Implementation Science and Medical Education Transformation

 From the 4/23/2021 newsletter

Perspective/Opinion

 

 

Implementation Science and Medical Education Transformation

 

 

Jeffrey Amundson, PhD, Michael Braun, PhD, and M. Chris Decker, MD

 

 

Drs. Amundson, Braun, and Decker provide an overview of the basic stages of Implementation Sciences, acknowledging that the process must attend to the people and culture where it occurs …

 

Implementation science - a thoughtful, structured rollout of a new initiative - can help make new programs more successful. In the April 2, 2021 issue of the Transformational Times, Drs. Amundson, Webb, Prunuske, and Kalet discussed the use of implementation science methods in the curriculum transformation process. As we move forward with this change, and with the broader transformation of medical education driven by the Kern Institute, let’s take some time to reflect on implementation science: why it’s important, and what it tells us about how and why to start off right.

 

Why are we talking about Implementation Science?

Successful implementation and maintenance of evidence-based practices for organizational changes or programs are a necessary precondition at Kern for providing successful programs, driving innovation at MCW and elsewhere, and generating scholarship. But there’s no guarantee that merely using an evidence-based practice (EBP) will lead to its adoption. For example, here is a story from Bauer and Kirchner’s (2020) article in Psychiatry Research:

“It was, by all estimations, a successful research effort. We had mounted a randomized, controlled clinical trial across eleven sites in the US Department of Veterans Affairs (USVA), testing an organization of care called the Collaborative Chronic Care Model (CCM) for bipolar disorder versus treatment as usual. Over three years of follow-up, the CCM showed significant positive impact on weeks in mood episode, mental health quality of life, social role function, and satisfaction with care - all at no increased cost to the healthcare system. In parallel, a two-year, four-site randomized controlled clinical trial of the bipolar CCM in the Group Health Cooperative of Puget Sound (now Kaiser Permanente), showed very similar outcomes at minimal cost, compared to treatment as usual. Both studies were published in the same year in mainstream psychiatric journals that are read and respected by mental health researchers, clinicians, and administrators. The CCM for bipolar disorders began to be endorsed by national clinical practice guidelines in the USVA and in Canada, and the bipolar CCM was listed on the US Substance Abuse and Mental Health Services Administration's prestigious National Registry of Evidence-Based Programs and Practices.

And yet, within a year of the end of the studies, none of the 15 sites had incorporated the CCM into their usual workflow. The clinicians who had participated in the CCM went back to their usual duties, and the individuals with bipolar disorder went back to receiving their usual form of care.” (Emphasis added)

Something more than sound evidence is needed for a program to be successful, and implementation science is an approach designed to address the how and the why of getting started right, once the “what” has been defined.

 

What is Implementation Science?

Implementation science is the systematic study and practice of program implementation to increase chances of acceptance, adoption, fidelity, and success. For a new initiative, this means the program is supported and practiced by a broad range of practitioners and stakeholders. It also means the practice of the program adheres to the program’s tenets and dictates. And it means that the program achieves desired outcomes predicted by theory and evidence. Notably, this process involves many similar components of continuous quality improvement (CQI). CQI also involves the continual review of an ongoing program’s implementation, fidelity, and outcomes to adjust the program while it remains in operation.

 

Basic Stages of Implementation Science

There are numerous specific models of implementation, and all identify similar stages of the process. Here are five basic steps to the process of implementation as guided by implementation science.

 

Exploration – Needs, Options, and Partners

The implementation team is responsible for getting the stakeholders and learning environments ready. They explore and research different EBPs to share. This might involve reaching out to other organizations who have implemented similar practices, literature reviews, and mock learning environment experiences to familiarize stakeholders with what evidence-based approach looks and feels like. The implementation team develops needs-assessments to ready stakeholders for the next stage of Installation.

 

Installation - Who, What, When, and How

During this phase, the implementation team identifies human and operational resources that become part of an implementation plan. This plan lays out who will be using the new program, where it will be used, who will be asked to do their work differently. It anticipates necessary training to prepare others for changes and details how the new program will be evaluated.

 

Initial Implementation - Measurement, Meetings, Learning Environment, Support, and Observation

When practitioners use the innovation for the first time, implementation teams help develop competencies required by the EBP, help administrators adjust organization roles and functions, and help leaders fully support the process. During this process, the team is rolling out the implementation plan, sharing EBPs chosen to implement, and displaying and modeling the use of resources.  The team is using valid tools to measure effective EBPs, look-fors (things that represent expected strategies and outcomes), peer support opportunities, plans for observation, and plans for touch-base/how are things going meetings.

 

Full Implementation - How Many People? Fidelity, Good Outcomes, New Standard of Work

During this stage, stakeholders involved are using an effective intervention with fidelity and good outcomes. Notably, expected outcomes should be realistic and aligned with theoretical predictions. The new ways are now the standard ways of work and Implementation Teams ensure that the gains in the use of effective practices are maintained and improved over time and through transitions of leaders and staff. This can involve follow-up meetings with staff, review progress monitoring with educators and administrators to ensure fidelity.

 

Sustainability - Financial and Programmatic

Sustainability planning and activities need to be an active component of every stage. These activities can involve ensuring that the funding streams are established, adequate, and sustainable (financial sustainability, e.g., funding for educators, staff, and administrative time) and ensuring that the implementation infrastructure is established, reliable, effective, and sustainable (programmatic sustainability, e.g., vertical articulation with new stakeholders to identify what worked for which stakeholders).

 

Attending to People and Culture

Another critical dimension for successful implementation in every stage is the people and cultural changes required. Though we may discuss implementation science as a prescriptive way to implement a new program, we would be remiss if we ignored the fact that any change within an organization requires extraordinary commitment and sacrifice from the individuals who are asked to carry out the change and live with the consequences (both good and bad) from the change. These changes will impact personal mattering, professional identity, feelings of purpose, and other emotional elements and must be treated by all with humility, empathy, and compassion. And as organizations learn within the implementation, rate of implementation, which can add to the impact of change, is an important consideration. We look forward to exploring these elements of implementation science in a future article.

 

 

In sum, Implementation Science can help effectively identify and validate a need, strategically plan for change through implementation plans, and provide structure for data collection and reporting on the impact of the change. Engaging employees at all levels (e.g., faculty, staff, learners, etc.) early in the implementation process is key to aligning an EBP with the values and culture of the organization. In future issues of the Transformational Times, we look forward to writing about additional important elements of successful implementation and also about the transformational journey of the MCW curriculum reimagining. Stay tuned!

 

 

Jeffrey Amundson, PhD is a postdoctoral fellow in the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

 

Michael Braun, PhD is a program manager with Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

 

M. Chris Decker, MD is Chief Transformation Officer and a Professor of Emergency Medicine at MCW. He is a member of the Human-Centered Design Lab, and has leadership roles in the Design Sprint Program and the Transformational Ideas Initiative (TI2) seed grant program for the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

 

 

Transforming Today’s Medical Learners Into Tomorrow’s Global Health Leaders

 From the 4/23/2021 newsletter

Perspective/Opinion 

 Transforming Today’s Medical Learners Into Tomorrow’s Global Health Leaders 

Lee Ann Lau, MD, FACS

Dr. Lau describes the GME Scholars in Global Health Program, a two-year voluntary curriculum for residents interested in exploring issues of global health equity...

We have all witnessed the global nature of health through the lens of the current pandemic. It is timely that our globally engaged faculty along with the Medical College of Wisconsin Office of Global Health have started a new training program for residents and fellows to build character and competencies to enhance care for patients and their communities. 

Reviewed and supported by MCWAH’s GME Committee, the GME Scholars in Global Health program is a two-year curriculum created to teach global health principles and concepts to residents and fellows. It is designed to cultivate cultural sensitivity, allowing the Scholars to appreciate the global burden of disease and understand how they can use their specialty training to collaborate to address health care inequities and improve access to care from neighborhoods to nations. With multi-disciplinary interactive didactics and biannual deeper dive seminars, the program will emphasize leadership and networking while developing global health skills and knowledge.

The inaugural cohort includes thirty-seven residents and fellows from twelve medical and surgical specialties. Many Scholars are new to the field of global health, but some already have extensive experience they wish to strengthen. During the application process, GME Scholars expressed a desire to incorporate global health skills and knowledge into their future careers. Gaining a broader perspective on how cultural, psychosocial, and economic factors impact the illness and injury experience and outcomes was noted as a priority to provide better care, both locally and globally. Scholars also noted interest in research and obtaining a better understanding of how environment and infrastructure impact care delivery.

 The Scholars are invited to compliment the core curriculum with other experiential learning activities during MCW’s Global Health Week and by participating in the Consortium of Universities for Global Health Virtual Capitol Hill Day, which includes teaching for how to effectively engage legislators.

To launch the new training program in January 2021, the Scholars participated in a discussion about the definition of global health, led by Dr. Stephen Hargarten, Associate Dean for Global Health; and Tifany Frazer, Office of Global Health Manager. The group reviewed the Biden-Harris Administration’s Statement on Global Health Security and considered what recommendations they would make if given the opportunity to influence the new administration’s global health agenda. Not surprisingly, the cohort’s main priority was COVID19 treatment, pandemic management, and vaccine distribution. However, they raised many other important issues including health care equity, rejoining the World Health Organization, addressing climate change, promoting maternal fetal health, and infectious disease research, as noted in their combined word cloud.

The curriculum is co-lead by Drs. Mac Longo, Radiation Oncology; and Ashley Pavlik, Emergency Medicine. Evaluation lead is Dr. Stephen Humphrey, Dermatology; and scholar development lead is Dr. Steve Hargarten, Associate Dean for Global Healtha. The program receives input from eighteen faculty members from more than ten specialties who have dedicated their content expertise to the training program. The didactic lectures and discussions will include a wide range of topics with a global health focus, including noncommunicable diseases, travel medicine, global EMS and disaster medicine, tropical dermatology, private/public partnerships, trauma care, imaging considerations, and eye disease. This rich learning environment will foster the passion and creativity needed for tomorrow’s global health leaders, strengthening their competence, care, and character.

For questions about the program or to apply, please contact the Office of Global Health Manger, Tifany Frazer at tfrazer@mcw.edu.

 Lee Ann Lau, MD, FACS, is currently completing the Hospice and Palliative Medicine Fellowship at MCW after spending 13 years in private-practice general surgery. After graduation, she is planning to start a faculty position with MCW in the Department of Medicine’s Division of Geriatrics and Palliative Medicine.

Practical Wisdom in Medical Education: A Student Perspective

 From the 4/23/2021 newsletter

Perspective/Opinion

 

Practical Wisdom in Medical Education: A Student Perspective

 

Clara Bosco – MCW-Milwaukee Class of 2022

 

Ms. Bosco explains how reframing the role of the medical student from “observer” to “an apprentice acquiring practical wisdom” can shift the relationships between faculty and learners in a meaningful, growth-centered way …

 

In the case of the virtues…we acquire them as a result of prior activities; and this is like the case of the arts, for that which we are to perform by art after learning, we first learn by performing, e.g., we become builders by building and lyre-players by playing the lyre. Similarly, we become just by doing what is just, temperate by doing what is temperate, and brave by doing brave deeds. (Aristotle, Nicomachean Ethics, 1103a 31-1103b 25).

 

 

 “You really should be coming into every room,” scolded my attending. Ugh, day one on internal medicine service and I’m already in trouble. “...all I mean is that there are important, sometimes difficult, conversations you should witness, even if they’re not technically your patient,” she concluded. I didn’t realize the importance of this aspect of clinical training until experiencing a later conversation, my very first family meeting at the VA.

This Monday morning meeting included our primary team, palliative care, social work, and the wife and daughters of our patient. The meeting was intended to convince the family of the gravity of the patient’s condition, a medical reality they had been resistant to thus far. The palliative care physician, due to her expertise in goals of care conversations, led the call with such decorum and grace. I was struck by her collected interaction with the distraught family, who parroted cosigned phrases like, “but he’s not like everyone else,” and “he’s a fighter” in response to the news that their loved one had only around six months to live. To these retorts, the palliative care physician recited a phrase I will never forget: “We have patients who surprise us on both ends of the spectrum, some living shorter or a lot longer.” Oddly enough, this admittance of uncertainty consoled the family, who now felt comfortable with our team’s recommendation for hospice care. The family agreed, the call ended, and arrangements were made; the patient was discharged on Wednesday and died on Sunday morning.

In light of the above anecdote, what is the significance of bearing witness as an apprentice? As a medical student, oftentimes, it entails feelings of floundering, imposing, and space-wasting, as we unreflectively trail in and out of patient rooms on the heels of actually useful attendings and residents. But, for Aristotle, apprenticeship is a cardinal experience since it is the vehicle to become practically wise in a field like medicine where “practical wisdom” is defined as “the art of deliberating well, to make the appropriate choice and to establish the right means through a specific action in order to achieve a particular moral end.” It is through witness of expert physicians interacting with patients that we, as trainees, can move beyond our pre-clinical, theoretical understanding of the human body to a patient-centric, bio-pyscho-socially driven medical practice.

To further elucidate the role of practical wisdom in clinical medicine, consider how an oncologist might deliberate whether to pursue chemotherapy vs. surgery to treat a patient’s cancer. Theoretical wisdom, i.e., knowledge of cellular mechanisms, surgical technique, etc., is certainly necessary to best treat a disease. However, theoretical considerations alone may not be sufficient to best treat a particular patient’s illness. For example, does the patient have certain comorbidities that exclude them from surgery? Do they have health insurance? Do they have reliable means of transport for serial chemotherapy sessions? Are they able to take off work for surgery and do they have some to care for them? These considerations illuminate the numerous extra-scientific dimensions that must be weighed, via practical wisdom, to achieve the best treatment plan for a particular patient.

From an educational standpoint, integrating foundational concepts like practical wisdom into medical school could prove to be useful for both trainers, and, especially, trainees. For educators, practical wisdom could provide the foundation for effective role-modeling and mentorship. For students, introducing practical wisdom early and often in medical school could provide a much-needed conceptual framework for students to better understand their role as an apprentice. The long hours at the hospital, the feelings of “shadowing,” and uselessness to the team are stressful realities of medical students that certainly contribute to burnout. However, if these challenging experiences were reframed as formative to developing one’s own practical wisdom surrounding clinical reasoning and patient care, a new sense of purpose and ownership of the apprentice role may be encouraged among medical students.

 

 

Clara Bosco is a third-year medical student at MCW-Milwaukee. She is interested in the philosophy of medicine, bioethics, and artificial intelligence and works with Fabrice Jotterand, Ph.D. Director of the Philosophies of Medical Education Transformation Laboratory (P-METaL) in the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

Three Questions for Jose Franco, MD: Perspectives on the Transformation of Medical Education

From the 4/30/2021 newsletter

Three Questions for Jose Franco, MD

Perspectives on the Transformation of Medical Education

The Kern Institute celebrates the appointment of our colleague, Jose Franco, MD to his new role as MCW’s Interim Senior Associate Dean for Academic Affairs. Dr. Franco has been part of the Kern Institute since its inception and has held major leadership roles. As he assumes his new position, he is stepping away from his Kern responsibilities. In this interview, he describes his journey with Kern and his hopes as MCW enters a time of curriculum redesign … 

Transformational Times: Tell us about your journey with the Kern Institute. 

Dr. Franco: Dr. Cheryl Maurana, the institute’s inaugural director, asked me to be the associate director of the Kern Institute at its inception after MCW received the Kern Foundation grant in 2017. During the first year, we were busy with planning and defining the role of the institute. When the four “pillars” were created (students, faculty, curriculum, culture), we developed the “cross-pillar” team that would focus on areas that were important but which none of the pillars owned; areas like wellness, character, and caring. Under Ryan Spellecy’s leadership, for example, we ran focus groups and developed scholarship around “character” in medical education.

When Dr. Adina Kalet became the institute director in 2019, she saw a need to connect more intentionally within the institution and with our urban community, so the cross-pillar activities evolved into community and institutional engagement roles in ways that focused on education. I took on a more active role with event planning, recruiting speakers and panelists, and hosting Grand Rounds, Kern Connection Cafes, and Journal Clubs. It has all been a virtual-reality challenge over the past year.

While this has been going on, I have retained my clinical identity in hepatology and continued to engage with students at all levels. I still look forward to my days in clinic working with our entire group of physicians, students, trainees, PAs, and NPs. They are a great team! I enjoy teaching M1 gastrointestinal physiology, hepatology in the M2 GI nutrition unit and clinical hepatology to the M3 students rotating on internal medicine. I often work with M4 students on electives. I spend time on the wards and in clinic with internal medicine and general surgery residents and fellows. I am fortunate to work with medical students and trainees along every point of the training spectrum. I enjoy that.

Transformational Times: What do you see as your most urgent tasks as you move into your new role as Senior Associate Dean?

Dr. Franco: First of all, we have to define who constitutes our customers in Academic Affairs. Our customers are the students and the faculty. 

For students:

Academic Affairs focuses on curriculum. We must ask ourselves: Is our curriculum really preparing the students for the next phase of their careers? We do a great job covering the basic and clinical sciences but could do a better job with the social sciences. For example, students must leave MCW with a robust understanding and engagement with issues surrounding social determinants of health, and the wellbeing of marginalized populations. Those educational and experiential areas need attention. 

As an educational institution, we must do a better job fostering an inclusive, diverse environment. We are fortunate to have students who identify as being from underrepresented in medicine groups. We must ensure that they feel welcome, included, and empowered. There are, of course, great people at MCW doing this already and I hope Academic Affairs will enhance these efforts. Diversity makes us all better. 

Focusing our efforts on student wellness and wellbeing will be critical. The gaps here constitute a national crisis. When students and young physicians are in crisis, they will “fall out of love” with medicine. Too often, physicians end up seeing medicine as a “job” and not a “calling.” We must explore how we can prepare students and residents to be fully engaged and resilient for their entire careers. I would love to play a part helping students optimize their physical, mental, and spiritual health as human beings. 

For faculty:

I sense that faculty often see the Office of Academic Affairs as a “black hole.” I believe that the Kern Institute has worked to inform the faculty what it does through regular engagement and communication. In much the same way, Academic Affairs needs to let the faculty know what it does. 

The office has many resources that can help the faculty perform their roles as teachers and mentors. We have expertise in instructional design and educational technology, for example. We need to let the faculty know what is available, who to talk to, and how they can be the best educators possible. 

Transformational Times: How do you see the current status of the curriculum redesign?

Dr. Franco: The answer to that changes from week-to-week. MCW’s faculty are well aware that there is no perfect curriculum and that there is always room to make improvements. That said, we have been through change before and, even though we know there is a need to make adjustments, these processes always cause anxiety. The process will always feel like a curveball.

First of all, I am certain that we will be given the resources to do the curriculum redesign correctly. Senior leadership is onboard, responsive, and wants this to succeed.

What is our goal? Let’s start by saying that our goal is to work together to deliver a quality product. We could, of course, put out something tomorrow, but would it be quality? 

I sense that there are two major faculty concerns as the process moves forward:

The first major area of concern revolves around faculty development and preparation for the redesign. 

MCW’s preclinical curriculum has often relied heavily on the traditional fifty-minute lecture format with few interactive opportunities. If we plan to institute a flipped-classroom, case-based teaching approach, we must have a fully engaged and prepared faculty. We must better understand how long it will take to bring everyone up to speed. 

We need to engage the clinicians who will be expected to take on new teaching responsibilities. Clinicians will be increasingly integrated into the process and the proposals will require different approaches that will expand their teaching approaches and challenge their skill sets. 

The second major area of concern is the timeline. 

Is the timeline for deploying the newly redesigned curriculum in August 2022 realistic and optimal? Although it is over a year away, we have a much shorter time to make a decision, since we will begin interviewing the entering class of students late this summer. They are the “customers,” as it were, of the new curriculum. They are the ones who will have to decide if they want to come and experience what we will be offering. We need to be clear with them as to what the curriculum will look like. 

I know that many of the faculty have expressed strong opinions. We must work together and make certain we are all ready and onboard. 

The curriculum belongs to the faculty and the Curriculum and Evaluation Committee (CEC) has the critical role here. I had the good fortune to be chair of the CEC when the pilot integrated curriculum was approved. A few years later, I brought proposals for curricular change to the CEC. I have been on both sides of the table. As a result, I hope I will be in a good position to listen to peoples’ concerns. What excites them? What worries them?

I am excited to take on this role at this important time for our students and our faculty. 

Jose Franco, MD is the Interim Senior Associate Dean for Academic Affairs. He is a Professor in the Department of Medicine (Gastroenterology and Hepatology) at MCW. He previously held leadership roles in the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.