A Strategy for a Permanente/Academic Partnership in a Small Medical Group | to pdf >>
by Barney D. Newman, MD; Eliot Moshman, MD; Karen S. Edwards, MD, MPH; Martha S. Grayson, MD; Elizabeth K. Kachur, PhD; Martin Klein, MPH

Although Permanente has had a long history of Graduate Medical Education (GME) involvement in the California Medical Groups, establishment of significant GME programs in the newer and smaller Permanente Medical Groups has not been a major focus. In our less established Divisions, which have been struggling for survival, there is no money ear-marked for GME or research. Further, the size of our Medical Groups does not afford the flexibility to allocate clinical staffing time for education except in a token manner. The dilemma is to satisfy the demands of an academic program for relevant content, supervision, and teaching while maintaining productivity and member satisfaction within the constraints of limited resources.

Over the past three years, the New York branch of the Northeast Permanente Medical Group (NPMG) has established a partnership with New York Medical College which has solved these problems for our Medical Group. In this article, we will outline the approach that has been successful for us. We believe that some of the underlying principles of our approach would be transferable in some form to other Permanente groups working in similar environments and probably to other multispecialty Medical Groups. The five elements which we found critical to our efforts will be discussed in this article. They are:

• Seed grant
• Educational champion
• Senior management support
• Interested academic partner
• A scheduling solution that maintains productivity

As our initial strategy, our Medical Group and New York Medical College jointly applied for and obtained a small grant from the Macy Foundation which served as seed money to fund our planning and development efforts. A small part of this funding came to the Medical Group to support devoting 10% of our Medical Education Director's time to concentrate on these initial activities. Lesser amounts of time from other staff members, necessary for parts of the curriculum development process, were absorbed by the Medical Group or came out of individual personal time. However, it was necessary to have one Permanente member freed to devote concentrated time to this effort, and the grant made this possible.

This grant money made it possible for us to enable the second critical component of our success: an "educational champion" for graduate education. As in many projects, the persistence and enthusiasm of a champion who was given the time to focus on establishing this program was a major factor in its successful development. Even prior to the grant, the desire of our champion to be involved in teaching sparked the initial relationship with our academic partner, and the champion was the originator of the idea to pursue a GME program.

The third component was senior management support. A senior management physician was a member of the core developmental team. This individual's involvement ensured that the operational and management concerns of the Medical Group were identified, and addressed as the program was being designed and implemented rather than allowed to become an issue at a later stage. The management physician was also important in moving the program through the necessary approval process of the Medical Group and the Health Plan. Being in a senior management role, this physician was able to shepherd the program through the approval process, facilitating the necessary political and administrative hurdles.

The fourth critical factor was the existence of an interested and supportive academic partner. Based on prior working relationships and previous exposure to Kaiser Permanente (KP) through earlier medical school teaching relationships, our New York Medical College partners had a positive view of KP. Coupled with their interest in promoting primary care and developing sites for ambulatory training, there was a strong interest in working with KP as a training site which would prepare residents for their future in managed care. KP was viewed as an attractive training site, and the physicians of the Permanente Medical Group were viewed as positive role models for the practice of managed care. The New York Medical College staff were therefore sincerely interested in working with us as partners. They understood the practical operational issues which had to be addressed and were open and flexible in working with us to develop solutions to these issues. They supported the principles of managed care in our context and were agreeable to structuring the educational curriculum around this focus rather than around clinical care. This allowed us to organize the educational goals of the rotation around managed care principles and competencies such as coordination of care, quality and resource management, practice guidelines, evidence-based medicine, and population management (see course description, below).

The fifth component, which was mandatory for NPMG,PC, was a creative but simple solution to scheduling teaching time while maintaining office productivity. Without this solution, the program would not have been practical for KP except as a limited short-term pilot. We structured the schedule so that residents and the precepting Permanente physicians were each scheduled to see two patients per hour. This maintained a productivity level of four patients per hour, allowed residents a slower pace to see patients, and gave the Permanente physicians adequate time between their own patients to see the residents' patients and have time for instruction. This approach has proved to be workable since it satisfies the needs of all parties.

This managed care rotation has now been in operation for over two years. We have had more than 30 second- and third-year primary care residents participate. Feedback from the residents and the preceptors has been very positive. As a reflection of growing support from our academic partner, one of the participating primary care residency programs has switched our rotation from an elective to a mandatory selection. Overall, we feel the program has been successful in accomplishing our joint goals, although, because of our size, the scale remains small.

As the focus of GME appropriately shifts more toward ambulatory care and the managed care approach, there will be increasing demand for training in ambulatory care sites such as ours. Both to support our own future recruiting needs and, more importantly, to fulfill our social benefit mission, the Permanente Medical Groups will need to expand our involvement in GME outside California. Eventually, GME funding mechanisms will be required to reflect this shift in the setting and approach to medical education with direct funding (from HCFA or other sources) to ambulatory training sites. Until that funding shift becomes reality, we will need to be flexible and creative to be able to fulfill this vital part of our social mission.

The following text was originally published in the Council on Graduate Medical Education Resource Paper, "Preparing Learners for Practice in a Managed Care Environment, September 1997. Kaiser Permanente, Northeast Region and New York Medical College In order to help physicians acquire the knowledge, skills and attitudes necessary to work in managed care settings. New York Medical College and Kaiser Permanente, Westchester have joined together to develop a curriculum geared towards Internal Medicine and Pediatrics residents. The training program includes a month-long rotation for second or third year residents at a group-model HMO as well as a lecture series which spans all three years of training and includes interested faculty. The program was piloted in 1995-96 and will be fully implemented in 1996-97. The curriculum focuses on "managed care principles and competencies" with educational goals in the following areas: Managed Care Fundamentals--Overview and population-based medicine. Systems within Managed Care--Quality management, resource-utilization, continuity of care, coordination of physician responsibilities, referral and consultation, hospital care, performance evaluation mechanisms. Interpersonal Skills--Patient-physician relationship, team work. Diagnosis and Treatment--Common outpatient conditions and practice guidelines, prevention and health maintenance, patient education, telephone medicine, ambulatory care procedures. Professional Issues--Ethical considerations and career decisions. Personal Learning Goal--To be determined by each resident in collaboration with a faculty preceptor. The managed care rotation in primary care provides residents with a variety of educational experiences including primary care and specialty patient-care sessions, production of a quality management project, attendance at organizational meetings, patient-education and telephone advice line sessions. These activities permit residents to observe and experience firsthand the principles of managed care such as coordination of patient care, quality management, resource management, referral mechanisms, and patient relations. The leaders from New York Medical College and Kaiser Permanente engaged in this collaboration to provide what they view as a much needed educational program that will stimulate learning for all involved, including the staff and patients at the HMO as well as the faculty in the Residency Training Program. They are also interested in the development of more informed attitudes about managed care. The program provides residents with an additional ambulatory training site in a large private practice environment with a large established population. Potential benefits for Kaiser Permanente include an increase in productivity, access to useful quality management projects conducted by the residents, and enhanced opportunities for physician recruitment for the HMO.

50 Years of Medical Education Program History. Given the philosophy that the opportunity for continued professional growth was necessary, Southern California Kaiser Permanente, during its formative years, 1945 to 1957, granted its physicians up to 2 half-days/week for educational activities (medical meetings, organized rounds at various hospitals, teaching and research). Physicians were encouraged to use this time and many actively participate in the teaching programs of neighboring universities. In 1957, these educational half-days were changed and 1 half-day was allocated to education, while the other was time off. Physicians were encouraged to combine the half-day off with their educational time to maintain their teaching commitments. As Southern California Kaiser Permanente grew, it became apparent that "in-house" departmental programs needed to be developed. Conferences now meet for a designated half-day/week and include case presentations and discussions, in-depth review of selected topics, radiology conferences, specialty specific pathology conferences including clinical pathological conferences (CPCs) and, more recently, videoconferencing and teleconferencing. Category 1 CME credit is given for attendance at these activities. Last year Southern California Kaiser Permanente offered over 5000 hours of Category 1 CMA accredited program hours of quality medical education to its physicians. In addition to these half-day "in-house" programs the need to have extended educational programs was recognized. (One- and two-day symposia in major specialties were instituted, circa 1955). Today, speakers at these symposia are both academicians and our own physicians. This has grown to the point where we now sponsor yearly symposia in approximately 35 different areas, on such topics as women's health and doctor-patient communication. An important part of Southern California Kaiser Permanente's educational program has been the intern, resident and fellow training programs. Since the formation of an OB-GYN residency program in 1995, Kaiser Permanente's graduate medical education program has grown in Southern California to include approximately 300 trainees in residency and fellowship programs. These programs include five separate family medicine residency programs. Kaiser Permanente believes that the residency and fellowship programs stimulate the attending staff, help attract high-quality physicians to the medical care program, improve patient care and contribute our share to the community by helping to train the next generation of physicians. Other aspects of the educational program include providing clerkships for 400 to 500 medical students/year. A school for training nurse practitioners began in 1972, and provides an opportunity to train nurse specialists in a number of primary care disciplines. Structure and Budget. There are currently about 3000 physicians of the Southern California Permanente Medical Group serving 2,600,000 Kaiser Health Plan members in 12 different medical centers and numerous medical offices. Each of the medical centers has a Director of Medical Education (DME) who is responsible for the overall quality of programs and for maintaining California Medical Association CME accreditation. The directors meet periodically to share innovative ideas, discuss important issues and participate in faculty development. Future Challenges. The future for Kaiser Permanente's educational program holds many challenges including the incorporation of new technology, developing programs suited to individual needs and, in a time of increasing concern about cost-effective medical care, measuring the value of this extensive commitment to education. This "value" may be measured by improved quality of care, coordination with the quality management program, and alignment with organization goals. Reprinted from HMO Practice, volume 11, number 4, by special permission. Copyright 1997 by The HMO Group.