h5.pdf - Regents of the University of California

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Office of the President TO MEMBERS OF THE HEALTH SERVICES COMMITTEE:

DISCUSSION ITEM

For Meeting of December 15, 2021 SPEAKER SERIES – INNOVATIONS IN MEDICAL EDUCATION

EXECUTIVE SUMMARY

Executive Vice President Byington will introduce speakers from the UC San Francisco (UCSF) and UC Davis (UCD) Schools of Medicine who have worked together with UC medical education leaders to strengthen and enhance select priorities in medical education systemwide. The agenda topic will be presented by Dr. Catherine Lucey, Executive Vice Dean for the UCSF School of Medicine, and Dr. Mark Servis, Vice Dean for Medical Education for the UCD School of Medicine.

BACKGROUND

Medical Education as a Public Good: The Innovative and Impactful Work of the UC Medical Schools General Overview of Medical Education: Medical school is the first formal stage of education for all physicians. Students typically enter medical school after graduating from a four-year college. The first phase of their education is predominantly classroom-based, where students learn foundational sciences and clinical skills. During the clerkship phase of medical education, students work on teams, supervised by faculty and residents to provide direct patient care in hospitals and ambulatory settings. During their final year of medical school, students apply to and interview for residency positions in their chosen specialty and finalize the clinical and research activities needed to prepare them to start their internship upon graduation.

HEALTH SERVICES COMMITTEE -2- H5 December 15, 2021

Most medical students complete their MD degree within four years; some will choose to participate in a longer course of study to engage in research, pursue a combined degree, or to navigate personal stressors. After medical school, all students must participate in a residency program to achieve the competencies needed for licensure, independent practice, and board certification.

Shared Commitment, Common Context and Current Goals: The UC medical schools are united in the shared commitment to serve the people of California in several impactful ways, including: providing opportunities for California students to attend outstanding medical schools; preparing those young adults to be members of the physician workforce that their

patients, communities, and state will need so that all can live long and productive lives, free from preventable illness and premature death; and

preparing these aspiring physicians to also use their voices as citizen advocates for a better society.

The devastating and widespread suffering and loss of life from COVID-19 was exacerbated by the longstanding health consequences of structural racism. These twin pandemics clearly illustrate the importance of designing medical education programs not only to educate physicians


who are prepared to respond to the next pandemic but, perhaps more importantly, to prepare a workforce that is engineered to deliver high-quality, equitable, patient-centered care every day, in every community, to every person, regardless of their power or privilege. Nowhere is this more important than in California, a state known for its diversity and progressive policies geared towards improving the lives of all Californians. A physician workforce that is educated to ensure that the most vulnerable of people receive outstanding care is a workforce that will bring the best care to all. Innovation is Essential in Medical Education: Innovation in medical education is often imagined as novel uses of technology to train people on procedures, innovative remote learning strategies, or new ways to help learners master the vast amounts of information needed for the practice of medicine. In fact, the facility with which UC medical schools use technology and other tools to support learning has been clearly evidenced in the collective abilities of UC medical schools to graduate students each year without lowering standards, despite the disruptions in clinical and classroom learning caused by COVID-19. Yet the transformative work done by the UC medical school deans and their faculty results not only from adoption of new technology and tools, but from a change in mindset. Each school has redesigned its curriculum to ensure that the current and future needs of patients and communities is at the center of the decisions about who matriculates into medical school, what content is taught, who teaches, and how learners are assessed, recognized and rewarded. Achieving the goal of creating the workforce that will improve the health of California communities requires educational leaders who can make sense of current unsolved problems affecting health as well as the healthcare trends that will change the roles that physicians must assume throughout their careers. The unsolved problems in medicine and healthcare direct how students are educated: The patient conditions facing this generation of physicians include complex chronic diseases such as cancer, diabetes, obesity, dementing illnesses, serious mental health disorders and diseases of despair (substance use, alcoholism, loneliness, and others). In addition, as a workforce, physicians must come to grips with the existence of syndemic conditions – defined as the deleterious impacts of complex chronic or severe acute illness with toxic social conditions. Addressing these problems guides the competencies that the students must master: The current and future physician workforces must be educated to understand that national and global health threats result from a complex interplay of biology, behavior, social systems, and environmental conditions. They must be prepared with the knowledge, dispositions, and skills needed to work collectively in support of diverse communities to solve chronic syndemic problems, as well as to respond to periodic pandemics. The physician workforce must be prepared to use and contribute to the tremendous advances in a diverse set of scientific and scholarly disciplines. Intellectually, they must be capable not only of applying today’s knowledge with fidelity and compassion, but also of rapidly reasoning through emerging ambiguous problems.


The personal qualities and values of the future UC physician workforce are important: The ideal post-pandemic workforce, from students to residents to faculty and practicing physicians, must be diverse in all identities and skilled at approaching people different than themselves with cultural humility. They must be willing to advocate for social justice; rigorous science; and the financing, design, and continuous improvement of robust and reliably equitable systems for health, healthcare delivery, and medical education. Finally, they must agree to accept the call to duty that exists as part of everyday work and that may be amplified in times of crisis. Enduring and emerging roles for physicians will enable them to better serve California communities: Outstanding Clinicians: The core curriculum for all medical schools in the UC system is geared toward preparing the optimal UC physician: one who is a skilled and compassionate physician, beloved by his/her/their patients and known for their superb team-based care skills. Supporting this work at all UC medical schools is robust infrastructure that educates and provides support for the tremendous personal transformation that learners must undergo as they transition from an aspiring physician to a graduate about to enter residency. Innovations to achieve this include the development of longitudinal coaching and mentoring relationships for students in each school, a pedagogical best practice. It also requires support for learning challenges; differing ability status in some students; the need for community building and support for students from marginalized communities; and robust wellness and mental health programs. Anti-Racism/Anti-Oppression Physicians: All UC medical schools are committed to embracing an anti-racism lens for their curriculum. This means that all aspects of education, from admissions decisions to curricular content to learner assessment, faculty preparation, and program evaluation are redesigned to ensure equity for all learners. In addition, it means that all learners are expected to demonstrate understanding of the history of racism and oppression in medicine and health care and to practice in a way that allows them to show deep caring for all patients, with an appreciation for the life context in which health and illness occur. Physician Scientists: the UC medical scientist training programs prepare physicians whose careers will focus on bench or clinical research. These programs lead to the combined MD-PhD degrees and typically take eight to nine years to complete. UCLA and UCSF also have MD-PhD programs for scholars in the social sciences, humanities, and anthropology. Leaders in Achieving Health Equity: The UC Programs in Medical Education (PRIME) exist and are being further developed in all UC medical schools and have been recently expanded with new ongoing support from the State. The goal of these programs is to prepare and create physician-community advocates and physician-anti-racism experts by recruiting and training individuals who are committed to serving the needs of historically excluded populations and communities, including but not limited to those serving Black/African American/Caribbean communities; Latinx; and Indigenous Peoples. These programs specifically seek to recruit and provide educational opportunities to individuals from these communities and to incorporate the training in leadership skills needed to prepare them to lead health system and community transformation. Other PRIME programs focus on the needs of underserved regions, including urban and rural communities, notably hard hit by the pandemic. The Joint Medical Program


between UC Berkeley and UCSF focuses on educating physician-public health leaders, a role whose critical importance continues to be highlighted during the pandemic. Innovative Partnerships to Improve Access to Underserved Populations in California: The UC medical schools understand the need for more physician access, particularly for communities in the Central Valley and the Inland Empire. Collectively, several schools have developed regional areas of focus that span the northern Central Valley (UC Davis); the San Joaquin Valley (UCSF and UCSF Fresno in partnership with UC Merced) and the Inland Empire (UC Riverside). In addition, several of the UC medical schools have developed novel partnerships to further expand educational access for aspiring physicians in underserved communities throughout the state. These programs involve partnerships that attract learners from communities that need doctors and support them in remaining there by providing curricular content relevant to the needs of their home communities and, in some cases, by creating continuous educational pipelines from medical school to residency in that geographic area. Examples include: The UCLA-Charles Drew University (CDU) partnership prepares learners from South Los Angeles to become leaders skilled at addressing the needs of this community. Learners participate in research and leadership training during their medical school experience. The UC Davis-Oregon Health Sciences University partnership, the California-Oregon Medical Program to Address Disparities in Rural Education and Health (COMPADRE) is a program spanning medical school and residencies to prepare physicians from rural, indigenous, and urban underserved areas in Northern California and Oregon to care for their communities of origin. The UCSF/UCSF Fresno/UC Merced San Joaquin Valley (SJV) PRIME+ partnership is building on the existing SJV PRIME program to create an eight-year BS-MD program for learners from the SJV and Central Valley. UC Merced will recruit and support students into an enhanced baccalaureate degree to prepare them for conditional acceptance to the UCSF School of Medicine regional campus in the SJValley. The work includes capacity-building at UC Merced (UCM) so that this campus will be able to provide the first phase of medical education at UCM. Learners will then transition to UCSF Fresno to embark upon their clerkship and final years of medical school, eventually earning their medical degree from UCSF. The program’s goal is to encourage students to pursue residency training at UCSF Fresno, Next Steps The UC medical schools function as a committed group of educational institutions, often partnering closely with UC Health, with one goal in mind: preparing the workforce that California patients and communities need so that all can live long, healthy, productive lives, free of preventable suffering. The support of the UC Board of Regents, President Drake, UC Health, the medical school deans, and the health system leaders will remain essential for this success.


Impactful Example of Recent Collaborative Efforts: UC Medical Education Responds to the National Opioid Crisis In November 2011, the U.S. Centers for Disease Control and Prevention (CDC) declared prescription drug abuse to be a nationwide epidemic, with drug overdose becoming the leading cause of accidental injury death, exceeding deaths due to motor vehicle accidents. According to the National Institute of Drug Abuse, more than 130 deaths due to opioid overdose occur every day in the United States, with nearly 100,000 total deaths in 2020, up from 70,000 in 2019. This rise in unintended opioid-related overdose deaths parallels increased sales of prescription opioids, which nearly quadrupled from 1999 to 2014, with over 72 percent of overdose deaths being due to synthetic opioids. Many factors have contributed to this crisis, including unchecked and poorly understood prescription paradigms for pain treatment; mandated recognition of pain as the fifth vital sign; limited education on pain management in medical and other health professional schools; and an underestimation of the risks and an overestimation of the benefits of opioids, particularly in the setting of chronic non-cancer pain. In recent years, policies to address opioid over-prescribing, such as state-based prescription drug monitoring programs and prescribing guidelines from the CDC, have led to nationwide reductions in opioid prescribing and deaths related to prescription opioids. However, many states, including California, continue to see increases in opioid-related deaths, with fewer deaths involving prescription opioids and more involving heroin and illicitly manufactured synthetic opioids such as fentanyl. Overdose deaths involving illicit opioids are part of a complex, intertwined epidemic with distinct supply and demand drivers. Moreover, there is growing recognition that over-zealous interpretation of opioid guidelines may be leading to harmful restrictions on opioid prescribing, particularly for patients who have developed physical dependence on opioids. Finally, the COVID pandemic has seen a return to the increased rate of opioid-related deaths first observed ten years ago. UC Medical Education Response to the Opioid Crisis: The deans and medical education deans of the six UC medical schools, together with UC Health, alarmed by the growing opioid overdose crisis and looking to establish a systemwide educational response, created the UC Opioid Workgroup in 2018. The workgroup, with multispecialty representation from all six schools, met monthly to: (a) address the education gap around opioid-associated morbidity and mortality, (b) develop a set of UC common educational competencies for adoption across the medical schools and (c) make recommendations regarding curricula, core competencies, assessment, and other educational interventions. The workgroup was appointed to ensure broad representation across specialties and disciplines relevant to the opioid epidemic, pain management, and substance use disorder. The UC Opioid Workgroup representation included experts in addiction medicine, addiction psychiatry, anesthesiology, anthropology, bioethics, emergency medicine, family medicine, general internal medicine, geriatrics, intensive care medicine, pain medicine, palliative medicine, pediatrics, psychiatry, psychology, public health, and toxicology. This multidisciplinary and multispecialty group was a striking example of the collective expertise that exists across the UC system when working collaboratively across disciplines and institutions. Not surprisingly, many members were also recognized national leaders in addressing the opioid crisis, but had limited cross-institutional collaboration prior to their participation in this workgroup.


The primary product of the workgroup was a set of core competencies to guide what is taught and assessed in both undergraduate and graduate medical education in the UC medical schools to address opioid-associated morbidity and mortality. The primary domains for the competencies focus on pain management, substance use disorder, and public health. A summary of the UC Opioid Workgroup core competencies and other initiatives was recently published in Pain Medicine (2021). https://doi.org/10.1093/pm/pnaa399 Recommendations from the UC Opioid Workgroup: In addition to creating and defining the core competencies, the Opioid Workgroup made the following six recommendations to the UC deans and medical education deans at the six UC medical schools for implementation:

1. Map and integrate the pain and substance use disorder competencies into existing curricula at each of the schools. These competencies provide a guide to what content should be taught, how it should be taught, and what should be assessed in medical students to ensure that these trainees are prepared to address the opioid crisis in the state and nation.

2. Establish a pain and substance use disorder thread(s) to promote optimal integration of the competencies, and to promote integrated learning and retention by students.

3. Recognize that the social determinants of health (e.g., regulatory mismanagement,

structural racism, patient poverty, insurance and substance treatment access challenges, criminalization of substance use, etc.) have played a critical role in the development of the U.S. opioid crisis and its ongoing health sequelae; thus the needs to effectively integrate pain and substance use competencies in the “Public Health” domain into efforts to teach social determinants of health and promote social justice and anti-racist medical education. For example, the content developed to educate medical students about structural factors and racialized health disparities could use the U.S. opioid crisis as a case study and address the following competency: “Describe the social, environmental, health care system, industry, and regulatory drivers that have shaped opioid prescribing and approaches to pain care, including the social determinants of health in the distribution of morbidity and mortality.”

4. Require students to take the Providers Clinical Support System (PCSS) online course for medical students. This online course consists of seven video modules and five webinars. It is well-designed, up to date, interactive, eight hours long, and is available at no cost. The course has broad educational objectives that address most of the workgroup’s recommended pain and substance abuse disorder competencies including:

a. identification and diagnosis of opioid use disorder (OUD); b. understanding of the multi-dimensional nature of pain and issues in pain

assessment and measurement, including the importance of context; c. review of evidence-based treatments for OUD, including, but not limited to

buprenorphine;

https://doi.org/10.1093/pm/pnaa399


d. understanding of buprenorphine induction, stabilization, and maintenance, and the use of other approved antagonist and agonist medications in the OUD patient; and

e. appreciation of the importance of identification and treatment of pain and other co-morbidities in the OUD patient, including counseling and other ancillary services.

The course can be completed at any time, but it was recommended that it be offered during the fourth year so that it builds on the clinical foundation acquired during clerkship rotations, and it is closer in proximity to the students’ clinical work as residents. The workgroup also recommended that the course be part of the integrated pain and substance use disorder thread(s) established in recommendation #2, and supplemented by small group, active-learning curricula using the opioid competencies. Completing the course also provides lifetime certification for the Medication Assisted Training (MAT) Waiver or X Waiver to prescribe buprenorphine when students become eligible after acquiring their DEA license. The PCSS online course for medical students can be found here: https://pcssnow.org/medications-for-opioid-use-disorder/waiver-training-for-medical-students/

5. Require that the PCSS eight-hour online course for physicians be mandatory for all UC

graduate medical education programs, for those who have not already completed MAT Waiver training. The PCSS online course for physicians can be found here: https://pcssnow.org/medications-for-opioid-use-disorder/waiver-training-for-physicians/

6. Integrate the assessment of selected pain and substance use disorder competencies into the California Consortium for the Assessment of Clinical Competence (CCACC) Clinical Performance Examination (CPX). This clinical skills examination is a fourth-year graduation requirement for all six UC medical schools and uses standardized patients and clinical scripts to assess fundamental aspects of the doctor-patient relationship, history-taking, physical examination skills, clinical reasoning, diagnostic and therapeutic skills, communication, and shared decision-making. The integration of the pain and substance use disorder competencies into one or more of the six to eight standardized patient cases will drive learning and ensure acquisition of core pain and substance use disorder competencies in UC medical school graduates.

Next Steps: These six recommendations were voted on and unanimously adopted by the UC medical school deans, together with UC Health, at a meeting on September 9, 2021. They are not intended to displace existing efforts within the UC system to address opioid-associated morbidity and mortality, but to complement what is currently being done at each school. Additionally, these recommendations are not viewed as exhaustive, but as the minimal standard, with schools encouraged to consider other goals to aspire to, such as establishing clinical experiences for students where pain and substance use disorder competencies are taught and supervised (e.g., elective clinical rotations in addiction medicine). These recommendations are intended to further position the UC medical schools and their graduates as national leaders in addressing pain and substance use disorders, which in turn will better serve patients in California and nationwide.

https://pcssnow.org/medications-for-opioid-use-disorder/waiver-training-for-medical-students/

https://pcssnow.org/medications-for-opioid-use-disorder/waiver-training-for-medical-students/

https://pcssnow.org/medications-for-opioid-use-disorder/waiver-training-for-physicians/


Biography – Catherine Lucey Dr. Catherine R. Lucey is Vice Dean for Education and Executive Vice Dean for the School of Medicine at the University of California, San Francisco (UCSF). She earned her medical degree from Northwestern University School of Medicine, completed her residency in internal medicine at UCSF, including service as Chief Resident at the UCSF-affiliated San Francisco General Hospital. She directs the undergraduate, graduate, and continuing medical education programs of the School of Medicine and the Office of Medical Education. Dr. Lucey is on the executive management team for the School of Medicine’s Differences Matters Initiative and oversees other strategic initiatives for the medical school and the campus. Dr. Lucey’s national portfolio of work has included membership on the National Academy of Medicine, the Board of Directors of the Association of American Medical Colleges, and the American Board of Medical Specialties. Additionally, she served as Chair of the American Board of Internal Medicine. In these roles, she has worked to influence the direction of academic medicine and the continuum of medical education in ways aligned with UCSF’s approach to education, culture and community. Biography – Mark Servis Mark Servis, M.D. is Vice Dean for Medical Education at the UC Davis School of Medicine and was chair of the UC Opioid Workgroup. He received his M.D. from Yale University School of Medicine and completed his internship and residency in Psychiatry at New York Hospital Cornell Medical Center before joining the faculty at the UCD SOM in 1989. He served as residency training director in psychiatry for 20 years and Vice Dean for Medical Education with administrative oversight of undergraduate medical education (UME) and graduate medical education (GME) for the past 12 years, while continuing to practice psychiatry and teach medical students, residents, and faculty. He is a nationally recognized leader in medical education and has occupied key leadership positions for the American Board of Psychiatry and Neurology, the Accreditation Council for Graduate Medical Education, and the National Board of Medical Examiners. Key to Acronyms CCACC California Consortium for the Assessment of Clinical Competence CDC Centers for Disease Control CDU Charles Drew University COMPADRE California-Oregon Medical Program to Address Disparities in Rural Education

and Health CPX Clinical Performance Examination GME Graduate Medical Education MAT Medication Assisted Training OUD Opioid use Disorder


PCSS Providers Clinical Support System PRIME Programs in Medical Education SJV San Joaquin Valley UME Undergraduate Medical Education

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