Strategy for a Permanente/Academic Partnership in a Small Medical
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.
- 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
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
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
The following text was originally published
in the Council on Graduate Medical Education Resource Paper,
"Preparing Learners for Practice in a Managed Care Environment,
Kaiser Permanente, Northeast Region and New York Medical
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
- Managed Care Fundamentals--Overview and population-based
- Systems within Managed Care--Quality management, resource-utilization,
continuity of care, coordination of physician responsibilities,
referral and consultation, hospital care, performance evaluation
- Interpersonal Skills--Patient-physician relationship,
- 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
- 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
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
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