THE ACADEMIC HEALTH CENTER: CHALLENGES AND OPPORTUNITIES FOR PROMOTION OF SOCIAL GOOD AND SOCIETAL WELLNESS L. Maximilian Buja, M.D. Executive Vice President for Academic Affairs

TEXAS MEDICAL CENTER  45 Member Institutions, 13 hospitals, and 2 specialized patient facilities  100+ Permanent Buildings with 44,188+ Parking Spaces  5.2 Million Patient Visits in 2004, including 10,456 International Patients  4,000+ Physicians, 11,000+ Nurses, & 12,000+ Volunteers  73,600 Employees  11 Educational Institutions with 22,000+ Students  $3.5 Billion committed to research  6 Million Projected gross square feet of space through 2008

THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT HOUSTON Components 1. Medical School4. School of Public Health 2. Dental Branch5. School of Health Information Sciences 3. School of Nursing6. Graduate School of Biomedical Sciences 7. Brown Foundation Institute of Molecular Medicine Personnel 1,273 Faculty800 Medical Residents & Fellows 3,651 Students3,154 Staff Budget $681.7 Million Operating Budget FY 2007 Major Affiliations Memorial Hermann Healthcare System – MHH & CMH-TMC; Harris County Hospital District – LBJ Hospital Harris County Psychiatric Center UT MD Anderson Cancer Center TIRR (The Institute for Rehabilitation & Research) Texas Heart Institute

CHALLENGES FOR THE AMERICAN HEALTHCARE SYSTEM  Healthcare Disparities  Discrepancies in Access to Healthcare  Increasing numbers of non-elderly uninsured  45.3 million in 2004  46.6 million in 2005  Aging Population  Medicare Beneficiaries:19 million (1966), 40 million (current), 77 million (2030)  Low Income Americans  40 million on Medicaid  Misaligned Incentives for Healthcare Providers and Consumers of Healthcare

CHALLENGES FOR THE TEXAS HEALTHCARE SYSTEM Texas (2005)*U.S.A. (2005) Uninsured Children>1,300,0009,000,000 Percent of Uninsured Children20.7%11.2% Total Uninsured>5,600,00046,000,000 Total Percent Uninsured24.2%15.9% * Houston1,469,146 (28%) Brownsville123,466 (33%)

National Health Expenditures (Current Dollars) And Percentage of GDP National Center for Health Statistics

International Comparison of Health Care As a Percentage of GDP and Infant Mortality Rates, 1996 Organization for Economic Co-Operation and Development (OECD) Health Data 2000

THE PARADOXES OF AMERICAN HEALTHCARE  While the future of biomedical research has never been brighter based on the advances to date and the promise of molecular and genomic medicine, national priorities and economic realities are constraining ongoing funding of research.  While the pace of biomedical discovery and new knowledge quickens, the pace of application of the knowledge to effectively prevent disease and improve the health of the population lags behind.  The effectiveness of the healthcare delivery system is constrained because of increasing dysfunction of its socioeconomical foundation.

GOALS OF MEDICAL EDUCATION The goals of medical education are to develop physicians with scientific knowledge and understanding of health and disease; proficiency in basic clinical skills; and attitudes that foster patient-centered care, disease prevention and wellness; and support the highest standards of medical professionalism.

The Continuum of Medical Education Liberal Arts Core Sciences Clinical Sciences and Practice Basic Sciences Research Opportunities MD-PhD Specialty Training Residencies Fellowships Research Fellowships Private Practice Academics Other CME Premed Ed Medical School Graduate Med Ed Graduate Med Ed Medical Practice Medical Practice

TRENDS IN MEDICAL EDUCATION  Evidence-Based Medicine  Problem-Based Learning  Team-Based Learning  Simulation - Interactive learning modules (computer-based) - Simulated patients (computer-based) - Standardized patients - Mannequins  Interdisciplinary Education  Competency- and Outcomes-Based Learning and Evaluation  Testing of Competencies - Objective Structured Clinical Examination (OSCE) - Clinical Performance Examination (CPX)

UT HOUSTON MEDICAL SCHOOL CURRICULUM Prevention and Public Health Issues Biostatistics8 hoursICM and Behavioral Science Courses Community Health6 hoursFamily Practice/Pediatrics Clerkships Epidemiology33 hoursICM and FCM, PBL Cases Family/Domestic Violence6 hoursBehavioral Science Course Medical Ethics25 hoursEthics Course Medical Socioeconomics6 hoursFCM and PBL Case Nutrition12 hoursIn ICM lectures and web-based module Population-based Medicine6 hoursFamily Medicine Prevent/Health Maintenance20 hours Family Practice, Pediatrics, Internal Medicine, PBL Case Substance Abuse20 hours Behavioral Science, Pharmacology, FCM, Psychiatry, Family Practice Clerkships

UT HOUSTON MEDICAL SCHOOL CURRICULUM Prevention and Public Health Issues Health Determinants6 hoursICM, FCM Disease Screening Tests10 hoursICM, Genetics, Pediatrics Immunization8 hoursPediatrics Environmental Health6 hoursPharmacology, Family Practice Counseling for Health Risk Education 6 hoursGenetics, Family Practice, Pediatrics Evaluation of Health Research Literature 10 hoursPBL, Pediatrics Patient Health Education8 hoursFamily Practice Racial/Ethnic Demographics of Illness 4 hoursICM, Family Practice PBL Cases Epidemiology, Prevention, Risk Factors, Substance Abuse, Screening Tests, Patient Education

COMPETENCIES AND OUTCOMES IN MEDICAL EDUCATION  ACGME/ABMS Competencies - Patient care - Medical knowledge - Practice-based learning/improvement - Interpersonal and communication skills - Professionalism - Systems-based practice

NATIONAL INITIATIVES AAMC Institute for Improving Medical Education (IIME) Institute for Improving Clinical Care (IICC) Academic Chronic Care Collaborative (in partnership with the McColl Institute for Healthcare Innovation) ACGME Committee for Innovations in the Learning Environment (CILE) AMA Council on Medical Education: Initiative to Transform Medical Education (ITME) IHI 100,000 Lives Campaign 5 Million Lives Campaign

PROMOTION OF COMPETENCY IN MEDICAL EDUCATION AND PRACTICE  LCME Medical School Accreditation  USMLE Licensing Exam – Steps 1, 2CK, 2CS, and 3  ACGME GME Program Accreditation  ABMS Specialty and Subspecialty Certification  State Medical Board Licensure  Continuing Medical Education (CME)  Maintenance of Certification by ABMS  Maintenance of Licensure by State Medical Board

FUTURE DIRECTIONS  Education of medical and other healthcare professionals - Continuity over the entire professional career - Competency-based  Interdisciplinary professional teams organized around themes and disease processes - Clinical practice - Biomedical research  Focus on balancing care for patients with disease prevention and promotion of health and wellness

PERSPECTIVES Julius B. Richmond and Rashi Fein. The Health Care Mess: How We Got Into It And What It Will Take To Get Out. Cambridge, Harvard University Press, 2005.

J.B. Richmond & M. Kotelchuck. Three-Factor Approach to Health Policy