Matrix or Silo — View from ACE Katie

Matrix or Silo - View from ACE Katie Margo, MD Predoctoral Director Department of Family Medicine and Community Health University of Pennsylvania School of Medicine

Goals v. Describe ACE v. Why collaborate? v. Examples of collaborations between specialties v. Barriers v. Key to success

Alliance for Clinical Education: ACE v Multidisciplinary group formed in 1992 to enhance clinical instruction of medical students. v Mission - foster collaboration across specialties to promote excellence in clinical education of medical students. v Members include representatives of the groups that direct the core clinical clerkships in American medical schools.

ACE Membership v. Family Medicine (STFM) v. Internal Medicine (CDIM) v. Neurology (CNCD) v. Ob-Gyn (APGO) v. Pediatrics (COMSEP) v. Psychiatry (ADMSEP) v. Surgery (ASE)

ACE leadership v. President - Lou Pangaro v. Exec Director - Gary Beck v. Council - Reps from each of the organizations v. Committees: ØResearch ØCommunications ØPublications

ACE Projects v Guidebook for Clerkship Directors - Rhee Fincher ed. v Survey of all Clerkship Directors - ongoing v Papers: Ø Expectations of and for CD’s (Pangaro) Ø Recommendation for clinical skills curriculum Ø Med student exposure to drug reps Ø TLM - Journal watch, proceedings etc.

Why collaborate? v Good for students: Ø Consistency of goals and purpose Ø Avoiding duplication Ø Making sure all topics/skills covered Ø Modeling teamwork Ø Remediation v Good for faculty/SOM Ø Economy of scale (sites, didactics, faculty development, administration etc) Ø Collegiality/cooperation

Types of Collaborations v. Preclinical courses v. Combined clerkships v. Joint didactics v. Joint evaluations/remediation v. Joint policies

Preclinical courses v Many cross specialty collaborations Ø Introduction to clinical medicine: § History and Physical § Communication skills Ø System based courses § Ex: Ophthal/neuro/psych Ø Professionalism courses v Small group sessions - leaders from different specialties

Challenges v. Who directs course? ØHow to split administration of the course? ØWho funds it? ØWho is the “heavy” in recruiting teachers? v. Getting faculty from the “other” departments

Joint clerkships v Often primary care or in rural settings Ø Similar goals Ø More cooperation bet specialties in rural settings v Part of overall curricular change v Specialties commonly paired: Ø FM and IM Ø Ob-gyn and Peds Ø Surgery and ER or anesthesia

Joint Clerkships - Rural v. RMED - Rural Medical Education Upstate Med Univ Syracuse (1989) ØStudents do FM and other clerkships in a longitudinal format ØOnly available to some students Ø 9 months ØRun by FM

Joint Clerkships v UCSF - one of oldest (since 1980) - when ambulatory settings recognized as critical for training Ø 3 rd and 4 th Year - 8 weeks Ø Choose from large number of sites - IM or FM Ø Include community projects Ø Tried integrating surgical subspecialties - didn’t work v Piloting integrated, longitudinal clerkship - like Cambridge Hospital - logistics huge barrier! Ø Shore Family Medicine 1993

Joint Clerkships v University of Connecticut: Ø Clerkship year divided into three: Multidisciplinary ambulatory experience: MAX 1, MAX 2, and inpatient - each is 16 weeks Ø Primary care rotation: FM/IM/Peds § Share topics in “home” weeks (obesity, patient safety) § Still individual rotations Ø Barriers - separating in-patient peds with outpatient - shelf exam etc.

Joint Clerkships v Kansas University Ø 6 Week FM paired with 6 weeks Ambulatory Med/Geriatrics Ø Advantages: § 12 week EBM curriculum § Coordinate didactics Ø Challenges: § Who makes decisions - holding accountable § Philosophical differences bet FM/IM § Fewer IM preceptors available

Office for Community-based Education and Research v Dartmouth - OCER office coordinates community preceptors all disciplines Ø Site visits Ø Faculty development Ø Faculty recruitment and retention Ø Coordinate curriculum Ø Evaluation/research v Developed by three primary care disciplines v Financed by Deans office: $180, 000 Ø Carney, Acad Med 2002

Centralized office v. Successes ØDatabase ØEvaluation ØFaculty recruitment, development v. Challenges ØLose specific relationship with departments ØTrouble scheduling meetings

Inter-sessions/Bridge v“Orphan” topics ØGenetics, domestic violence, geriatrics etc. v. UVM Ø 6 weeks scattered through clerkship year ØBig issues: death and dying, CAM, EBM Ø 1 week shared IM/FM/Peds - clinical skills (interviewing, M/S exam, adolescence, domestic violence)

Collaborative Curriculum for Chronic Obesity v Med Coll Wisconsin - obesity curriculum divided bet Peds/IM/FM § Collaborated on objectives then divided per specialty § Funded by a State grant § Students get an online toolkit to take to preceptors office for screening in each specialty rotation

Cross clerkship collaboration v. Combined exams ØOSCE - Penn has FM/IM OSCE at end of 12 weeks ØMany schools have end of clerkship year clinical skills exam - collaborative effort v. Joint didactics/skills sessions ØSurgery/anesthesia

Cross clerkship collaboration v. LCME Policies ØED 2 response - Dartmouth log system interdisciplinary (Nierenberg Acad Med 2007) v. Jefferson - policy for remediation Ø IEP (individual education plan) ØOutlines where and when to remediate struggling students

Barriers/Challenges to Collaboration v Imposed from above - will there be new resources that go along? v Not convinced interdisciplinary programs will be superior - don’t see need v Loss of control v Different approaches of different disciplines are good for students to experience

Barriers/Challenges to Collaboration v. Competition among specialties for student interest- esp in primary care specialties where numbers decreasing v. Sense that only collaborate when convenient v. Different cultures/traditions v. Different schedules v. Shelf exams/Evaluations/Grades

Keys to Success v. Mutual respect! v. Communication formal and informal v. Clear objectives and understanding of mutual needs v. Getting buy in up front from all partners v. Adequate support from SOM, department chairs, colleagues

Keys to Success v Clerkship directors should meet monthly Ø Coordinate curriculum to meet ACGME competencies - share information about curriculum, didactics, evaluations v Coordinators should also meet as a group v Joint Policies: absence, holiday, faculty development etc. v Informal networks

Deans Office Support v. Setting clear goals for change with adequate input from all involved parties v. Facilitating and participating in meetings v. Financial support for all involved departments v. Administrative support

In Conclusion v. Many great reasons to collaborate v. Lots of ways it can be done v. Needs to be done thoughtfully and collaboratively