The structure of medical practice is undergoing an extraordinary transformation. The percentage of physicians salaried and employed by hospitals and health care groups has increased dramatically. Growing numbers of patients are using health information technologies that facilitate transparency and enable patients to use the internet and health tracking devices to better manage their health care. This article aims to start a dialogue on how these changes may affect the key responsibilities of medical professionalism: putting patient interests first, maintaining and enhancing physicians' medical competence, and sustaining trust in the doctor-patient relationship. We identify several potentially effective strategies. They include policies to promote an institutional culture committed to professionalism and to enlarge physicians' role in institutional leadership. We also address how the principles of professionalism might guide physician compensation formulas, policies governing transparency, and best practices for strengthening the relationships between physicians and newly empowered patients.

Abstract Dual-chamber pacemakers, more sophisticated and costly than single-chamber pacemakers, are being used with increasing frequency, often with unclear indications. Proponents of dual-chamber ...

The emergency department (ED) is the natural venue for the provision of acute unscheduled care. However, little is known about the nature and proportion of this care that goes to addressing adverse events (AEs)—physical injury to a patient due to health care that requires some intervention—that are present on arrival (POA) to the ED. Described here are AEs that are POA, and population prevalence estimates for these events.This retrospective observational study tested the ED Trigger Tool, using data from an urban academic medical center. Patients aged ≥18 completing an ED visit were eligible (N = 92,859). A total of 5,582 visits with triggers (findings that increase the likelihood of an AE) were reviewed using the two-tier trigger approach. AEs were categorized by severity, type, and whether they were POA. POA AEs, and sociodemographic and trigger associations with AEs are described.Of 1,181 AEs identified, 718 (60.8%) were POA to the ED. Patients with POA AEs were more often white (51.1% vs. 39.7%, p < 0.001) and older (median age 62 vs. 50, p < 0.001). The majority of POA AEs were medication-related and patient care–related events. In the population at this center, POA AEs account for an estimated 7.6% of ED visits (95% confidence interval = 6.9%–8.2%).In this single-center study, the majority of AEs detected using the ED Trigger Tool were POA. These findings highlight the importance of the ED as a safety net for harm occurring across the health system.

In February 2020 when I was asked to submit some thoughts on trends in the future of health professions education, I had no idea that we were about to experience a once in a century pandemic that would profoundly change healthcare and the lives and education of health professionals in this country As I write these personal reflections, we are still in the midst of the COVID-19 pandemic and cannot yet define what the ?new normal? will be for health care, health professional education or society as a whole on the other side of the pandemic Acknowledging this uncertainty, I believe that the trends I have identified will be more relevant than ever in the post-COVID world with some specific caveats

Letters Health AffairsVol. 39, No. 4: Integrating Social Services & Health Medical Professionalism: The Authors ReplyDavid J. Rothman, David Blumenthal, and George E. Thibault AffiliationsColumbia University New York, New YorkCommonwealth Fund New York, New YorkHarvard Medical School Boston, MassachusettsPUBLISHED:April 2020Free Accesshttps://doi.org/10.1377/hlthaff.2020.00234AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSPhysiciansHealth professionalsWe appreciate the letter from Eliza Chin and coauthors about our article (Jan 2020). We support the incorporation of a diversity, equity, and inclusion imperative into organizational culture, processes, and practices—both on its own merits and as a method for promoting clinicians’ professionalism. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 6 April 2020 Information© 2020 Project HOPE—The People-to-People Health Foundation, Inc.PDF downloadRelated articlesDiversity And Medical Professionalism06 Apr 2020Health Affairs

Humanism has been at the core of the medical profession since its inception, and it has been a foundation throughout modern history for political and community values. But today, countries and leaders are increasingly adopting antihumanistic policies and positions. In this Invited Commentary, the author probes whether humanism in medicine can survive in the current culture. The author defines humanism as any system or mode of thought or action in which human interests, values, and dignity predominate. He traces humanism as a philosophical and political movement from the Renaissance through the Enlightenment to the development of liberal democracies in the 20th century. He identifies the humanistic roots of the medical profession and describes efforts to revitalize humanism in medicine in recent decades. He then details antihumanistic behaviors and policies in the current political environment and makes the case that these behaviors and policies threaten humanism in medicine. He calls on the medical profession to renew its commitment to humanism and to oppose antihumanistic behaviors and policies. It will be hard, he concludes, to have humanism in medicine if there is no humanism in the world around us.

Optimizing clinician education is an essential step toward enhancing health outcomes, and graduate medical education (GME)—as the pipeline for producing the nation’s physicians—is an appropriate target for improvement. This Invited Commentary focuses on the need to clarify the specific goals of GME and measure achievement of those goals, using consistent metrics. The authors report on an October 2017 National Academies of Sciences, Engineering, and Medicine (NASEM) workshop focused on this agenda. A broadly representative group of participants reflected strong consensus in support of using GME outcomes data to develop better approaches to education and related policy. Implementation challenges include identifying meaningful metrics, minimizing administrative burden, addressing privacy concerns, and recognizing variability in institutional mission and capabilities. The authors recommend creating a national inventory of current data sources and initiating a pilot program to collect and share common metrics, while advancing a national effort via a “neutral” convener, such as the NASEM. The authors assert that measuring and reporting GME outcomes is a professional responsibility that must now be tackled.

Health care systems around the world are transforming to align with the needs of 21st-century patients and populations. Transformation must also occur in the educational systems that prepare the health professionals who deliver care, advance discovery, and educate the next generation of physicians in these evolving systems. Competency-based, time-variable education, a comprehensive educational strategy guided by the roles and responsibilities that health professionals must assume to meet the needs of contemporary patients and communities, has the potential to catalyze optimization of educational and health care delivery systems. By designing educational and assessment programs that require learners to meet specific competencies before transitioning between the stages of formal education and into practice, this framework assures the public that every physician is capable of providing high-quality care. By engaging learners as partners in assessment, competency-based, time-variable education prepares graduates for careers as lifelong learners. While the medical education community has embraced the notion of competencies as a guiding framework for educational institutions, the structure and conduct of formal educational programs remain more aligned with a time-based, competency-variable paradigm. The authors outline the rationale behind this recommended shift to a competency-based, time-variable education system. They then introduce the other articles included in this supplement to Academic Medicine, which summarize the history of, theories behind, examples demonstrating, and challenges associated with competency-based, time-variable education in the health professions.

Through a series of six recent conferences, the Josiah Macy Jr. Foundation wanted to try to change the discussion about graduate medical education (GME) reform to one that is about the innovations needed to better prepare residents for the changing world of practice they will be entering and for meeting the needs of the patient population they will serve. These conferences featured some of the encouraging innovations in GME that are occurring at local and regional levels. An ongoing theme from many of these reforms is the empowerment of residents. The author examines what it would mean for health care systems, residency programs, and residents themselves to pursue empowerment for this significant portion of the health care workforce. Residents should be seen as a valuable component of the health care workforce with the ability to contribute to institutional and societal goals. The author highlights examples of existing programs that use residents in this way, but to accomplish this more broadly will require culture change and greater flexibility on the part of GME and institutional leadership.

More than a decade ago, women achieved parity with men in the number of matriculants to medical school, nearly one-third of the faculty of medical schools were women, and there were some women deans and department chairs. These trends were promising, but today there are still significant differences in pay, academic rank, and leadership positions for women compared with men in academic medicine. Though there has been progress in many areas, the progress is too slow to achieve previously recommended goals, such as 50% women department chairs by 2025 and 50% women deans by 2030.The author points to the findings presented in the articles from the Research Partnership on Women in Biomedical Careers in this issue, as well as research being published elsewhere, as an evidence base for the ongoing discussion of gender equity in academic medicine. More attention to culture and the working environment will be needed to achieve true parity for women in academic medical careers.

The first national report of findings from the Clinical Learning Environment Review (CLER) Program, published as a supplement to this issue of the Journal of Graduate Medical Education, is a very important initiative recently undertaken by the Accreditation Council for Graduate Medical Education (ACGME).1 Prior discussions about interventions to improve the quality of graduate medical education (GME) have included important issues, such as standard setting, the balance of service and education, assessment, sites of training, and the content of training. The focus has been primarily on individual program review. More recently, the general quality of the learning environment in which GME takes place has been raised as one of the most important elements in determining the quality of the educational experience. This, of course, is not an entirely new idea, but it has risen in significance in an era of more rapid clinical throughput, increasing intensity of care in all clinical settings and increasing economic pressures on faculty and sponsoring institutions. One of the conclusions of a Macy Report on GME in 2011 was that “GME must be organized and supported at the institutional and national levels to ensure that residency and fellowship programs are designed and conducted according to sound, broadly endorsed educational practices, within an environment conducive to education.”2The CLER initiative is the first significant attempt to formally assess that learning environment so it can be improved. The review chose 6 areas of focus to evaluate the environment: patient safety, health care quality (including health care disparities), care transitions, supervision, duty hours/fatigue, and professionalism. The findings should serve as a wake-up call; there is much we can do to improve the learning environment. This is not because we do not have conscientious faculty overseeing training programs; rather, it reflects the intensity and complexity of the environment in which training is occurring. There has generally not been enough effort to make the education mission synchronous with the care mission and with the overall success of the institutions. As a consequence there is the risk (and the reality) that education becomes marginalized and is seen as less relevant to the institution's mission.The specific findings of the report include both encouraging news and guidance for areas of improvement. In the area of safety, it is encouraging that almost all residents are being exposed to the principles of patient safety. Much more needs to be done, however, to involve them in a meaningful way in the real work of reporting, analyzing, and improving patient safety in their institutions. This is a missed opportunity for learning and a missed opportunity for using the experiences of talented front line health professionals.In the area of health care quality, residents are aware of the quality priorities in their institutions, and most are participating in some projects. They are not, however, as knowledgeable as one would want them to be in the concepts and methodology of quality improvement work. This is another lost opportunity for learning and for institutional improvement. In the related area of improving health care disparities, resident knowledge and involvement is highly variable. Unlike patient safety and quality of care where there are mandated structures, activities, and reporting in all institutions, there are not comparable standards or structures in health disparities. This creates an opportunity for residency programs to take a leadership role in this important area.Care transitions are central to the activities of all residency programs, including both “internal” transitions (handoffs) and transitions from one site of care to another. This is another area where residency programs could (and in some cases they have) provide institutional leadership. This also is an important area for residents to be engaged in interprofessional collaboration and interprofessional learning.Supervision is an area that has improved markedly in recent years, and the residents do report that they feel they are closely supervised. There is still much we have to learn about how to titrate supervision appropriately to allow for the full development of clinical judgment and the ultimate readiness for independent practice. We need to achieve greater understanding of how appropriate supervision can positively contribute to professional development. We also have not taken full advantage of the insights to be gained from experienced interprofessional supervision.The ACGME has taken a leadership position through courageous decisions in the areas of duty hours and fatigue management. There is no doubt that this has dramatically changed the environment in this area. But it is not surprising that this has not solved all the problems. Programs, faculty, and residents are still struggling with the application of the duty hour rules, and it is likely that modifications will be forthcoming based on research that is now being sponsored by the ACGME. It is also important to realize that there is more to resident fatigue and burnout than just duty hours. Adequate attention needs to be given to work load, work conditions, and personal factors. The ready availability of counseling and emotional support for residents is an important part of the optimal clinical learning environment.Programs, in general, seem to be more aware of the importance of including discussions about professionalism in the curriculum. It is less clear that they are dealing constructively or consistently with breaches of professionalism. Professionalism for residents does not occur in isolation from professionalism for all of the staff. In evaluating the learning environment, one would want to know whether the institution supports professionalism for all the staff through its policies and incentives. Is bad professional behavior of the staff called out, corrected, or disciplined?The CLER initiative will lead to some important questions about values and culture at the sponsoring institutions. How important is education in the organization? Are learners valued or seen as a burden? Are investments made in faculty development for teaching? Does the institution foster a collaborative team approach to care that is a model for learners? Is there mutual respect among all the health professions? How does the institution relate to and help the community it serves? Are patients included on advisory groups and is shared decision making encouraged and supported? How these value questions are answered can have a profound effect on the overall quality of the educational experience and on the kind of physicians we produce.At a time of dramatic change in health care delivery and important necessary changes in how we prepare physicians for 21st century practice, it is imperative that we develop closer links between education and health care delivery.3 We need to stop thinking of education and health care delivery as 2 separate systems, but rather think of them as united in the common goal of improving the health of the public they serve. I believe we have undervalued our residents (and other learners) as important members of the health care team and as contributors to improvements in our health care delivery system. We need to change this value equation. The CLER initiative is an important step in that direction.

In this article the authors discuss the reinvention of U.S. public health education for the 21st century. They argue that the role of public health in creating population health and improving public health education must be better defined, cite several reports by public health organizations calling for a reexamination of public health education, such as the Lancet Commission, and discuss the challenges of reenvisioning public health education.

AffiliationsGeorge E. Thibault is a guest editor for this issue and is the President of the Josiah Macy Jr. Foundation, New York, NY.

The size, composition, distribution, and skills of the health care workforce will determine the success of health care reform in the United States. Whatever the size of the workforce that will be required in the future to meet society's needs, how health professionals are educated merits additional attention. Reform of health professions education is needed in the following six critical areas: interprofessional education, new models for clinical education, new content to complement the biological sciences, new educational models based on competency, new educational technologies, and faculty development for teaching and educational innovation. Institutional and public policies need to support these innovations and the closer integration of education reform and health care delivery reform.

Societal changes around the world have resulted in new public health challenges; larger, more complex and uncoordinated delivery systems encompassing acute and chronic care; a greater reliance on t...