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Haukåsen OA, Hermanrud I. Creating a lean mind-set: Change of practice towards early treatment. MANAGEMENT LEARNING 2022. [DOI: 10.1177/13505076221122152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This paper reports the findings of a qualitative study on lean implementation viewed as an organisational learning process. By using a scaffolding framework, we investigate the ways in which human resource development facilitates learning among clinicians. This study contributes to the temporary role of human resource development in learning processes within multi-disciplinary professional groups. We identify scaffolding activities from which we have identified three human resource development practices: phase 1 – cognitive scaffolding, in which human resource development acts as a ‘mindsetter’ that aims to motivate the learning of lean in relation to the clinicians’ practices; phase 2 – peer-to-peer scaffolding through ‘doing’ lean, in which human resource development performs the role of an ‘experience creator’ who creates knowledge engagement between peers – in order to put lean into practice; and phase 3 – fading of the scaffolding, in which human resource development performs the role of a ‘delegator’ who transfers the responsibility to the clinicians to promote learning. This contributes to our understanding of how knowledge is negotiated in a multidisciplinary context. We contribute to the learning literature by emphasising how learning trajectories are initiated by learning initiatives, highlighting the role limitations of human resource development in this context, and demonstrating how a new learning tension arises between different versions of ‘lean’ in the organisation.
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Kulo V, Fleming S, Gordes KL, Jun HJ, Cawley JF, Kayingo G. A physician assistant entry-level doctoral degree: more harm than good? BMC MEDICAL EDUCATION 2021; 21:274. [PMID: 33985497 PMCID: PMC8120902 DOI: 10.1186/s12909-021-02725-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/30/2021] [Indexed: 05/20/2023]
Abstract
BACKGROUND As most health professions in the United States have adopted clinical or practice doctorates, there has been an ongoing debate on whether physician assistants (PAs) should transition from a master's to a doctorate as the terminal degree. The authors examined perceived risks, benefits and impact of transitioning to an entry-level PA doctoral degree. METHODS A multi-prong, mixed-methods approach was used that included a literature review and collecting quantitative and qualitative data using a survey and interviews. Bivariate analysis and binomial logistic regression were performed to evaluate relationships between perceptions/perspectives on an entry-level PA doctoral degree and the anticipated impact of it causing more harm than good to the PA profession. Deductive content analysis was used to analyze the qualitative data. RESULTS Of 636 PA clinicians and students (46% response rate), 457 (72%) disagreed that an entry-level PA doctoral degree should be required. More than half of the respondents (54%) agreed that it should be offered but not required and 380 respondents (60%) agreed that an entry-level doctoral degree would cause more harm than good. Race, educational attainment, occupation, and length of practice as a PA were significantly associated with having a perception of causing more harm. There was strong positive association between the perception of a doctoral degree causing more harm with expectations of having a negative impact on the availability of clinical training sites (OR = 4.39, p < .05). The most commonly cited benefits were parity with other professions and competitive advantage, whereas the perceived risks were increased cost for education, decreased diversity in the profession, and negative impact on the PA/physician relationship. CONCLUSIONS The major takeaway of our study was that perceived benefits and risks are strongly influenced by the lens of the stakeholder. While the majority of PAs and students appear to be not in favor mainly due to the potential harm, the proportion of those in favor is not insignificant and their views should not be ignored. Addressing concerns with key stakeholders could help the PA profession to transition to a doctoral degree with minimal adverse impact.
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Affiliation(s)
- Violet Kulo
- Physician Assistant Leadership and Learning Academy (PALLA), University of Maryland Baltimore Graduate School, 620 West Lexington Street, Baltimore, MD, USA
| | - Shani Fleming
- Physician Assistant Leadership and Learning Academy (PALLA), University of Maryland Baltimore Graduate School, 620 West Lexington Street, Baltimore, MD, USA
| | - Karen L Gordes
- Physician Assistant Leadership and Learning Academy (PALLA), University of Maryland Baltimore Graduate School, 620 West Lexington Street, Baltimore, MD, USA
| | - Hyun-Jin Jun
- Physician Assistant Leadership and Learning Academy (PALLA), University of Maryland Baltimore Graduate School, 620 West Lexington Street, Baltimore, MD, USA
| | - James F Cawley
- Physician Assistant Leadership and Learning Academy (PALLA), University of Maryland Baltimore Graduate School, 620 West Lexington Street, Baltimore, MD, USA
| | - Gerald Kayingo
- Physician Assistant Leadership and Learning Academy (PALLA), University of Maryland Baltimore Graduate School, 620 West Lexington Street, Baltimore, MD, USA.
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Bernard ME, Laabs SB, Nagaraju D, Allen SV, Halasy MP, Rushlow DR, Garrison GM, Maxson JA, Matthews MR, Sobolik GJ, Lampman MA, Foss RM, Rosas SL, Thacher TD. Clinician Care Team Composition and Health Care Utilization. Mayo Clin Proc Innov Qual Outcomes 2021; 5:338-346. [PMID: 33997633 PMCID: PMC8105520 DOI: 10.1016/j.mayocpiqo.2021.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective To test the hypothesis that a greater proportion of physician time on primary care teams are associated with decreased emergency department (ED) visits, hospital admissions, and readmissions, and to determine clinician and care team characteristics associated with greater utilization. Patients and Methods We retrospectively analyzed administrative data collected from January 1 to December 31, 2017, of 420 family medicine clinicians (253 physicians, 167 nurse practitioners/physician assistants [NP/PAs]) with patient panels in an integrated health system in 59 Midwestern communities serving rural and urban areas in Minnesota, Wisconsin, and Iowa. These clinicians cared for 419,581 patients through 110 care teams, with varying numbers of physicians and NP/PAs. Primary outcome measures were rates of ED visits, hospitalizations, and readmissions. Results The proportion of physician full-time equivalents on the team was unrelated to rates of ED visits (rate ratio [RR] = 0.826; 95% confidence interval [CI], 0.624 to 1.063), hospitalizations (RR = 0.894; 95% CI, 0.746 to 1.072), or readmissions (RR = –0.026; 95% CI, 0.364 to 0.312). In separate multivariable models adjusted for clinician and practice-level characteristics, the rate of ED visits was positively associated with mean panel hierarchical condition category (HCC) score, urban vs rural setting, NP/PA vs physician, and lower years in practice. The rate of inpatient admissions was associated with HCC score, and 30-day hospital readmissions were positively associated with HCC score, lower years in practice, and male clinicians. Conclusion Care team physician and NP/PA composition was not independently related to utilization. More complex panels had higher rates of ED visits, hospitalization, and readmissions. Statistically significant differences between physician and NP/PA panels were only evident for ED visits.
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Affiliation(s)
| | - Susan B Laabs
- Department of Family Medicine, Mayo Clinic, Rochester, MN
| | | | - Summer V Allen
- Department of Family Medicine, Mayo Clinic, Rochester, MN
| | | | | | | | - Julie A Maxson
- Department of Family Medicine, Mayo Clinic, Rochester, MN
| | | | - Gerald J Sobolik
- Department of Health Care Administration, Mayo Clinic, Rochester, MN
| | | | - Randy M Foss
- Department of Family Medicine, Mayo Clinic, Rochester, MN
| | - Steven L Rosas
- Department of Family Medicine, Mayo Clinic, Rochester, MN
| | - Tom D Thacher
- Department of Family Medicine, Mayo Clinic, Rochester, MN
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Pany MJ, Chen L, Sheridan B, Huckman RS. Provider Teams Outperform Solo Providers In Managing Chronic Diseases And Could Improve The Value Of Care. Health Aff (Millwood) 2021; 40:435-444. [DOI: 10.1377/hlthaff.2020.01580] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Maximilian J. Pany
- Maximilian J. Pany is an MD-PhD candidate in health policy at Harvard Medical School, in Boston, Massachusetts. Pany and Lucy Chen are co–first authors
| | - Lucy Chen
- Lucy Chen is an MD-PhD candidate in health policy at Harvard Medical School. Chen and Maximilian Pany are co–first authors
| | - Bethany Sheridan
- Bethany Sheridan is a senior manager of the Research and Insights team at athenahealth, Inc., in Watertown, Massachusetts
| | - Robert S. Huckman
- Robert S. Huckman is the Albert J. Weatherhead III Professor of Business Administration and the Unit Head for Technology and Operations Management at Harvard Business School, in Boston, Massachusetts
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Norcini J. Is it time for a new model of education in the health professions? MEDICAL EDUCATION 2020; 54:687-690. [PMID: 31860934 DOI: 10.1111/medu.14036] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Affiliation(s)
- John Norcini
- FAIMER, Philadelphia, Pennsylvania, USA
- Department of Psychiatry, State University of New York (SUNY) Upstate Medical University, Syracuse, New York, USA
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Can PAs and NPs manage complex patients? JAAPA 2020; 33:53-54. [DOI: 10.1097/01.jaa.0000684140.98683.92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cawley JF. Formal Training for Practice: How Much Is Too Much? ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:972. [PMID: 32576755 DOI: 10.1097/acm.0000000000003362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- James F Cawley
- Professor, School of Physician Assistant Practice, Florida State University, Tallahassee, Florida, and visiting professor and scholar-in-residence, University of Maryland, Baltimore, Baltimore, Maryland;
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Medical education for primary care: Is the paradigm shifting? JAAPA 2020; 33:51-53. [DOI: 10.1097/01.jaa.0000660176.57140.2e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Nelson NR, Jones M, Wilbur LG, Romanelli F. Making Diagnostic Instruction Explicit in US Pharmacy Education. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2020; 84:7791. [PMID: 32577039 PMCID: PMC7298214 DOI: 10.5688/ajpe7791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 12/03/2019] [Indexed: 06/11/2023]
Abstract
The profession of pharmacy and standards directing the education of student pharmacists are constantly evolving. The profession continues to emphasize patient-centered practice as a model for the future. The US health care system is faced with an impending shortage of primary care providers, which will affect the ability of patients to access the health care system. The pharmacy profession should position itself to contribute to meeting this need. The explicit instruction of differential diagnosis within Doctor of Pharmacy degree programs is a critical consideration in advancing pharmacy practice and potential contributions to the primary care gap.
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Affiliation(s)
- Nicholas R. Nelson
- University of North Carolina, Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Mandy Jones
- University of Kentucky, College of Pharmacy, Lexington, Kentucky
| | - Lee G. Wilbur
- CHI St. Vincent Infirmary, Department of Emergency Medicine, Little Rock, Arkansas
| | - Frank Romanelli
- University of Kentucky, College of Pharmacy, Lexington, Kentucky
- Executive Associate Editor, American Journal of Pharmaceutical Education, Arlington, Virginia
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Dewan MJ, Norcini JJ. We Must Graduate Physicians, Not Doctors. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:336-339. [PMID: 31688033 DOI: 10.1097/acm.0000000000003055] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Today, medical schools graduate doctors, not physicians. Thousands of doctors who are U.S. citizens and graduates of U.S. and international medical schools will never become physicians because they do not obtain a residency position. Doctors need at least one year of residency to become a licensed physician. However, 4,099 applicants in 2018 and 4,170 in 2019 failed to get a position through the National Resident Matching Program Main Match; about 1,000 students get positions after the Main Match each year. The personal and societal cost is enormous: each year, approximately 3,000 nonphysician doctors cannot use 12,000 education years and three-quarters of a billion dollars they invested in medical education and cannot mitigate the shortfall of 112,000 physicians expected in 2030.To ameliorate this problem, medical schools could guarantee one year of residency. This is affordable: despite federally funded slots being capped, residency positions have increased for 17 consecutive years (20,602 in 2002 to 32,194 in 2019) because residents are cost-effective additions to the workforce. Alternatively, a 3-year curriculum plus required fourth-year primary care residency is another option. The salary during the residency year could equal other first-year residents', or there could be a token amount for this "internship." Both models decrease the cost of medical education; the second financially unburdens the hospital.Since the Flexner Report (when there was no formal postgraduate training), the end point of medical education has moved from readiness for independent medical practice (physician) to readiness for postgraduate training (doctor). To benefit individuals and society, medical education must take steps to ensure that all graduates are physicians, not just doctors.
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Affiliation(s)
- Mantosh J Dewan
- M.J. Dewan is interim president and SUNY Distinguished Service Professor, Upstate Medical University, Syracuse, New York. J.J. Norcini is president emeritus, Foundation for the Advancement of International Medical Education and Research, Philadelphia, Pennsylvania, and research professor, Upstate Medical University, Syracuse, New York
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Warm EJ, Kinnear B. What Can the Giant Do? Defining the Path to Unsupervised Primary Care Practice by Competence, Not Time. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2019; 94:937-939. [PMID: 30998573 DOI: 10.1097/acm.0000000000002753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
In this issue of Academic Medicine, Dewan and Norcini examine the significant variability of time-in-training between patient care "giants"-the physicians, nurse practitioners, and physician assistants who practice primary care-and they call for further studies to determine optimal training duration and eventual scope of practice. They ask, what is the minimum education and training required to practice primary care, or "how tall is the shortest giant?" In this Invited Commentary, the authors reframe the question from identifying the minimum length of training required, to identifying desired patient care outcomes. Primary care is not a uniform entity. It ranges from complex elderly chronically ill patients, to twentysomething millennials with acute problems, to pregnant women, to families, and everything in between. The authors argue that training should be fit for purpose and produce high-quality outcomes for patients. Competence should be defined by these outcomes. Drawing parallels with Major League Baseball, the authors note that time to competence development will be variable for different training programs depending on purpose, and also variable for people within those programs, even with shared purpose. While time is a tool for competence attainment, it should not be the metric by which readiness for practice is measured.
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Affiliation(s)
- Eric J Warm
- E.J. Warm is professor of medicine and program director, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; ORCID: https://orcid.org/0000-0002-6088-2434. B. Kinnear is assistant professor of medicine and pediatrics and associate program director, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; ORCID: https://orcid.org/0000-0003-0052-4130
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Whitehead C, Paradis E. One Size Does Not Fit All: Balancing Individual and System Needs in Primary Care and Beyond. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2019; 94:940-942. [PMID: 30973367 DOI: 10.1097/acm.0000000000002749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
In this issue, Dewan and Norcini invite readers to reconsider the basic minimum standards for independent primary care practice. Their willingness to push boundaries, question turf wars, and suggest innovative ways forward is laudable. Although their piece is timely and provocative, it does not fully consider the interplay between individual and system factors that influence people to pursue different kinds of degrees and practice in this context. In this Invited Commentary, the authors discuss imperatives that are underacknowledged by Dewan and Norcini: the importance of diversity in health system planning; status, power, and privilege; the extension of their argument beyond primary care; the conflation of time in training with competence; and important issues of distribution of health care resources. Ultimately, the authors argue that there may be strength in diversity, one that should not be obscured by attempts to normalize training time.
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Affiliation(s)
- Cynthia Whitehead
- C. Whitehead is director and scientist, Wilson Centre, BMO Financial Group Chair in Health Professions Research, University Health Network, vice president of education, Women's College Hospital, and associate professor, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada. E. Paradis holds the Canada Research Chair in Collaborative Healthcare Practice and is assistant professor, Leslie Dan Faculty of Pharmacy, Department of Anesthesia and Department of Sociology, University of Toronto, Toronto, Ontario, Canada
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Sklar DP. Training Models for Physician Assistants and Nurse Practitioners: Disruptive Innovations That Could Improve Health Professions Education and Practice. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2019; 94:917-920. [PMID: 31241562 DOI: 10.1097/acm.0000000000002738] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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