900, most states required licensure • 1926: Critical Carnegie report reorganized dental education. • WWII: recruits’ poor dental health raised public health awareness; Selective Service eliminated all dental standards • 1940s: Public health dentistry est. by U of Michigan; dental public health now a recognized field with American Board of Dental Public Health Dentistry • Specialties (83% of 155,000 are generalists) 1. Dental public health 2. Endodontics 3. Oral & maxillofacial pathology 4. Oral & maxillofacial radiology 5. Oral & maxillofacial surgery 6. Orthodontics & dentofacial orthopedics 7. Pediatric dentistry 8. Periodontics 9. Prosthodontics Dentistry: Trends • Recognition of Dental Anesthesiology under review in 2012 by the ADA as new specialty • Decline of 1200 graduates per yr. since 1980 • Operates as “cottage industry” unaffected by managed care, health reforms; most in solo practice serve only paying patients; many lowincome are underserved; absent dental “safety net. Pharmacy • Practice dates to ancient times • Colonial U.S.: Hospital pharmacists were apprentice MDs; separated in 1765 • American Pharmaceutical Association founded 1852; now, 85 U.S. colleges of pharmacy • Employment growing: aging population; increasing involvement in clinical decisions and physician/nurse/patient counseling • 127 accredited schools grant Pharm.D in 6 year programs; License requires internship & state exam Pharmacy • ~12,000 graduates/yr.; ~275,000 active; employment demand will exceed supply through 2020 • Board of Pharmaceutical Specialties certifies specialists in: nuclear, … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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