The Education of Physician-Scholars: Preparing for Leadership in the Health Care System.

In this column, members of the College's Vantage Council review books that they have identified as being of interest to the medical management profession. Reviews from other sources are included in Physician Executive as space permits.

As health care reform comes to dominate the delivery of medicine in the 1990s, it will also have a profound impact on how we educate physicians to deal with this new future. Clearly, the emphasis of reform will be on containing health care costs and, as possible, providing progress toward universal access. While it is acknowledged to be important, little concern is being articulated for advancing the quality of medicine through continuing or enhancing the national infrastructure of medical research. The Education of Physician-Scholars attempts to make this argument through delineating the need for special training for MD/PhDs to continue to fill the medical research infrastructure

The book is a result of the tenth anniversary of the Medical Scholars Program at the University of Illinois. Its goal is to evaluate how well MD/PhD physician scholars have been trained in the past and what they will need to succeed in an uncertain future. Unfortunately, the main emphasis of the book and of most of its authors is on traditional basic science scholarship and how to maintain it. Thus the subtitle, "Preparing for Leadership in the Health Care System," is really a misnomer. There is extremely little content on advocating understanding and development in health policy, health services research, and the health of populations. While epidemiology, health economics, and interpersonal management skills are noted the receive very little play. This is a mistake, as these areas and the skills needed to work in them will be critical to containing costs, providing universal access, and ensuring high quality in health care delivery systems of the future. This is particularly true for future physician leaders. After reading this book, one begins to understand why academic medical centers are in such trouble today as health care moves to cost-effective and value-based delivery systems. Once again, academicians, in the self-serving cloisters of their ivory towers, have failed to understand the needs of society. If the editors wish to use the subtitle of "leadership in the health care system," they should hold an eleventh anniversary symposium and concentrate on developing MD/PhD programs in health economics, medical information systems, quality improvement, outcomes and guideline development, clinical epidemiology, fiduciary ethics, etc. Otherwise, the subtitle should be dropped, and the book should be directed at their contemporaries in the basic and clinical medical sciences.

In summary, this is not a book for physician executives, but rather for research scientists. The continuation and national financial support for basic and clinical science research definitely needs to be advocated. But, as the national focus on health shifts to problems of access, affordability, effectiveness, and efficiency, it is suggested that the current national physician-scholar leadership shift some of its emphasis as well. Otherwise, they will be lacking support for the physician-scholar concept altogether.

AMBULATORY CARE EVALUATION UNDER WAY AT MEDICA 

Medica, a Minneapolis HMO with 600,000 members, recently began to evaluate care provided in physicians' offices. The Ambulatory Care Evaluation (ACE) uses clinical guidelines to assess management of common conditions seen in office practice. Medica evaluates all participating primary groups in the Twin Cities against the criteria. It then provides the group with feedback on its performance and the aggregate scores of its specialty.

The program design began in 1989 in conjunction with Dr. Michael McCoy of UCLA. Medica began to formalize the guidelines in 1992. Physicians in the Medica network worked with Medica to write the clinical guidelines. During guideline development, primary care and nonprimary care specialists reviewed and changed the guidelines to meet the current standards.

The guidelines evaluate performance for the most frequent diagnoses seen in the office. The physician network helped Medica select the diagnoses for evaluation and develop the evaluation criteria. Each ACE guideline has nine criteria categories. Each category contains a number of questions pertinent to the category; the number of questions in a category varies with diagnosis.

Prior to an ACE visit, the clinic receives a list of Medica patients selected randomly by the computer. At the visit, Medica review nurses review the charts of these patients. They find visits for targeted diagnoses on the charts and compare the documentation to the guideline standards developed with the physician network. Medica has guidelines for 39 diagnoses for family practice, pediatrics, internal medicine, and ob/gyn. During the review, the nurse enters the scores for each episode of care into a laptop computer. The clinic receives its scores for each category at the end of nurse review of the records. The nurse analyst reviews the scores with clinic personnel and physicians, if they are available. At this time, the reviewer answers any questions and is prepared to give limited advice if the clinic requests it.

After each review, clinic data are loaded into a central computer that develops a profile for the clinic and aggregate data for each specialty. After all clinics for a given specialty are reviewed, each clinic again receives its own data, this time compared to the aggregate for its specialty. Medica can also compare specialties to each other for the same diagnoses - for example, pediatrics and family practice for otitis media. After aggregate data are distributed, the review nurse and a medical director visit clinics that performed poorly to review the data with clinic physicians and management. As a final step, Medica network physicians review to determine if questions measure reasonable standards and provide the information needed for quality assessment. In addition, guidelines are reviewed for currency and pertinence to actual practice.