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2008 feedback

Wildacres 2008 Physician Formation notes by Anne Mounsey

Notes from small group meetings on physician Formation: Wildacres 2008
 
Themes on white board:
 
Ideas that are important to FM physician formation:
 
1)      House calls – bring them into daily practice
2)      Capture patient stories in chart/EMR
3)      Creating time to reflect – morning reports, lunch etc
4)      Reflection on key life events – birth death marriage etc
5)      Role model the “cathedral builder” in medicine – the person in Rachel Remen’s allegory who sees the work of cutting stones as contributing to something glorious.
6)      Defining appropriate boundaries between professional life and personal life
7)      Model doctor patient relationship
 
 
Key themes that could form a core of the clerkship:
 
1)      Focus on role models is key to formation. Recruitment and retention of excellent preceptors is crucial
2)      Reintegrate home visits. Key to helping students understand the context of the patient but need to be seen by the students as “useful”
a.       Home visits with Community Care Case Managers
b.      Home visit after hospital discharge framed as “pre-visit” for upcoming office visit
3)      Focus clerkship on relationship with patients. Focus on advanced interview skills to give students practical skills in establishing rapport, assuring understanding and counseling.
4)      Patient Centered Medical Home needs to be introduced but systems of care skills are likely advanced skills more appropriate for courses such as Advanced Practice course.
5)      Incorporate life events in some way in the clerkship.
 
Ideas for medical student education.
 
1. Continuity track in medical school so that students learn continuity in the clerkships.
  1. Mediation Skills – A key element of the curriculum.
  2. Significantly change basic science – start patient care in MSI.
  3. Build teams in medical school.
  4. Change admissions – emphasize the traits such as people centeredness, positivity and engagement, rather than skills.
 
 
 
Residency Groups. Ideas for Formation of Family Physicians.
Professional Development Curriculum would include:
 
1.      Time for reflection not only for residents but faculty should role model this. What does being a physician mean? What do I bring to being a physician?
2.      Graduated physicians return a year or so later and talk to current residents about their formation and what they have learnt in practice.
3.      Value of the family physicians professional community
4.      Time to share the aspects of family medicine residents value and what they will look for in their future practices
5.      Sharing the non professional part of faculty lives is important for residents to see faculty as people.
6.      Develop Meaning in Medicine sessions for all teaching practices to emphasize the importance of rediscovering joy and meaning in their work.
7.      Improve the quality of mentoring relationships more contact outside the work environment. Change the advising system. Add other professionals to it and think about when it is done. Must make it both at the beginning and regularly but also when it’s necessary
8.      Behavioral health advisors
9.      House calls with advisor (time to connect with advisor) or house calls with the behavior medicine faculty.
10. Residents writing (or discuss) about being a physician, why did I become a physician and patients stories.
11. Team meetings which are cross generational.
12. Residents talking to medical students or even high school students about being a family physician also gives them a chance to think about what it does mean.                               
13. Change in residency culture – underscoring hope and healing.                          This requires a community and also an emphasis on healing as opposed to illness.
14. Help residents gain ownership by giving them a panel of patients. This will help them take personal responsibility for a set of patients and accelerate that empowerment. An extension of this is the USC idea of incorporating panels at the basis of a lot of curriculum and explicit early introduction to the panels.
15. Develop a sense of team in the FMC that you have in the inpatient setting. Part of this is the intense affect and collegiality that inpatient care comes forward. One might do that with huddles, sense of problem solving and involvement of the team, not just the MDs
 
 
More Focused Ideas for Implementation in Residency
10/21/08
 
(The idea now is to put in place proposals that could be implemented in the near future or for which a grant could be written.)
 
  1. Change the advising system of residencies/mentoring. Add other professionals (non-MDs) and also make some explicit link to the larger group that must be present to train a physician (it take a village…)
  2. Go back to pre-Flexnerian medical education, emphasizing apprenticeship to clinical masters from day one rather than the basic sciences.
  3. Build into medical student and residency training other sorts of learners—nursing, PharmD’s, etc.—in order to overcome the bigotry that often takes place. One could do this by specifically combining experiences such as lectures but also other extracurricular things such as SHAC and other elements of curriculum.
  4. Rethink the half day clinic experience. Emphasize huddle with the nurse before, time to reflect afterwards with balance panels รก la USC and a continuity of the nurse experience who plays a significant role in the development of the young doctors.
  5. Modify our current junior clerkship to emphasize life events and transitions. Require each student to visit a patient in the hospital and at home, perhaps along with a behaviorist or some other physician. The notion is to explicitly capture key life events and reflection in addition to the List of Diseases.
  6. Establish a culture of positivity, understanding the very real benefits from positive frames. Ways of doing this include embedding a requirement for elements of things that have gone well as part of huddles, inpatient team rounds and the like. This is “many Rachel Remen moments at every stage.” Faculty must model this both in faculty meetings and in other settings.
  7. Create a culture of case discussion or stories. We want a residency in which case stories are constantly discussed. Sometimes this would be in formal ways through CPC’s or implementing the requirement that rounds start with a physical patient being present. But, we also need to create a culture in which stories are shared among clinicians at every stage. We do this by having space in which people can meet and talk, faculty leadership to encourage the sharing of stories and time spent together over food and other settings. It’s important that any regular conference to share stories happen frequently so that it is a regular rather than an unusual event.
 
 
 
Research ideas on Physician Formation:
 
  • Measurement: How do you measure/gauge formation? Metrics of professional and personal development, current measures of satisfaction, burnout; Study “exemplar physicians”
    • Johns Hopkins longitudinal study of graduates
  • Impact of context on physician formation: How does “community” (medical home, office, hospital, residency) contribute to or inhibit physician formation? What is the interaction between individual physicians and their communities?
    • National Health Service Corp
  • What are the individual and contextual influences on formation? Are the differences due to generational or age effects? How has technology impacted formation?
  • Educational: “slow” medical providers (i.e., residents and physicians who spend a great deal of time with their patients; poor productivity but great patient care); Does patient continuity impact formation?
  • Community health: How have family physicians contributed to the health of their communities?
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