UNIVERSITY OF PENNSYLVANIA

Philadelphia, Pennsylvania

Team Contact/Coordinator: Lorna Lynn

E-mail: lynnl@mail.med.upenn.edu

Phone: 215/662-3799

Fax: 215/349-5091

Faculty Development Needs to Address at the Models That Work Conference

We hope to help faculty learn how to teach while practicing in ways that 1) allow residents to develop independence, 2) maintain practice efficiency, 3) meet documentation/billing requirements and 4) can be reflected in academic productivity.

Improving ambulatory care training is a top priority for the internal medicine residency at the University of Pennsylvania, and we see our residents' continuity practices are the cornerstone on which other ambulatory training experiences are built. For many years, most of our residents have had their continuity practices at a traditional hospital-based residents' clinic. The patients who seek care at the clinic come primarily from the community surrounding the hospital, represent ethnic minorities, have low income, and either depend on medical assistance or have no insurance. The patients are also some of the most difficult patients to care for in our health system; they often have multiple medical problems, complicated by psychiatric illnesses and poor social support. Residents have frequently voiced frustrations with their continuity practice experience, saying that while they enjoy caring for their patients, and value the doctor-patient relationship which they develop with their patients, they feel that they cannot provide adequate care because of problems with continuity-of-care and inefficiencies of the practice. The structure of the residents' practice experience poses impediments to continuity. Residents practice one half-day each week, and have some extended periods with no practice sessions (during intensive care unit or emergency department rotations, and while on vacation). When a patient's resident physician is not practicing, the patient is seen by one of two nurse practitioners or by any resident physician who might be available on a given day. Efficiency in the residents' practice is a chronic problem because the clinic practice is understaffed in terms of clerical support compared to our other hospital-based practices. In addition, physician services have not been billed, and the practice has required significant hospital support to remain open, making if difficult to improve services to this patient population.

In July of 1997, a multispecialty task force was created to examine ambulatory education in our training program. Given that the cornerstone of ambulatory training is the continuity practice, we focused on that. After long consideration, we decided that it would be better to decentralize the continuity practices rather than attempt to improve the traditional clinic. In the decentralized system, residents practice as junior colleagues with clinician-educator faculty in the faculty practices. After one year of planning, the first phase of the program was implemented in July of 1998. We hope and hypothesize that patients, residents, and faculty will all benefit from the change. Patients will benefit from closer involvement of faculty physicians, better continuity of care, and from receiving care in practices which run more effectively. Residents will benefit from closer mentoring and role-modeling with faculty preceptors, and from working in practices which are more heterogeneous with regard to patient demographics and diagnoses, which function well, and which more closely represent the "real world" of medicine than does a traditional residents' clinic. Faculty will benefit in terms of professional satisfaction resulting from closer involvement with the residents and their patients, and decreased frustrations from no longer precepting in the inefficient clinic system.

The challenges to implementing the system are daunting, particularly with regards to faculty. Our clinician-educator faculty are taking on new practice and teaching responsibilities while facing daily pressures regarding their clinical and academic productivity. In the past, faculty preceptors spent one half-day per week in the residents clinic, waiting for residents to present cases, and only sometimes seeing patients. The ratio of resident to faculty was generally five or six to one. The linking of faculty physician and patient was very loose; faculty did not practice at the site and had little responsibility for patients during other hours. This precepting assignment met a teaching requirement of the Department of Medicine.

In the decentralized system, two different models are employed. In the first, a faculty member practices with a group of four residents, utilizing the Medicare primary care exemption rules for billing and documentation. In the second, the faculty member practices with one resident, seeing his or her own patients in parallel during the session, and billing only for those services which the attending actually provides to the patient. Because each resident must practice one half-day session per week, the number of faculty sessions required for precepting is increased. With both models, administrative and educational challenges are significant. Administratively, examination room space must be found for the residents, and there is an influx of patients with complex medical and social needs into already busy practices. Not least, billing and documentation requirements are complex, and the stress around this is compounded by our institution's history of a $30 million Medicare fine for inadequate documentation and alleged inappropriate billing. Despite repeated training sessions, considerable confusion remains in this area. Educationally, faculty must adapt to a teaching style that is both efficient and patient-centered, without compromising the development of independence by the resident or negatively affecting the office routine. From the perspective of the residency program, there are other administrative and educational challenges. The several distinct faculty practices need some autonomy with regards to style and scheduling. But appropriate curricular material must be covered for all residents. In summary, our key faculty development needs are helping faculty learn 1) how to teach while practicing 2) how to co-manage patients with a resident without smothering the resident or unduly impacting practice efficiency 3) how to master the billing and documentation needs 4) how to reflect their teaching in their academic productivity 5) and how to build camaraderie among hard-working faculty at several geographically scattered sites.

During this first year of implementation, 23 of 42 first-year categorical internal medicine residents were randomly assigned to one of three general internal medicine faculty practices, with the remainder practicing at either the Philadelphia Veterans' Administration Medical Center or in a multi-specialty clinic at Presbyterian Medical Center. An additional eight first-year primary care residents practice in another faculty practice. We plan to look at satisfaction with the continuity practice experience for all residents, and to look at practice panels to compare patient demographics and diagnoses. Patient satisfaction is routinely measured by the health system, and we will evaluate samples of patients from each site. Helping the faculty adjust to the new system, measuring its impact on the faculty, and justifying the increased resources demanded from and required of the faculty is more difficult. Receiving expert guidance in both process and assessment as a pilot team would be of inestimable value.

Preliminary Thoughts on Addressing Faculty Development Needs

To address our perceived key faculty development needs (efficient teaching that allows the development of resident independence, mastery of billing and documentation requirements, helping clinician-educator faculty with personal academic development, and building rapport), we plan the following steps. First, semi-annual faculty retreats for the clinician-educators will be held to allow an opportunity to identify the strengths and problems at each site, to share experiences, and to focus on the development of a skill that will be of benefit in our teaching. Examples of such skills include aspects of physical diagnosis and a more conscious approach to creating a learning climate. We hope to both use expertise from within our own faculty and to invite outside speakers to provide a fresh perspective and to emphasize the importance of the occasion. Second, we are considering having one of our health service researchers conduct one-on-one or small group interviews with the faculty to more formally identify attitudes and experiences related to teaching in a decentralized system. Third, we need to find ways of quantifying the effort of faculty that go into the teaching program. The purpose of such a quantification is at least two-fold; we want to use our best educators most appropriately, and the Department of Medicine plans eventually to move to a system in which teaching is financially recognized as are clinical and research efforts. Fourth, we hope to find ways of measuring professionalism in our residents and explore methods of teaching professionalism at the resident level. The clinician-educators who precept the continuity practices will be key faculty for this effort.