- Email: [email protected]
Teaching Integrative Medicine to Residents
Teaching Integrative Medicine to Residents A Focus on Populations Rather Than Individual Patients Sajida S. Chaudry, MD, MPH, MBA,1,2 Maura J. McGuire, MD,2 Clarence Lam, MD, MPH,1 Elham Hatef, MD, MPH,1 Scott M. Wright, MD,2 Miriam H. Alexander, MD, MPH1 Introduction: Integrative medicine (IM) is by its very definition patient centric: “It reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches.” Best methods for teaching IM in residency have not been well described. Methods: An IM curriculum for preventive medicine (PM) residents was thoughtfully developed and iteratively revised using Kern’s six-step approach. The centerpiece of this curriculum was to have learners work collaboratively within teams on projects that would facilitate IM-focused care within primary care practices. Before embarking on specific IM-related projects, residents immersed themselves within the practices to understand the needs of the community. Results: Forty-eight PM residents have participated in the curriculum in the last 3 years, and 27 unique physician preceptors served as mentors for the projects. Both residents and preceptors enjoyed working on the projects, and both groups considered the work to be a valuable educational pursuit. Common IM content areas covered by the projects dealt with interprofessional collaboration, health promotion, and population-based prevention. Although there were challenges associated with implementation of the projects, overcoming these enhanced the PM residents’ confidence and ability to serve as agents of change. Conclusions: An IM curriculum was successfully incorporated into a PM residency program. The focus on serving the community, or a population health approach, may not be the most common approach in IM, but it worked effectively to enhance the IM knowledge and skills of PM residents. (Am J Prev Med 2015;49(5S3):S285–S289) & 2015 American Journal of Preventive Medicine. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
I
ntegrative medicine (IM) is defined as healingoriented medicine that takes account of the whole person, including all aspects of lifestyle with the goal of optimal health, emphasizing the therapeutic relationship between practitioner and patient, informed by evidence, and making use of all appropriate therapies, including conventional and complementary and From the 1General Preventive Medicine Residency Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; and 2 Johns Hopkins Community Physicians, Johns Hopkins Medicine, Baltimore, Maryland Drs. Scott Wright and Miriam Alexander served as co-senior authors on this manuscript. Address correspondence to: Sajida Chaudry, MD, MPH, MBA, Johns Hopkins Community Physicians at Odenton, 1106 Annapolis Road, Odenton MD 21113. E-mail: [email protected]. 0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2015.08.001
alternate medicine approaches.1,2 IOM’s definition emphasizes “therapeutic factors known to be effective and necessary for the achievement of optimal health throughout the lifespan.”3 The emphasis of IM on the relationship between patient and physician4 has to some extent hindered efforts of truly integrating all of the modalities of healing within the context of populations. Furthermore, little attention has been devoted to teaching the principles of IM to medical learners because of the unfamiliarity with the scientific evidence and slow-growing empiric basis for improved clinical outcomes.2 Most IM programs at the graduate medical education level are taught within the context of family medicine residency programs, where residents are intimately involved in direct patient care.5 Because direct patient care experiences are limited in preventive medicine (PM) residency training, the best ways to teach IM’s patient-centered philosophies and
& 2015 American Journal of Preventive Medicine Published by Elsevier Inc. This Am J Prev Med 2015;49(5S3):S285–S289 S285 is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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approaches have not been well described. When applying for the Health Resources and Services Administration grant and describing our interest in developing an innovative curriculum to teach IM to PM residents, the authors promised to focus on systems change and to take a population health approach.6,7
Methods Subjects and Setting Targeted learners were PM residents at Johns Hopkins University School of Public Health. In order to gain a deep understanding of healthcare delivery systems, the residents are assigned to one of the Hopkins-affiliated community-based primary care practices (Johns Hopkins Community-based Physicians) for 24 months. As part of this longitudinal experience, the residents spend 1 day each week and are tasked with developing a project that will positively influence IM care delivery at the site. To date, four cohorts of PM residents have gone through the iteratively improved curriculum.
Curriculum Development The curriculum was developed during a year-long curriculum development course that has been running for 32 consecutive years at Hopkins. The overarching curricular objective was to ensure that after participating in the educational experience, learners would have successfully developed an IM initiative that was both innovative and effective in enhancing the IM care offered by providers to patients at the practice site. The approach was to think about IM from a population perspective with a goal of improving health for the population of each health center. This strategy for addressing IM is unlike others where the perspective relentlessly considers IM at the level of a single provider interacting with a single individual with a patient-centered approach. Although the centerpiece of the curriculum was the mentored project, the following content areas were taught using variant methods and formats because of their relevance to IM or to integrating a clinical innovation into practice: quality improvement, electronic medical record training, behavior change, health promotion, complementary and alternative medicine approaches, lifestyle medicine (including but not limited to nutrition, exercise, smoking, and alcohol),3 and project management. Reflective practice, usually in the form of writing prompts, was incorporated into the curriculum at regular intervals to push trainees to think about their work deeply and to consider perspectives that may be unusual or overlooked. For the resident-led projects, each PM resident was paired with a faculty preceptor who would serve as mentor, connector, sounding board, and project champion to help pitch or sell the project to peers. Core curricular faculty (n¼4) and the faculty preceptors from the community-based practices (n¼27) received extensive training from the curriculum development team (>10 hours). Preceptors were not offered monetary compensation for their time and effort; their involvement was entirely voluntary and generous. Both the curricular content that was taught and the discussions between PM residents and faculty preceptors about selecting an appropriate project were framed in and heavily considered Berwick’s principles of IM.3 Given the limited financial resources available to
support the roll out and implementation of projects, costs and feasibility were discussed when considering the effort and likely yield. When costs of proposed projects were going to be moderate, reflection about whether improved quality and outcomes could be proven in the context of the opportunities afforded to Accountable Care Organizations through the Affordable Care Act occurred.
Project Teams, Effort, Deliverables, Selection, and Feedback Beyond the resident and faculty physician preceptor, interprofessional teams were recruited within each practice to support the project. The PM resident was expected to devote 8 hours per week to the project and to manage the team such that additional hours were invested by other team members. Each project was expected to yield clinically relevant deliverables at the end of a 2-year time period. Project selection was a multistep process. Each year, several projects were proposed as being needed and beneficial to communities served, as well as individual patients. These suggested project areas were recommended based upon alignment of strategic priorities of Johns Hopkins Community-based Physicians and availability of baseline data. Ideas were considered most appropriate for addressing as part of this curriculum if they would allow many providers to be more effective in their delivery of IM care to their patients, both individuals and the community served by the practices. Residents were, of course, also invited to submit ideas. After potential projects were vetted and refined, residents were invited to choose projects from the list based on their interest. In the majority of cases, PM residents were able to secure their first choice. It became apparent that residents were most interested in working with underserved populations and addressing issues wherein there would also be mentorship from faculty at the Johns Hopkins Bloomberg School of Public Health. Although some residents worked individually with their preceptor and support team, resident teams of two to three were allowed to be placed in the sites. In addition to getting regular input from members of the project team, residents presented their work at quarterly informal work-in-progress meetings. Once annually, more detailed and more formal presentations were made; on these occasions, experts from a wide array of disciplines were invited to provide feedback.
Curriculum Evaluation A basic element of the evaluation process involves questionnaires that are completed by residents and faculty at the end of each year. The questionnaires include both quantitative and qualitative questions. All assessments are completed anonymously using an electronic format. Data analyzed for this paper included perspectives from the last 2 years because the curriculum was fairly different, and less refined, in the prior iteration.
Results Residents appreciated most of the curricular content that was delivered in small group sessions. Lifestyle health sessions were rated the highest (90% of residents agreed that educational objectives were fully met) and health coaching the lowest (only 50% concurred with the notion of the material meeting the educational objectives). www.ajpmonline.org
Chaudry et al / Am J Prev Med 2015;49(5S3):S285–S289
Almost all residents felt as if their faculty preceptor was committed to their success and was invested in the project. Over time, residents agreed more fully that their preceptors had an expanding understanding of the specialty of PM and its mission (Year 1, 50%; Year 2, 57%; Year 3, 82%). Similarly, residents felt positively that the curriculum provided useful knowledge and experiences that would help them in both their job searches and future careers (Year 1, 66%; Year 2, 86%; Year 3, 94%). Most residents (76%) were convinced that their faculty preceptors were aware of and committed to the curriculum’s educational objectives. Although residents were encouraged to seek project guidance from many (including those at Hopkins’ Business School8 and the Armstrong Institute for Patient Safety and Quality9), a majority (65%) were satisfied with the quality and quantity of teaching offered by their primary preceptor. Of note, the faculty member overseeing the curriculum (SC) also collected this type of information on an ongoing basis and stepped in to help when necessary (either in the form of coaching the preceptor or providing additional support herself). Preceptor feedback regarding their experiences with the curriculum was uniformly positive. Most preceptors (75%) believed that residents were spending an adequate amount of time and effort working on their projects, and 60% rated the collaboration of the project team as “outstanding” (top box on Likert scale). Although nearly all preceptors (86%) reported spending no more than 60 minutes weekly with the residents, there were differing opinions among preceptors about whether they had sufficient time to mentor their resident(s). Nevertheless, 87% responded that they would be willing to serve as a preceptor, and most (70%) believed that participation in the program enhanced the quality of patient care delivery at their practice. The preceptors identified several strengths of the projects, which included the broad scope and impact of project outcomes, the high value for patients and potential for financial value, the possibility of improved health outcomes, and the use of quality improvement tools to analyze complex practices and processes. Areas of improvement identified by preceptors included narrowing the scope of the project to a manageable size, improving the definition of the project at onset, better data collection and assistance with data interpretation, and the ability to engage staff and colleagues. The products that may most emphatically speak to the success of the curriculum are the projects that were developed and nurtured by the PM residents. Table 1 provides select examples of the initiatives that were established as part of this curriculum. In discussing the
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Table 1. Select Exemplary Projects Developed By Residents, Preceptors, and Multidisciplinary Teams as Part of the Integrative Medicine Curriculum Establishing sustainable healthy-weight behavior-change patient groups using the PDSA (plan, do, study, act) approach Improving access to smoking-cessation resources and reducing barriers to smoking cessation Designing and implementing a “health promotion campaign”: lifestyle and behavior change for health center staff Improving patient compliance with screening mammograms by comparing different methods of encouragement Improving access to healthcare resources for Spanish-speaking patients as part of a Latino health program Designing obstetric group visits for adolescent patients Reducing unnecessary emergency department visits and improving after-hours phone service with a behavioral-change communication campaign Improving transitions of care between a community hospital and a primary care practice Engaging office staff in the clinical unit safety program to improve patient safety Implementing health-risk assessments for Medicare patients through the annual wellness visits Improving human papillomavirus vaccination completion rates for pediatric patients utilizing electronic medical record enhancements Employing a community strategy to reduce hospital admissions for congestive heart failure in geriatric patients Enhancing screening for diabetic retinopathy with retinal photography to ensure optimal care and follow-up Implementing a nurse outreach and care-coordination program for patients at risk of poor clinical outcomes
educational value of working on these projects, the following themes were mentioned repeatedly:
Strong working relationship with preceptors and other
members of the healthcare team emerge from respectful collaboration. Complex problem cannot usually be fixed quickly— patience and persistence are key. Thinking about how IM approaches can serve a community can ultimately lead to best IM practices that the physician–patient dyad can use during clinical visits. Consideration of big picture healthcare reform can be overlaid onto IM’s goal of promoting optimal health for the individual. Electronic medical records can either be used to promote IM or they can be a hindrance; both the design and the operator determine how they are perceived.
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Celebrating the projects’ successes was done formally each year at a summit that highlighted IM, safety, and quality improvement. In addition to the residents, preceptors, and the curriculum’s core faculty, healthcare leaders from different Hopkins schools and leaders of clinical practices attended.
Discussion High-quality curriculum development can result in transformative educational experiences.10 Although some educators feel compelled to push and deliver much teaching and didactics to learners, evolving educational theory has suggested that experiential learning can result in the largest amount of growth and development. This curriculum focused on IM for PM residents and was developed and implemented with painstaking attention and care. Lessons learned in the first pilot years were used to iteratively revise the curriculum. Initially trying to satisfy the educational needs of both firstyear residents, who are new to the curricular content and processes, and those in their second year, who are on their way into the implementation phase of their project, was considered to be a big problem by the team. The residents assured them that peer teaching and learning was valuable. The Health Resources and Services Administration IM grant support was instrumental in stimulating and facilitating the development of this curriculum. When the funding ended, institutional entities rallied to find money to support its maintenance. Although this might have happened because the teaching of IM to PM residents was believed to be a priority worth backing, the reality is that for a small investment, wonderful projects that were advancing IM care delivery were being created and launched that were helping providers and benefitting patients. As the team reflected on the factors that have allowed this curriculum to succeed and become one of the jewels in the crown of the residency program, three deserve special mention. First, just as IM mandates a patient-centered approach to care, this curriculum was modeled with the same respectful tone to be extremely learner centered. As the residents and members of the multidisciplinary team requested support or teaching in specific areas to help advance their project, the preceptors and core curricular faculty were open and responsive to their needs. Second, there was a creative spin that made everyone excited about the curriculum, because IM is normally operationalized exclusively at the level of the doctor–patient relationship; in this curriculum, PM residents were challenged to envision how IM can be delivered to meet the needs of specific communities.11 Lastly, few residents are allowed to take the reins of a project that will translate into changes in practice. As the leaders of their projects, the PM residents guided multidisciplinary teams and gained skills that will
undoubtedly help them in their future work experience and professional roles.
Limitations Several limitations of this study should be considered. First, curriculum and evaluation revisions were mainly done annually and midyear revisions, beyond minor tweaks, were not carried out. Second, this curriculum was implemented and evaluated within a PM residency at a single institution. The success realized here may not be reproduced everywhere. Third, although the authors were able to find busy clinicians who were eager to mentor PM residents, such individuals may not be found everywhere. Finally, resources to support curriculum development or refinement are usually extremely limited.12 Fortunately, the grant and institutional commitment allowed the residents to be immersed in a transformative curriculum that solidified their appreciation for IM. Conclusions The growing number of medical schools in the Academic Consortium for Integrative Medicine and Health indicates tremendous interest in teaching these concepts to medical learners.13 The curriculum described in this paper offers one curriculum that was both well received by learners and resulted in IM innovations in clinical practice that helped both the individuals and the communities served by multiple university-affiliated practices. Publication of this article was supported by the Health Resources and Services Administration (HRSA-12-182). Drs. Scott Wright and Miriam Alexander served as co-senior authors on this manuscript. We would like to thank Dr. Elizabeth Salisbury-Afshar, Dr. Laura Sander, Thomas Bogetti, and the Johns Hopkins University School of Medicine Curriculum Development Program for their valuable contribution in the development of the curriculum. Dr. Wright is a Miller Coulson Family Scholar and he receives support through the Johns Hopkins Center for Innovative Medicine. The authors are grateful for the funding support from the Health Resources and Services Administration (HRSA) of the U.S. DHHS, and their IM Program, HRSA grant #IMOPH25100. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by, the HRSA, DHHS, or U.S. Government. Grant IM0HP25097-01-00, for Integrative Medicine Programs, was funded at $150,000. No financial disclosures were reported by the authors of this paper.
www.ajpmonline.org
Chaudry et al / Am J Prev Med 2015;49(5S3):S285–S289
References 1. University of Arizona, Arizona Center for Integrative Medicine. What is integrative medicine? Andrew Weil, MD. http://integrativemedi cine.arizona.edu/about/definition.html. Accessed February 1, 2015. 2. Kligler B, Maizes V, Schachter S, et al. Core competencies in integrative medicine for medical school curricula: a proposal. Acad Med. 2004; 79(6):521–531. http://dx.doi.org/10.1097/00001888-200406000-00006. 3. Schultz A, Chao S, McGinnis M, IOM. Integrative Medicine and the Health of the Public: A Summary of the February 2009 Summit. Washington, DC: The National Academies Press; 2009. 4. Maizes V, Silverman H, Lebensohn P, et al. The integrative family medicine program: an innovation in residency education. Acad Med. 2006;81(6): 583–589. http://dx.doi.org/10.1097/01.ACM.0000225225.35399.e4. 5. Locke AB, Gordon A, Guerrera MP, Gardiner P, Lebensohn P. Recommended integrative medicine competencies for family medicine residents. Explore (NY). 2013;9(5):308–313. http://dx.doi.org/10.1016/ j.explore.2013.06.005. 6. Public Health Agency of Canada. What is the population health approach? http://www.phac-aspc.gc.ca/ph-sp/approach-approche/indexeng.php. Accessed July 26, 2015.
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7. Kindig D, Stoddart G. What is population health? Am J Public Health. 2003;93(3):380–383. http://dx.doi.org/10.2105/AJPH.93.3.380. 8. Johns Hopkins Carey Business School. http://carey.jhu.edu/. Accessed July 26, 2015. 9. Johns Hopkins Medicine. Armstrong Institute for Patient Safety and Quality. http://www.hopkinsmedicine.org/armstrong_institute/. Accessed July 26, 2015. 10. Gozu A, Windish DM, Knight AM, et al. Long-term follow-up of a 10-month programme in curriculum development for medical educators: a cohort study. Med Educ. 2008;42(7):684–692. http://dx.doi.org/ 10.1111/j.1365-2923.2008.03090.x. 11. The National Coordinating Center for Integrative Medicine. Core integrative medicine competencies for incorporation into preventive medicine education curricula. http://www.imprime.org/integrative-medi cine-in-preventive-medicine-competencies.html. Accessed May 2, 2015. 12. Maizes V, Schneider C, Bell I, Weil A. Integrative medical education: development and implementation of a comprehensive curriculum at the university of arizona. Acad Med. 2002;77(9):851–860. 13. Academic Consortium for Integrative Medicine and Health. Introduction. https://www.imconsortium.org/about/about-us.cfm. Accessed May 9, 2015.
Introduction
I
ntegrative medicine (IM) is defined as healingoriented medicine that takes account of the whole person, including all aspects of lifestyle with the goal of optimal health, emphasizing the therapeutic relationship between practitioner and patient, informed by evidence, and making use of all appropriate therapies, including conventional and complementary and From the 1General Preventive Medicine Residency Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; and 2 Johns Hopkins Community Physicians, Johns Hopkins Medicine, Baltimore, Maryland Drs. Scott Wright and Miriam Alexander served as co-senior authors on this manuscript. Address correspondence to: Sajida Chaudry, MD, MPH, MBA, Johns Hopkins Community Physicians at Odenton, 1106 Annapolis Road, Odenton MD 21113. E-mail: [email protected]. 0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2015.08.001
alternate medicine approaches.1,2 IOM’s definition emphasizes “therapeutic factors known to be effective and necessary for the achievement of optimal health throughout the lifespan.”3 The emphasis of IM on the relationship between patient and physician4 has to some extent hindered efforts of truly integrating all of the modalities of healing within the context of populations. Furthermore, little attention has been devoted to teaching the principles of IM to medical learners because of the unfamiliarity with the scientific evidence and slow-growing empiric basis for improved clinical outcomes.2 Most IM programs at the graduate medical education level are taught within the context of family medicine residency programs, where residents are intimately involved in direct patient care.5 Because direct patient care experiences are limited in preventive medicine (PM) residency training, the best ways to teach IM’s patient-centered philosophies and
& 2015 American Journal of Preventive Medicine Published by Elsevier Inc. This Am J Prev Med 2015;49(5S3):S285–S289 S285 is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
S286
Chaudry et al / Am J Prev Med 2015;49(5S3):S285–S289
approaches have not been well described. When applying for the Health Resources and Services Administration grant and describing our interest in developing an innovative curriculum to teach IM to PM residents, the authors promised to focus on systems change and to take a population health approach.6,7
Methods Subjects and Setting Targeted learners were PM residents at Johns Hopkins University School of Public Health. In order to gain a deep understanding of healthcare delivery systems, the residents are assigned to one of the Hopkins-affiliated community-based primary care practices (Johns Hopkins Community-based Physicians) for 24 months. As part of this longitudinal experience, the residents spend 1 day each week and are tasked with developing a project that will positively influence IM care delivery at the site. To date, four cohorts of PM residents have gone through the iteratively improved curriculum.
Curriculum Development The curriculum was developed during a year-long curriculum development course that has been running for 32 consecutive years at Hopkins. The overarching curricular objective was to ensure that after participating in the educational experience, learners would have successfully developed an IM initiative that was both innovative and effective in enhancing the IM care offered by providers to patients at the practice site. The approach was to think about IM from a population perspective with a goal of improving health for the population of each health center. This strategy for addressing IM is unlike others where the perspective relentlessly considers IM at the level of a single provider interacting with a single individual with a patient-centered approach. Although the centerpiece of the curriculum was the mentored project, the following content areas were taught using variant methods and formats because of their relevance to IM or to integrating a clinical innovation into practice: quality improvement, electronic medical record training, behavior change, health promotion, complementary and alternative medicine approaches, lifestyle medicine (including but not limited to nutrition, exercise, smoking, and alcohol),3 and project management. Reflective practice, usually in the form of writing prompts, was incorporated into the curriculum at regular intervals to push trainees to think about their work deeply and to consider perspectives that may be unusual or overlooked. For the resident-led projects, each PM resident was paired with a faculty preceptor who would serve as mentor, connector, sounding board, and project champion to help pitch or sell the project to peers. Core curricular faculty (n¼4) and the faculty preceptors from the community-based practices (n¼27) received extensive training from the curriculum development team (>10 hours). Preceptors were not offered monetary compensation for their time and effort; their involvement was entirely voluntary and generous. Both the curricular content that was taught and the discussions between PM residents and faculty preceptors about selecting an appropriate project were framed in and heavily considered Berwick’s principles of IM.3 Given the limited financial resources available to
support the roll out and implementation of projects, costs and feasibility were discussed when considering the effort and likely yield. When costs of proposed projects were going to be moderate, reflection about whether improved quality and outcomes could be proven in the context of the opportunities afforded to Accountable Care Organizations through the Affordable Care Act occurred.
Project Teams, Effort, Deliverables, Selection, and Feedback Beyond the resident and faculty physician preceptor, interprofessional teams were recruited within each practice to support the project. The PM resident was expected to devote 8 hours per week to the project and to manage the team such that additional hours were invested by other team members. Each project was expected to yield clinically relevant deliverables at the end of a 2-year time period. Project selection was a multistep process. Each year, several projects were proposed as being needed and beneficial to communities served, as well as individual patients. These suggested project areas were recommended based upon alignment of strategic priorities of Johns Hopkins Community-based Physicians and availability of baseline data. Ideas were considered most appropriate for addressing as part of this curriculum if they would allow many providers to be more effective in their delivery of IM care to their patients, both individuals and the community served by the practices. Residents were, of course, also invited to submit ideas. After potential projects were vetted and refined, residents were invited to choose projects from the list based on their interest. In the majority of cases, PM residents were able to secure their first choice. It became apparent that residents were most interested in working with underserved populations and addressing issues wherein there would also be mentorship from faculty at the Johns Hopkins Bloomberg School of Public Health. Although some residents worked individually with their preceptor and support team, resident teams of two to three were allowed to be placed in the sites. In addition to getting regular input from members of the project team, residents presented their work at quarterly informal work-in-progress meetings. Once annually, more detailed and more formal presentations were made; on these occasions, experts from a wide array of disciplines were invited to provide feedback.
Curriculum Evaluation A basic element of the evaluation process involves questionnaires that are completed by residents and faculty at the end of each year. The questionnaires include both quantitative and qualitative questions. All assessments are completed anonymously using an electronic format. Data analyzed for this paper included perspectives from the last 2 years because the curriculum was fairly different, and less refined, in the prior iteration.
Results Residents appreciated most of the curricular content that was delivered in small group sessions. Lifestyle health sessions were rated the highest (90% of residents agreed that educational objectives were fully met) and health coaching the lowest (only 50% concurred with the notion of the material meeting the educational objectives). www.ajpmonline.org
Chaudry et al / Am J Prev Med 2015;49(5S3):S285–S289
Almost all residents felt as if their faculty preceptor was committed to their success and was invested in the project. Over time, residents agreed more fully that their preceptors had an expanding understanding of the specialty of PM and its mission (Year 1, 50%; Year 2, 57%; Year 3, 82%). Similarly, residents felt positively that the curriculum provided useful knowledge and experiences that would help them in both their job searches and future careers (Year 1, 66%; Year 2, 86%; Year 3, 94%). Most residents (76%) were convinced that their faculty preceptors were aware of and committed to the curriculum’s educational objectives. Although residents were encouraged to seek project guidance from many (including those at Hopkins’ Business School8 and the Armstrong Institute for Patient Safety and Quality9), a majority (65%) were satisfied with the quality and quantity of teaching offered by their primary preceptor. Of note, the faculty member overseeing the curriculum (SC) also collected this type of information on an ongoing basis and stepped in to help when necessary (either in the form of coaching the preceptor or providing additional support herself). Preceptor feedback regarding their experiences with the curriculum was uniformly positive. Most preceptors (75%) believed that residents were spending an adequate amount of time and effort working on their projects, and 60% rated the collaboration of the project team as “outstanding” (top box on Likert scale). Although nearly all preceptors (86%) reported spending no more than 60 minutes weekly with the residents, there were differing opinions among preceptors about whether they had sufficient time to mentor their resident(s). Nevertheless, 87% responded that they would be willing to serve as a preceptor, and most (70%) believed that participation in the program enhanced the quality of patient care delivery at their practice. The preceptors identified several strengths of the projects, which included the broad scope and impact of project outcomes, the high value for patients and potential for financial value, the possibility of improved health outcomes, and the use of quality improvement tools to analyze complex practices and processes. Areas of improvement identified by preceptors included narrowing the scope of the project to a manageable size, improving the definition of the project at onset, better data collection and assistance with data interpretation, and the ability to engage staff and colleagues. The products that may most emphatically speak to the success of the curriculum are the projects that were developed and nurtured by the PM residents. Table 1 provides select examples of the initiatives that were established as part of this curriculum. In discussing the
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Table 1. Select Exemplary Projects Developed By Residents, Preceptors, and Multidisciplinary Teams as Part of the Integrative Medicine Curriculum Establishing sustainable healthy-weight behavior-change patient groups using the PDSA (plan, do, study, act) approach Improving access to smoking-cessation resources and reducing barriers to smoking cessation Designing and implementing a “health promotion campaign”: lifestyle and behavior change for health center staff Improving patient compliance with screening mammograms by comparing different methods of encouragement Improving access to healthcare resources for Spanish-speaking patients as part of a Latino health program Designing obstetric group visits for adolescent patients Reducing unnecessary emergency department visits and improving after-hours phone service with a behavioral-change communication campaign Improving transitions of care between a community hospital and a primary care practice Engaging office staff in the clinical unit safety program to improve patient safety Implementing health-risk assessments for Medicare patients through the annual wellness visits Improving human papillomavirus vaccination completion rates for pediatric patients utilizing electronic medical record enhancements Employing a community strategy to reduce hospital admissions for congestive heart failure in geriatric patients Enhancing screening for diabetic retinopathy with retinal photography to ensure optimal care and follow-up Implementing a nurse outreach and care-coordination program for patients at risk of poor clinical outcomes
educational value of working on these projects, the following themes were mentioned repeatedly:
Strong working relationship with preceptors and other
members of the healthcare team emerge from respectful collaboration. Complex problem cannot usually be fixed quickly— patience and persistence are key. Thinking about how IM approaches can serve a community can ultimately lead to best IM practices that the physician–patient dyad can use during clinical visits. Consideration of big picture healthcare reform can be overlaid onto IM’s goal of promoting optimal health for the individual. Electronic medical records can either be used to promote IM or they can be a hindrance; both the design and the operator determine how they are perceived.
S288
Chaudry et al / Am J Prev Med 2015;49(5S3):S285–S289
Celebrating the projects’ successes was done formally each year at a summit that highlighted IM, safety, and quality improvement. In addition to the residents, preceptors, and the curriculum’s core faculty, healthcare leaders from different Hopkins schools and leaders of clinical practices attended.
Discussion High-quality curriculum development can result in transformative educational experiences.10 Although some educators feel compelled to push and deliver much teaching and didactics to learners, evolving educational theory has suggested that experiential learning can result in the largest amount of growth and development. This curriculum focused on IM for PM residents and was developed and implemented with painstaking attention and care. Lessons learned in the first pilot years were used to iteratively revise the curriculum. Initially trying to satisfy the educational needs of both firstyear residents, who are new to the curricular content and processes, and those in their second year, who are on their way into the implementation phase of their project, was considered to be a big problem by the team. The residents assured them that peer teaching and learning was valuable. The Health Resources and Services Administration IM grant support was instrumental in stimulating and facilitating the development of this curriculum. When the funding ended, institutional entities rallied to find money to support its maintenance. Although this might have happened because the teaching of IM to PM residents was believed to be a priority worth backing, the reality is that for a small investment, wonderful projects that were advancing IM care delivery were being created and launched that were helping providers and benefitting patients. As the team reflected on the factors that have allowed this curriculum to succeed and become one of the jewels in the crown of the residency program, three deserve special mention. First, just as IM mandates a patient-centered approach to care, this curriculum was modeled with the same respectful tone to be extremely learner centered. As the residents and members of the multidisciplinary team requested support or teaching in specific areas to help advance their project, the preceptors and core curricular faculty were open and responsive to their needs. Second, there was a creative spin that made everyone excited about the curriculum, because IM is normally operationalized exclusively at the level of the doctor–patient relationship; in this curriculum, PM residents were challenged to envision how IM can be delivered to meet the needs of specific communities.11 Lastly, few residents are allowed to take the reins of a project that will translate into changes in practice. As the leaders of their projects, the PM residents guided multidisciplinary teams and gained skills that will
undoubtedly help them in their future work experience and professional roles.
Limitations Several limitations of this study should be considered. First, curriculum and evaluation revisions were mainly done annually and midyear revisions, beyond minor tweaks, were not carried out. Second, this curriculum was implemented and evaluated within a PM residency at a single institution. The success realized here may not be reproduced everywhere. Third, although the authors were able to find busy clinicians who were eager to mentor PM residents, such individuals may not be found everywhere. Finally, resources to support curriculum development or refinement are usually extremely limited.12 Fortunately, the grant and institutional commitment allowed the residents to be immersed in a transformative curriculum that solidified their appreciation for IM. Conclusions The growing number of medical schools in the Academic Consortium for Integrative Medicine and Health indicates tremendous interest in teaching these concepts to medical learners.13 The curriculum described in this paper offers one curriculum that was both well received by learners and resulted in IM innovations in clinical practice that helped both the individuals and the communities served by multiple university-affiliated practices. Publication of this article was supported by the Health Resources and Services Administration (HRSA-12-182). Drs. Scott Wright and Miriam Alexander served as co-senior authors on this manuscript. We would like to thank Dr. Elizabeth Salisbury-Afshar, Dr. Laura Sander, Thomas Bogetti, and the Johns Hopkins University School of Medicine Curriculum Development Program for their valuable contribution in the development of the curriculum. Dr. Wright is a Miller Coulson Family Scholar and he receives support through the Johns Hopkins Center for Innovative Medicine. The authors are grateful for the funding support from the Health Resources and Services Administration (HRSA) of the U.S. DHHS, and their IM Program, HRSA grant #IMOPH25100. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by, the HRSA, DHHS, or U.S. Government. Grant IM0HP25097-01-00, for Integrative Medicine Programs, was funded at $150,000. No financial disclosures were reported by the authors of this paper.
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