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Chapter 4 Current Educational Activities in the Core Competencies This chapter reviews current undergraduate and graduate educational activities for medicine, nursing, pharmacy, and selected allied health professions with respect to the core competencies outlined in Chapter 3: provide patient-centered care, employ evidence-based practice, work in interdisciplinary teams, apply quality improvement, and utilize informatics. The focus is on what, how, and when health professionals are taught these competencies in academic programs. There is broad variation in this regard. Some of these competencies are intrinsic to the historical vision of certain professions, while others are inadequately addressed in the educational programs of any of the professions. The chapter concludes with a discussion of how educational institutions are moving toward an outcome-based education approach to ensure that students can demonstrate such competencies upon graduation, and a review of the issues surrounding this approach. The committee obtained information published in the professional literature and supplemented these published descriptions by soliciting input from educational institutions The committee notes that there are few rigorous evaluations of educational interventions in the health professions. Indeed, the lack of evidence-based education is an issue that the committee decided to address with a recommendation and that a working group at the summit deemed important to address (see Appendix C). Studies examining the effect of education in any quantifiable manner come largely from medical education, which accounts for the predominance of references related to medical education in this chapter. In discussing preparation in the five competencies, the professions are addressed in order of the extent of available evidence: medicine, nursing, pharmacy, and allied health. Provide Patient-Centered Care In general, comprehensive attention to patient-centered care in medical education is lacking. The 75

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HEALTH PROFESSIONS EDUCATION dominant biomedical model of practice, whereby patients are viewed in terms of signs and symptoms, remains a large barrier to redressing this need (Mead and Bower, 20004. Though efforts to teach patient-centered care, however defined, are increasingly being advocated and incorporated into the training of physicians (Lewin et al., 2001), such efforts are regarded as ad hoc and are often not ascribed significant value, energy, and financial resources (Flores et al., 2000; Malloch et al., 20004. Shared and informed decision making with patients needs greater emphasis in medical education. One survey of medical students and residents revealed that over 90 percent of respondents believed physicians should have greater input in decisions than patients; as training and experience increased beyond medical school, there was an increased tendency toward a belief in physician-only decision making (Beisecker et al., 19964. Medical students also are not adequately prepared for promoting prevention and healthy lifestyles with patients. Although an expert panel convened by the Association of Teachers of Preventive Medicine proposed a curricular requirement "of making preventive medicine an integral part of the education, training, and practice of physicians" (Collins et al., 1991 :307), the integration of disease and illness prevention and welIness into medical education has largely not been achieved (Garr et al., 2000; Heller et al., 2000; Institute of Medicine, 1988; Pomrehn et al., 2000~. Indeed, given the tradition in medicine of overwork, sleep deprivation, and neglect of one's own welIness, medical students and residents cannot even serve as good examples for patients of healthy lifestyles and welIness. Medical education has recently placed more emphasis on enhancing patient-clinician communication, and such efforts have been shown to increase patient satisfaction and improve patient outcomes (Halpern et al., 2001; Henbest and Stewart, 1990; Langewitz et al., 1998; Lewin et al., 2001; Lipkin, 1996; Smith et al., 1995; Swick et al., 1999~. However, there is broad variation in the content and evaluation of communication courses. The American Association of Medical Colleges (AAMC) has begun to address this lack of uniformity by developing communication competencies through its Medical School Objective Project (American Association of Medical Colleges, 2000~. Nurses have long been taught to focus on the patient's needs, the family, or in some cases, a clinically defined population group. On balance, they are educated to use preventive and health-promoting interventions, to counsel and communicate with patients, to apply community and behavioral interventions, and to be highly sensitive to the needs of individuals (Allen, 2000; Milio, 2002; O'Neil and the Pew Health Professions Commission, 19984. However, the realities of the day-to-day practice environment and systems design often constrain opportunities to utilize this knowledge fully (Peterson, 20014. Further, some worry that there . . . ~~ . are mayor clliterences among nursmg programs with regard to educational preparedness in competencies associated with population- focused care, health protection, and promotion and prevention (Institute of Medicine, 19954. In the last decade, pharmacists have reformulated their vision of the profession, shifting from an orientation primarily toward the dispensing of drugs to a greater focus on pharmaceutical care, an approach designed to promote health; prevent disease; and assess, monitor, initiate, and modify medication use to ensure that drug therapy regimens are safe and effective (American Pharmacuetical Association, 20024. The result has been a widespread curricular change in pharmacy education during the last decade to better prepare graduates for this new mission (American Association of Colleges of Pharmacy Commission to Implement Change in Pharmaceutical Education, 1993; Center for the Advancement of Pharmaceutical Education tCAPE] Advisory Panel on Educational Outcomes, 1998; Pharmacy Deans Task Force on Professionalism, 2000~. In these reform efforts, considerable emphasis has been placed on a revision of curricula to include more 76

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CURRENT EDUCATIONAL ACTIVITIES service learning opportunities and education of students in new communication and health promotion and disease prevention competencies (Murawski et al., 19994. Though changes have been substantial, a recent survey of pharmacy faculty revealed that training in communication skills is irregular and not well developed in some schools (Beardsley, 20014. Prevention and health promotion, as well as shared decision making with patients, are intrinsic to the vision of a number of allied health professions, including dental hygienist, registered dietician, physical therapist, and occupational therapist, and the educational preparation and curricula for these professions reflect this fact. However, the Association of Schools of Allied Health Professions and the National Commission on Allied Health (Health Resources and Services Administration, 1999), citing allied health professionals' frequent contact with patients and their relative lack of preparation in this area, have suggested that allied health curricula be strengthened further to include communication and patient and family education. Being competent in providing patient- centered care includes easing pain and providing comfort to patients who need it. These skills are particularly important in end-of- life care. Yet review commissions have found that pain management is not sufficiently addressed in the education of all the health professions to meet the needs of the American people (Institute of Medicine, 2001; 2002b). In one survey, the authors reviewed postgraduate medical training programs on the care of seriously ill and dying patients and found that the majority included no training in pain assessment and management (Weissman and Block, 20024. And while nurses have been central in the development of the international hospice movement, specific educational opportunities for nurses in pain management are still rare (Institute of Medicine, 2002b). The American Association of Colleges of Nursing has concluded that "end-of-life education and training is inconsistent at best and sometimes completely neglected within nursing curricula" (American Association of Colleges of Nursing, 2002:1) Understanding the patient's values and experience outside of the hospital necessitates cross-cultural awareness and competence. However, there is little documentation of the extent to which cross-cultural issues are covered in the education of health professionals (Institute of Medicine, 2002a). Summit participants stressed the need to develop cultural competency standards to promote better understanding of and communication with diverse populations, as well as increased education in community settings in the form of home visits and community-based partnerships with schools. Participants emphasized the importance of involving patients and their families in all aspects of the educational process, including having them rate student performance in providing care, holding more clinical discussions at bedside, videotaping encounters between students and patients, and using patient focus groups to provide feedback on performance. Research supports the view that these techniques greatly enhance patient satisfaction and facilitate better student performance with patients (Branch, 2000; Branch et al.,2001; Chisholm and Wade, 1999; Eyler et al., 2001; Gerteis et al., 1993; Maguire et al., 1996; Novack et al., 1999; Self et al., 19984. Box 4-1 presents some examples of effective education in patient-centered care. 77

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HEALTH PROFESSIONS EDUCATION B ............................................................................................................................ . .. ................... .......... ..... ...... ... ................................................................................................................................ ~ j j b ~ 1 I~ ~ 11 ~ ~ h ............ ......... ................................................... ........ ........................... . ................ .. ... ........................... ................................................... ..................................... . .- -o. - - -c. - - -u. - . -s. - - -e. - < -o. ~ n - --s- - - ' ~ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::: ............................................................................................................................. ............................................... . ,j .. ......... . I. . j,. . . .,.j,. . I,. ......... :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::: :: :: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: : ::::::::::::::::::::::::::::::::::::::::::::::::::::::: ..... ............................................... . ~ T-h ~ b-i- -h I~ m- d- I~ ~""""QC ~ Ca :---o-n~ off -no- burn--- e- is-- of K-o-c-n-esm-r~ ~-c-n-o-or~ ol--- . ... --Me-di-ci~ e as es he esse :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: . . ... .. . .... . ... ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::~:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~:::::::::::::::::::::::::::~: ::.::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~::::::::~::~::~:::::::::::::::::::::::::::: --t-re-es---a--nd--- Itl"' '' """"' e- s al lil - ss~ atl ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::: ::::::::::::::::::::::::::::::::::::::::::::::::::::: - j j M M j 1 1 ..... ... .. .......................................................... _ .. ............. - _ M eU~-- -I--ne ~ ~ ~-ase~ w-es t e n~ ~ese- ve~ u--n-I- e-~-~ t' """"bC' n-oo-l~ o t""""'M' ea-I-c-I--n- e~ ar Q~ P- a-~ ~ a~ ~ ... --ye- """""" "i" 'i'' ' i' ' """"' ' "' '' '' ' """""' ' """"' " " """""M j j ............................................................................................................................. h Ith i a i d 1 i 1 th t i b d th t i ~ 1 t ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ............. ~ n ~ .~ ~ O~-~-I-- Q~ ~- a-l-- -al-lo-n~ le-c-n--n--lq-- -es~ lo~ m-~-a$-u-~ l-n-~ co-m-m--u--n-l-cal-l-o-n~ co-m--pele-~-ce~ ~ sl-u0-~-n-ls~ .... ... d j .. . . . . -health m-m- - '1' at-l-- ''"'"""""'A' ~ a~ ''''d"I'tl''''"""""'~"""""th" '1""""""'' ad'- -i- ati ~ t-h~ th e~ i- - tt- ~ ~ ha -- ....-'-'c.-'-u.~ r.~r.--~..-'-'c''' "1"' "' """""'' '' ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: . , , . j . . ........................................... .. i M i l M i l i l ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ~n-g-~-l-es~ ua-mo-rn--l-a~ ~-~es~ l-n-~ l-oca-l~ co-m-m-u--n--l-ly~ oT~ p-reC-o-m-l-n-a-n-l-l-y~ lv-l-~xI-ca-n~ ^m-~-rl-ca-n-s~ n-a-!T--- ........ . . f ,! . .. 78

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CURRENT EDUCATIONAL ACTIVITIES Work in Interdisciplinary Teams The Quality Chasm report (Institute of Medicine, 2001:83) envisions a future in which clinicians "understand the advantage of high levels of cooperation, coordination and standardization to guarantee excellence, continuity, and reliability. Cooperation in patient care is more important than professional prerogatives and roles. There is a focus on good communication among members of a team, using all the expertise and knowledge of team members, and where appropriate, sensibly extending roles to meet patients' needs." As discussed in Chapter 3, this level of cooperation and coordination across all the professions is not yet a reality. There is generally a great lack of understanding among the professions for what each profession does, its level of training and education, and its existing or potential competencies. The absence of a common language, differing philosophies, politics, and turf battles across the professions remain the norm. This situation is exacerbated by the fact that in the vast majority of educational settings, health professionals are socialized in isolation. hierarchy is fostered, and individual responsibility and decision making are relied upon almost exclusively (Hall and Weaver, 20014. Health professions education occurs largely in an environment of separately housed professional schools and separate clinical arenas governed by powerful separate deans, directors, and department chairs. Professional schools also have their own separate faculty, school calendars, and different points of entry into the profession. Frequently, separate schedules prevent the development of new courses and innovative curriculum design (Holmes, 19994. A lack of appreciation of the actual or potential contributions of each of the health professions is reinforced by such settings, and more important, students learn little about the high levels of coordination and collaboration needed to provide quality care for Americans. There is a profound disconnect between current role- oriented, isolated academic preparation and practice environments that rely on teams or wish to do so (Stumpf and Clark, 1999~. One key to fostering interdisciplinary practice is interdisciplinary education, whereby a group of students from the health-related occupations with different educational backgrounds learn and interact together during certain periods of their education in order to collaborate in providing health-related services (Holmes, 19994. Educating the professions together affords students the opportunity to develop the collaborative relationships essential for cross-fertilization among disciplines in the practice environment and supports respect among the disciplines as well (Hayward et al., 1996~. There are many examples of successful efforts to provide education in working in teams and in developing team-related skills in a variety of care settings (Hall and Weaver, 2001; Headrick et al., 1996; Lavin et al., 2001; McCallin, 2001; Zwarenstein, 19994. One example involves an interdisciplinary team of student nurses, physical therapists, occupational therapists, and patient care assistants who developed interventions around patient activity and mobility, resulting in reduced incidence of immobility- as s ociated complications (Markey and Brown, 2002~. In another example, teams of students in physical and occupational therapy, speech and language therapy, and exercise physiology worked over a semester to provide wellness and prevention interventions to the homeless and the chronically ill senior population (Hamel, 2001~. Although such successful examples exist (Murray et al., 2000), interdisciplinary education has yet to become the norm in health professions education. This is true despite efforts over the past 50 years on the part of foundations, private organizations, and government agencies, with enthusiasm waxing and waning, often in relationship to funding support. In 1995, fewer than 15 percent of U.S. nursing and medical schools had any interdisciplinary programs (Larson, 1995) despite the calls for this approach for decades from a variety of disciplines (American Association of Colleges of Nursing, 1995; 79

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HEALTH PROFESSIONS EDUCATION Health Resources and Services Administration, 1999; National League for Nursing Interdisciplinary Health Education Panel, 1998; Pharmacy Deans Task Force on Professionalism, 20004. Although some professions and programs have revised their mission statements and written learning objectives related to interdisciplinary teams, few have set benchmarks and standards that all students must attain before graduation (Stephenson et al., 2002~. One barrier is that differences persist around the roles of team members and interprofessional relationships and attitudes among students (Hall and Weaver, 2001~. A recent study of health professions students revealed that medical residents were less inclined overall toward interdisciplinary teamwork, although residents in internal medicine or family practice and students of advanced practice nursing and masters-level social work were positively inclined (Leipzig et al., 20024. The researchers concluded that for physicians, exposure to interdisciplinary teamwork and team decision making needs to occur earlier than residency training. Other studies have echoed the notion that early introduction to interdisciplinary education is key to success (Horak et al., 19984. Some of the reluctance on the part of schools that educate health professionals to embark on interdisciplinary education is related to the limited research on the effect of such education on interdisciplinary practice and patient care (Zwarenstein, 1999~. Some fear that professional identities, hierarchies, and power relationships may be diluted if the focus becomes interdisciplinary (Headrick et al., l998b). Many questions about when, whom, and how to educate remain unanswered and are open to future research (Hall and Weaver, 2001), though preliminary studies show that problem-based learning is highly effective for training students in teams (Brickell and Cole, 19964. Box 4-2 provides selected examples of successful efforts in interdisciplinary education. 80

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CURRENT EDUCATIONAL ACTIVITIES Employ Evidence-Based Practice Given the constant changes in knowledge and management of health care systems, a major challenge for the educational process is to prepare students for lifelong learning. As explored in Chapter 2, the amount of knowledge that health professionals must acquire has grown immensely. Genomics, proteomics, neuroscience, epidemiology, and emerging infectious diseases, especially as they relate to bioterrorism, are just some of the recent additions to the expanding knowledge base needed to use new diagnostic and therapeutic agents for the 21St century. Professionals in training cannot hope to provide competent care to patients over their career unless they have the ability to update their knowledge and skills. The formal curricula of health professional schools are dated almost as soon as students graduate. The traditional emphasis, especially in medicine, on teaching a core of knowledge focused largely on the basic mechanisms of disease and pathophysiological principles, with the expectation that students will memorize the hundreds of facts presented to them, is outdated in light of this ever-expanding knowledge base. William Stead, Vanderbilt University, noted at the summit: The root of the problem stems from the design of our curricula...the curriculum places a premium on individual knowledge. And that individual knowledge is memorized, and it's applied with individual flair. That works in what [can be] referred to as medical care, or for an acute problem where we can actually fix it. It does not work in a case where the rate of development of knowledge exceeds what you can learn and retain. If you read two articles every night, you're 500 years behind at the end of the first year. That's if you remember those two articles. (Stead, 2002) Many medical schools are making strides in shifting away from rote memorization and incorporating evidence-based practice as part of the curriculum (Grad et al., 2001) In a 1999 AAMC survey, however, more than a quarter of the graduates of the 88 percent of medical schools teaching skills related to evidence-based medicine reported feeling unprepared to interpret clinical data, research, literature reviews, and critiques (American Association of Medical Colleges, 1 999a). A national survey of internal medicine Association residency programs found that 37 percent of those 81

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HEALTH PROFESSIONS EDUCATION surveyed had a freestanding evidence-based practice curriculum, but fewer than half offered faculty development in this area or performed an evaluation of the course (Green, 20004. As discussed in Chapter 3, the collection of evidence related to the contribution of nursing to care has been thwarted in part by a failure to gather relevant data at practice sites. This lack of data has impacted the diffusion of evidence- based practice into nursing curricula. Scattered educational experiences exist (French, 1999), but these are not the norm. Most programs that grant doctor of pharmacy degrees require coursework in subjects related to skills needed for evidence- based practice. These include courses in statistics, drug information, literature evaluation, and research methodology, the latter being required least often. In a recent survey, however, only 12.9 percent of schools required an extensive project involving data collection, analysis, and write-up (Murphy et al., 19994. Like nursing, pharmacy is currently attempting to identify and disseminate evidence related to its profession (Etminan et al., 1998) The teaching of evidence-based practice is thwarted in part by a lack of easily replicable teaching methods, and questions remain regarding how such courses are translated into practice (Norman and Shannon, 1998; Taylor et al., 2000~. Work has been done on assessing the skills associated with learning about evidence- based practice and evaluating the ability of students to apply evidence in managing common clinical problems (Bradley and Humphris, 1999~. Problem-based learning has also been shown to facilitate the development of critical appraisal skills, and collaboration between researchers and practitioners within and among disciplines has been found to enhance the diffusion of innovations in evidence-based practice (Lusardi et al., 2002; Rosswurm and Larrabee, 19994. The success of evidence-based instruction may also be related to the point at which it is offered. One study found that evidence-based instruction enhanced knowledge of epidemiology in undergraduate programs, but not necessarily at the residency level (Norman and Shannon, 1998~. Box 4-3 presents selected examples of education in evidence-based practice. 82

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CURRENT EDUCATIONAL ACTIVITIES Apply Quality Improvement Current evidence for educational activities in quality improvement across the health professions is sparse. There is little available information on the extent to which students are educated in such skill areas as error reduction, process measurement and redesign, and monitoring of patient data (Headrick et al., l99Sa; Henley, 2002; Mosher and Colton, 2001). In medicine, scattered experiences in educating students or residents in quality improvement principles have been documented. Researchers recently tested a new quality improvement curriculum by comparing a group of internal medicine students who took the course with a control group who did not. The intervention group scored significantly higher scores on post-tests compared with the control group (Ogrinc et al., 2002~. One course at the University of Illinois College of Medicine at Rockford had a quality improvement curriculum in which students performed a series of chart audits of diabetes and made improvement recommendations to clinic directors (Henley, 20024. In another study, resident involvement was deemed critical to the success of a quality improvement intervention that significantly decreased the use of unnecessary intravenous catheters (Parent) et al., 1994~. Recent efforts by AAMC have articulated the learning objectives and educational strategies that should be used to integrate quality improvement into education (American Association of Medical Colleges, 20014. In nursing, content on quality improvement is most commonly incorporated into lectures within management courses and rarely included in clinical courses. Moreover, most nursing education programs have not required students to implement quality improvement strategies in clinical areas through experiential learning strategies (Buerhaus and Norman, 2001~. A large barrier to education in this competency is the shortage of practitioners knowledgeable in practices of quality improvement who can understand and implement quality improvement innovations in their clinical settings. With regard to safety in particular, surveys have shown that there is a shortage of teachers and researchers who have a profound understanding of how safety is maintained and can pass on those insights and associated innovations (Croskerry et al., 2000; Institute of Medicine, 20004. Moreover, the shift from traditional classroom-based lectures to project-oriented learning that is required for quality improvement activities is a source of tension for some educators (Schillinger et al. 2000~. Evaluation of quality improvement activities also remains an issue, with student satisfaction scores or other less rigorous 83

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HEALTH PROFESSIONS EDUCATION measures being the norm (Baker et al., 1998; Gordon et al., 1996; Headrick et al., 1998a; Weeks et al., 20004. A recent study by Ogrinc et al. (2002) made some progress on this front by developing a more reliable method for evaluating a quality improvement course for medical residents. Quality improvement is usually discussed in terms of teams improving processes or systems, but there is another aspect of quality improvement that is more narrowly focused on the individual clinician continuous self- assessment. There is as yet no clear understanding of how health professionals are or should be educated to reflect on their own performance strengths and weaknesses in order to identify learning needs, conduct a review of their performance, and reinforce new skills or behaviors so they can improve their performance. Education that addresses the various dimensions of ensuring continuing competency past the initial preparation for practice therefore requires attention. Box 4-4 describes selected examples of educational programs that have addressed quality improvement. 84

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CURRENT EDUCATIONAL ACTIVITIES Utilize Informatics Without a basic education in informatics, health professionals are limited in their ability to make effective use of communication and information technology in their practice. Yet without appropriate input from health professionals skilled in informatics, it may be impossible to implement a clinical computing infrastructure that meets the needs of clinicians and patients. Educating health professionals in informatics should enable many important capabilities, including appropriate interaction with clinical information systems for making decisions and mitigating error, use of the Internet to inform themselves and their patients, and facility in using e-mail to communicate and coordinate with their team members and patients. Though many studies focus on the use of computers in the delivery of educational content, very few studies document how students or professionals in practice are educated to use information technology in support of patient care. Many institutions are now offering degrees (masters and doctorate), fellowships, certificates, and short courses in this area, some through remote learning; the website of the American Medical Informatics Association (2002) lists over 50 such programs. However, these are usually special degrees and optional courses not required of the professions. According to findings from a 1999 AAMC medical school graduation questionnaire, about 86 percent of respondents felt comfortable using the Web to locate and acquire information, and nearly three-quarters felt confident about using a computer-based clinical record-keeping program for both finding and recording patient- specific information (American Association of Medical Colleges, l999b). During 2000-2001, 46 percent of medical schools required their students to own or rent personal computers (Barzansky and Etzel, 20014. AAMC, through the Medical School Objectives Project, recently identified core informatics competencies in medicine (American Association of Medical Colleges, l999b). Probably as a result of resource constraints in the settings in which they are educated, nursing and allied health professionals have embraced informatics on a more limited scale as compared with their medical counterparts (Gassert, 1998; Hovenga, 2000; McDaniel et al., 1998~. Community colleges, where the majority of registered nurses are trained, do not provide access to information technology to the same extent as academic medical centers. A 1998 survey of accredited diploma, associates, bachelors, and masters nursing programs revealed that a majority of schools lacked a coordinated plan for technology implementation and were underfinanced for technology and related personnel; fewer than one-third of the schools addressed nursing informatics in the curriculum (Carty and Rosenfeld, 19984. Issues around competencies associated with the use of informatics and whether they are discipline-specific or broad-based hinder progress on widespread education in this area (Masys et al., 20004. One recent effort to address discipline-specific competencies has been the International Medical Informatics Association recommendations regarding courses by profession, by type of specialization in health, and by stage of career progression (e.g., bachelors, masters). These recommendations address educational programs in medicine, nursing, health care management, dentistry, pharmacology, public health, health record administration, and informatics/computer science, as well as dedicated health informatics programs (American Medical Informatics Association, 20024. Another example is the multitiered set of technology competencies specifically designed for occupational therapy practitioners authored by the American Occupational Therapy Association Technology Special Interest Section (Hammer and Angelo, 1996~. A number of issues help explain the current barriers to integrating informatics into health professions curriculum: the lack of a clear understanding of informatics as a discipline, limited support for informatics education among administrators and faculty, the overcrowded 85

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HEALTH PROFESSIONS EDUCATION nature of existing curricula, inadequate time for faculty to develop associated skills (Jerant, 1999), and the lack of quick and easy access to local informatics experts (Cartwr~ght et al., 20024. The difficulty in conceptualizing informatics education is often exacerbated by a "tendency to conflate education in informatics with the use of computers to deliver education" (Buckeridge and Goel, 2002:4~. Interacting with computing resources in the educational process is not the same as applying informatics to patient care. Box 4-5 describes some examples of successful efforts to provide education on the use of informatics. .......................................................................................................................................... ........................ ......... ............. ~ ...... .. .... . . ~. T1e -c --u-ca :--o-n-a- ~ ~-e-~--ces~ e-n-a-r :-me-n ~ -ewe --or ~ --n--l-~-rs--l- am Alec --l-ca- . . . . . ~ -l--n- ;-ro-c -u-ce-c ~~ a m-u-- -l-c ~'SClp --l--n-a-~ l--n-To~-a I'CS"""'CU'~!'C'U' --u-m~ l-e-c --u-a-l-n-g~ a m-e-n--u~ ~~ ~-rl-n-g-s~ ln-a-l~ can ................................................................. be- d t d---t t th- i ~ kill do do h-- do l ............................................................................................................................................................................................................................. ~~""~ ""ad 2-2-a-""n--""^e' """"''Q"' ''' """""s""""a - v v ~ ~ l v p vVl~Q"a ~n~orma~lcs solely are Unpeg a-~-~- ................................................................................................................................................................................................................................................. 86

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CURRENT EDUCATIONAL ACTIVITIES A Vision of the Future Health Professions Student The five competencies described in this chapter define the environment that leaders in health professions education, such as those who attended the Health Professions Education Summit, must address. These competencies can enable both students and practicing professionals to better meet the needs of patients. Box 4-6 presents a scenario depicting an educational experience as it could be if these competencies were incorporated into the curriculum of the health professions. B- - I D i i. i h h i i ...................................................................................................................................................................................................................................................... .-.-.i-.n-te-rn-al~ m -at i a- so all the i- - t ~ h- - -it -1~ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ............................................................... ........ ........................................................................................................................................................................... E-- ~ revea- -e-c ~ 1a ~ 1e as e -pe-rl-e--n-c-l-ng~ an a-cu ;e~ meccas --la- ~ l-en arc -l-o-n~ a-e-c ~-e~ was ......... """"""""""""" '"""""" ''''''''1''"""""'''' """i" '''' e"""""'''e' '''''1''' '"""""" ''"""""""'' '''""""""" ''"''"""""" . ""' Is"""""'''' ;' Is""""' ''IS '-'I' ''''""""'''l'S'I' IS""""'' ;o~ a co-m-m-u--n--lw~ Tea --in Tac-l--l--llv~ l--n-To-rm-al-l-o-n~ ano-ul-- I. ~ ~ ~ ---we- l lea e-as-l--l-v a-- - es Iol ~ it- " ""T' 't" " e"""U'Se"""~""a'n'~""'OT"""~ ............. ........ .................. ~ ........ ....................... ............ ..... ~ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ................................. . j m j j j ....................... ,................................................................................................................... 87

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HEALTH PROFESSIONS EDUCATION M ................................................................................. ........... ................................................................... ....................................... .................................. . -o-n-l-ca~ a-n-< -bustling per o-rm~ a p a-~-l-ca- ~ exam--l-n-at-l-o-n~ wilt- n~ g-u--l-< -a-n-ce~ -~-m~ t n-e-l-r~ acu- By . --l-s ........ .......... ......... . .... .......................... ...... ..... ....... ~v- -la- ~ s-lg-n-s~ are spa- it- -Ed a-e-c ---is cal ~-ererl-zall-on~ wo-u--n-c ~ s-l-le~ less sea- --l--ng~ we- ~ a- -. Young- A ....... ........ ............ ............................................ .... ...... , ...... ............. ............................................................................................................................. ::::::::::: :::::::::::::::::::::::::A::::' ::::::::::::::::::::::::::::::::j: :::::::::::::::::::::::::::::::::: .-.-ove-~e-l~-nl~ ~e-r~ a-l-sc-u-s-s-i-o-n~ am-o-nn~ l-n-e-m-se-l-ves~ an-a l-n-e-l-r~ Tacu-llV One slucenls :: :....:::: :....:::: :.. :.: :....:: :~::::: :...:::::::: :::::: ::::::: ::.:..:.:.:.:: ::::::: :.:.:.:.:::::::.:.:.:. ::.:.:.::.:.:.:.::.:.:-:-:::-:-:-:- ::: ::-:-:-:- :::: ::::::: -:-:-: :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::-::::::::::::::::::::::: ..an.~ m--l-l- -Neal Al sT- a-~-l-o-a ~ al-l-n-o-- -a--n~ -no- lie- Q-l~ of n-l-s~ ca-~-l-ac~ en- miss nest a-ec'e-aseo~ s-l- Iced :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~::::::::::::::::::::::::::::::::::::::::::::::::::::::: . . .n .l s . . .a.~-m--l s-s-l-o.n~ I n ~ l a t I a I a a e ~ ~ l ~ Il t ..... T t J a ~ ~ ~ a ~:::::~Tl::a:a :~a :T:O':':':':':~^ a a '1:'l:~':':':':': a~ a -a ~-a -t-~i :':':':':'i':l':T:':':':'T~:8 ':':':':'I~:fl-i ~ :8 -I l t7 a -~ a -~- ::::::a:~::::::a::::::::: ::::::::::::::::::i:::J::::::a::::::::::::: :::::::::a::::::::::: ::::::::::::::i:::::::::::::::::::::a::: .... ~ I.a.~.eles.--- i l.g n -cn-ol-es e-a ol~ a- ~ m-~ca-r a--l-a-a~ l-ma' cl-l-o-n~ a-' ases LoUac~ ~ a-n~ ls~ we~-a~ a-a ove~ ~-l-$~ o-pl-1-m-a-a~ we-1-g--a al a a-e~ a-a--s-o~ ~-as~ 7 a a ~ a co-n-cern-s~ aa 0 al lne COSI OT nis mealcal caa ~ as~ e-l-l~ a-s~ n-l-s~ an-l--l--l-~ lo~ ~-nl-l--n--u-e~ wCa Kln a~ l~ n-e~ 's't''''O'e'''n'ts""'0" ' '1" "'~'' """""'1"''M' -'' 't' ~ I -tn t"""'' O'0 ..... .... M J ~ o-n-l-ca~ ms-ea-mn-es~ a-pep o-prl-ate~ ~--l-ag-~-ost-l=~ a-n-~ In-~- a-p- """tO'a"""'M'a'"""""'~" "1' '--- ........................................................................................................ . . ... ~ ~ a ~ ~ ~ ~ a ---~--l-s-e-a-se~ ~--l-a-~- tQS nign cnoleste'ol~ a-n-~ re-n-a-l~ ~--l-seas-~ ~-n-~ a ecr- --l-ts~ as-s-ls-ta-n-ce~ t' O'a a""""tn'B"' ... .. .. ..a..e.sign an e e~lse p~g m TQr l~r lz lo assisl ln ls cove~ an i i i a a i ,,,,w,,,o.a K~ a-n-~ Trom~ ln-e~ a--l-a-Dell-c~ le-a-m~ to~ a-ov-l-se~ o a~ co-nlrol~ oT~ n-l-s~ a--l-s-e-ase~ a-n-a~ l-ls~ com--~-l--lcall-o-n-s~ M a.a l.a ~ l--n- ..................................................................... ........................................................ ~ a ~ e - - - - a~ a ~ a a a ~ a J i ~ a ~p-a S.e.nt la eir t eatmenl pl..a.n tO a la ~ al~ a-e~ e -pea pSes lnteresl ln {ne p some suggestions aDoUl wa s~ ~ l-nteg--a te~ t-n-e~ cn-a-n-g-es~ 88

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CURRENT EDUCATIONAL ACTIVITIES Outcome-Based Education Identification of general competencies represents an articulation of what health professionals should know and be able to do. In the previous chapter, the committee defined five competencies that it deems critical for all clinicians to possess, with the understanding that the way in which these competencies are integrated into educational programs will be discipline-specific. In this chapter, the committee has explored the extent to which such competencies are addressed in educational curricula. The identification of competencies is not an isolated activity identifying competencies is just the first of many steps in ensuring that students are prepared to deliver quality health care. Once competencies have been established, the knowledge, skills, and attitudes underpinning each competency need to be clearly articulated in writing and related measures developed. Assessment tools must then be matched to each competency to evaluate outcomes the results providing evidence that goals and objectives have been accomplished (Carraccio et al., 2002; Calhoun, 2002~. This articulation of what students should be able to do and of education based on related objectives is often referred to as competency-based or outcome-basec1 educations Epstein and Hundert (2002) note that the outcomes of assessment serve many needs for learners, academic institutions, and the public, including the following: Learner fosters learning, inspires confidence, and enhances the ability to self- monitor. Curriculum drives change, certifies achievement of curricular goals, and creates coherence. Academic institutions drives self- assessment, expresses values, serves to develop faculty, and provides data for educational research. Public certifies competence of graduates, and offers comparative data on the quality of educational programs. Hendricson and Cohen (2001) outline three questions that educational institutions must answer to develop competency-based health 89

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HEALTH PROFESSIONS EDUCATION professions education: What knowledge, skills, and professional/ personal values should the student possess at the time of graduation so he or she will be ready for the next level of training (e.g., a postgraduate year one) or be prepared to serve as an independently functioning entry- level general practitioner? What learning experiences will enable students to acquire these competencies? What proof, or evidence, is needed to establish for faculty that a student has attained competency? Hendricson and Cohen describe a competency-based curriculum as ideally having three features: (1) top-down planning based on analysis of the health care needs of patients, (2) a readiness-based model in which students advance through the curriculum at different rates based on their individual capabilities, and (3) a horizontal curriculum structure in which students progress through competency modules hierarchically sequenced by level of difficulty. Scattered clinical education institutions have restructured their curricula and student learning methods using a competency-based approach (DeWald and McCann, 19994. However, little attention has been devoted to defining the standards for such competencies; determining how to attain them; or evaluating competence, particularly with respect to professionalism and humanism. Each of these areas remains a large challenge (Carraccio et al., 2002~. A major impediment to moving towards competency-based education is making additions to existing overcrowded curricula. Some institutions have integrated competencies as "themes" into existing coursework rather than instituting new courses. Examples of themes that are woven into the entire education experience include evidence-based practice, ethics, and AIDS (Dartmouth Medical School, 1998; Harvard Medical School, 20004. At the same time, the environment for health professions education is changing with respect to the use of computers and new educational approaches, such as problem based learning which in combination may allow the same amount of content to be conveyed more efficiently and effectively. One 3-year study of a new curriculum that integrated computer- based activities and problem-based learning found that students could identify and retrieve information more rapidly and were more self- reliant in solving problems, therefore making fewer time demands of faculty and tutors. This new curriculum also resulted in reducing laboratory time from the national norm of 141 hours to 93 hours (Levine et al.. 19991. Educational reformers posit that by supporting students in directing their own learning and providing the tools they need to access, analyze, and apply information, education will be transformed. Distance learning technology, standardized patients, and clinical skilIs-testing techniques also hold the potential for revolutionizing health professions education, offering students the opportunity to customize their learning and to progress at their own pace and at geographic locations that meet their educational needs. Of course, such an approach would need to be closely monitored bY faculty and validated through testing. Colleen Conway-Welch, Vanderbilt University, commented at the summit on the need to focus more on students: Wouldn't it be interesting if we also thought that the student was the center of the educational system? And perhaps, if the focus moved to the patient and the student, that might reinforce this whole idea that they are both highly valued. And the students then may start asking some of the tougher questions because they themselves feel that they have been valued in the process and can transfer some of those [earnings over to the patient. Perhaps we could accelerate this change (Conway- Welch, 2002~. 90

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CURRENT EDUCATIONAL ACTIVITIES Conclusion The committee concludes with the following observations on the current state of educational preparation in the five competencies: . . The extent to which health professionals are prepared to achieve the five competencies necessary for optimum patient-centered care requires more standardization across and within the professions. The core set of competencies needs to be integrated more thoroughly into a cohesive educational experience and to be offered using interactive methods. Evaluation of the effects of health professions education requires increased attention. Few investigators study whether curricula, courses, or teaching methods are having the desired impact on learners and their practice or on the delivery of health care to the American public. When evaluations are done, they often do not have the types of designs necessary to provide an adequate understanding of those effects. References Great Lakes Geriatric Interdisciplinary Team Training (GITT). Online. Available at http://gitt. cwru.edu/ [accessed Sept., 20023. Allen, C.E. 2000. Public health nursing vital. Nations Health 30 (54:3. American Association of Colleges of Nursing. 1995. Interdisciplinary Education and Practice. California: AACN. . 2002. "Recommended Competencies and Curricular Guidelines for End-of-Life Nursing Care." Online. Available at http://www.aacn. nche.edu/publications/deathfin.htm [accessed Sept., 20023. American Association of Colleges of Pharmacy Commission to Implement Change in Pharmaceutical Education. 1993. What is the mission of pharmacy education. American Journal of Pharmacy Education 57:374-76. American Association of Medical Colleges. l 999a. Evidence Based Medicine Instruction . Vol 2, No.3 edition Washington, DC: AAMC. . l 999b. Keeping Up with Technology and the Changing Role of Medicine . Vol 2 No.2 edition Washington, DC: AAMC. American Association of Medical Colleges. 2000. Report III: Communication in Medicine. Medical School Objectives Project. Washington, DC: Assoication of American Medical Colleges. American Association of Medical Colleges. 2001. Report V- Contemporary Issues in Medicine: Quality of Care. Washington, DC: Association of American Medical Colleges. American Medical Informatics Association. 2002. "AMIA Web site." Online. Available at www. amia.org [accessed Feb. 15, 20023. American Pharmacuetical Association. 2002. "Principles of Practice for Pharmaceutical Care." Online. Available at http://www.aphanet.org/ pharmcare/prinprac.html [accessed 20023. Baker, G.R., S. Gelmon, L. Headrick, M. Knapp, L. Norman, D. Quinn, and D. Neuhauser. 1998. Collaborating for improvement in health professions education. Quality Management in Health Care 6~24:1-11. Barzansky, B., and S.I. Etzel. 2001. Educational programs in U.S. medical schools, 2000-2001. Journal of the American Medical Association 286 (9~:1049-55. Beardsley, R.S. 2001. Communication skills development in colleges of pharmacy. American Journal of Pharmaceutical Education 65 (4) Beisecker, A.E., R.A. Murden, W.P. Moore, D. Graham,andL.Nelmig. 1996. Attitudes of medical students and primary care physicians regarding input of older and younger patients in medicaldecisions. MedicalCare 34~2~:126- 37. Betancourt, J.R., A. R. Green, and J. E.Carrillo. 2002. Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches.The Commonwealth Fund. 91

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HEALTH PROFESSIONS EDUCATION Bloom, S.W. 1989. The medical school as a social organization: The sources of resistance to change. MedicalEducation 23~3~:228-41. Bradley, P., and G. Humphris. 1999. Assessing the ability of medical students to apply evidence in practice: The potential of the OSCE. Medical Education 33 (114:815-17. Branch, W.T., Jr. 2000. Supporting the moral development of medical students. Journal of General Internal Medicine 15 (74:503-8. Branch, W.T., Jr. MD, D. Kern, P. Haidet, P. Weissmann, C.F. Gracey, G. Mitchell, and T. Inui. 2001. The patient-physician relationship. Teaching the human dimensions of care in clinical settings. Journal of American Medical Association 286~94:1067-74. Brickell, J.M., and C.M. Cole. 1996. Using a problem-based learning format to teach CLS students interdisciplinary health care practice. Clinical Laboratory Science 9 (14:48-54. Buckeridge, D.L. and V. Goel. 2002. Medical informatics in an undergraduate curriuclum: An qualitative study. Bio Medical Central Medical Informatics and Decision Making 2 (6~: 1-5. Buerhaus, P.I., and L. Norman. 2001. Its time to require theory and methods of quality improvement in basic and graduate nursing education. Nursing Outlook 49 (2~:67-69. Calhoun, J.G., P.L. Davidson, M.E. Sinioris, E.T. Vincent, and J.R. Griffith. 2002. Toward an understanding of competency identification and assessment in health care management. Qual Manag Health Care 11~14:14-38. Carraccio, C., S.D. WolLsthal, R. Englander, K. Ferentz, end C. Martin. 2002. Shifting paradigms: From flexner to competencies. Academic Medicine 77~5~:361-67. Cartwright, C.A., N. Korsen, and L.E. Urbach. 2002. Teaching the teachers: Helping faculty in a family practice residency improve their informatics skills. Academic Medicine 77 (54:385-91. Carty, B., and P. Rosenfeld. 1998. From computer technology to information technology. Findings from a national study of nursing education. Computer Nursing 16 (5~:259-65. Center for the Advancement of Pharmaceutical Education [CAPE] Advisory Panel on Educational Outcomes. 1998. "Educational Outcomes." Online. Available at http://www. aacp . org/D oc s/MainNavigation/ Resources/3933_edoutcom. doe? DocTypeID=4&TrackID=&VID= 1 &CID=410& DID=366 [accessed Dec. 10, 20023. Chisholm, M.A., and W.E. Wade. 1999. Factors influencing students attitudes toward pharmaceutical care. Am J. Health Syst Pharm 56 (224:2330-2335. Collins, T., K. Goldenberg, A. Ring, K. Nelson, and J.Konen. 1991. The Association ofTeachers of Preventive Medicines recommendations for postgraduate education in prevention. Academic Medicine 66 (6~:317-20. Conway-Welch, C. 2002. ""Crossing the Quality Chasm: Next Steps for Health Professions Education"; Panel Discussion." Online. Available at http://www.kaisernetwork.orgl health_cast/hcast_index. ctm? display=detail&hc=601 [accessed Nov. 12, 20023. Croskerry, P., R.L. Wears, and L.S. Binder. 2000. Setting the educational agenda and curriculum for error prevention in emergency medicine. [Review] [40 refs]. Academic Emergency Medicine 7 (11~:1194-2000. Dardnouth Medical School. 1998. "Welcome to the integrated primary care clerkship--IPCC." Online. Available at http://cobweb.dartmouth. edu/~biomed/IPCC/ [accessed 20023. DeWald, J.P., and A.L. McCann. 1999. Developing a competency-based curriculum for a dental hygiene program. Journal of Dental Education 63 (114:793-804. Epstein, R.M., and E.M. Hundert. 2002. Defining and assessing professional competence. Journal of the American Medical Association 287 (24:226-35. Etminan, M., J.M. Wright, and B.C. Carleton. 1998. Evidence-based pharmacotherapy: Review of basic concepts and applications in clinical practice. Annals of Pharmacotherapy 32 (11~:1193-2000. Eyler, J.S., D.E. Giles, Jr., C.M. Stenson, and C. J. Gray. 2001. AtA Glance: What We Know about The Effects of Service-Learning on College Students, Faculty, Institutions and Communities, 1993- 2000: Third Edition.Corporation for 92

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CURRENT EDUCATIONAL ACTIVITIES National Service Learn and Serve America National Service Learning Clearinghouse. Faraino, R.L. 1998. Teaching medical informatics a la carte: A curriculum for the professional palate. Medical Reference Services Quarterly 17 (2~:69-77. Felt-Lisk, S., and L. Kleinman. 2000. Effective Clinical Practice in Managed Care, Findings From Ten Case Studies. Boston, MA: The Commonwealth Fund. Flores, G., D. Gee, and B. Kastner. 2000. The teaching of cultural issues in U.S. and Canadian medical schools. Academic Medicine 75 (54:451-55. Forrest, J.L., and S.A. Miller. 2001. Integrating evidence-based decision making into allied health curricula. Journal of Allied Health 30 (4~:215-22. French, P. 1999. The development of evidence- based nursing. Journal of Advanced Medicine 29 (1~:72-78. Garr, D.R., D.T. Lackland, and D.B. Wilson. 2000. Prevention education and evaluation in U.S. medical schools: A status report. Academic Medicine 75 (7~: 14S-21. Gassert, C.A. 1998. The challenge of meeting patients needs with a national nursing informatics agenda. Journalofthe American Medical Informatics Association 5 (34:263-68. Gerteis, M., S. Edgman-Levitan, J. Daley, and T. Delbanco, editors. 1993. Through the patient Eyes. Vol. San Francisco, CA: Josey-Bass. Gordon, P.R., L. Carlson, A. Chessman, M.L. Kundrat, P.S. Morahan, and L.A. Headrick. 1996. A multisite collaborative for the development of interdisciplinary education in continuous improvement for health professions students. Academic Medicine 71 (9~:973-78. Gorman, P.J.M., A.H.M. Meier, C. Rawn, and T.M. M. Krummel. 2000. The future of medical education is no longer blood and guts, it is bits and bytes. American Journal of Surgery 180 (5~:353-56. Gould, B.E., M.R. Grey, C.G. Huntington, Gruman, J.H. Rosen, E. Storey, L. Abrahamson, A.M. Conaty, L. Curry, M. Ferreira, K.L. Harrington, D. Paturzo, and T.J. Van Hoof. 2002. Improving patient care outcomes by teaching quality improvement to medical students in community-based practices. Academic Medicine 77 ( 10~: 1 0 1 1 - 1 8. Grad, R., A.C. Macaulay, and M. Warner. 2001. Teaching evidence-based medical care: Description and evaluation. Family Medicine 33 (84:602-6. Green, M.L. 2000. Evidence-based medicine training in internal medicine residency programs a national survey. Journal of General Internal Medicine 15 (24:129-33. Hagar, M. 2001. Enhancing Interactions Between Nursing and Medicine. Chicago: Josiah Macy Jr. Foundation. Hall, P., and L. Weaver. 2001. Interdisciplinary education and teamwork: A long and winding road. MedicalEducation 35~94:867-75. Halpern, R., M.Y. Lee, P.R. Boulter, and R.R. Phillips. 2001. A synthesis of nine major reports on physicians competencies for the emerging practice environment. Academic Medicine 76 (6~:606-15. Hamel, P.C. 2001. Interdisciplinary perspectives, service learning, and advocacy: A nontraditional approach to geriatric rehabilitation. Topics in Geriatric Rehabilitation 17 (14:53-70. Hammel, J. and J. Angelo. 1996. Technology competencies for occupational therapy practitioners. Assistive Technology 8 (14:34-42. Hamner, J., and B. Wilder. 2001. A new curriculum for a new millennium. Nursing Outlook 49 (34:127-31. Harvard Medical School. 2000. "Themes Harvard Medical School." Online. Available at http:// www.hms.harvard.edu/oed/themes2/ [accessed 20023. Hayward, K.S., L.T. Powell, and J. McRoberts. 1996. Changes in student perceptions of interdisciplinary practice in the rural setting. JournalofAlliedHealth 25~4~:315-27. Headrick, L.A., M. Knapp, D. Neuhauser, S. Gelmon, L. Norman, D. Quinn, and R. Baker. 1996. Working from upstream to improve health care: The IHI interdisciplinary professional education collaborative. Joint Commission Journal on Quality Improvement 22 (3~:149-64. Headrick, L.A., A. Richardson, and G.P. Priebe. 93

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