Viewpoint: Creating Centers of Lifelong Learning
AAMC Reporter: October 2012
—By Sanjeev Arora, M.D., Director, Project ECHO, and Professor of Medicine at the University of New Mexico Health Sciences Center
Academic medical centers are, by definition, hubs for education, research, and patient care. They are essential to creating a health care system in which new knowledge is translated into practice for real-time treatment and quality improvement.
Academic medical centers should be centers of lifelong medical learning and knowledge sharing, where medical professionals expand their expertise and competencies throughout their careers and where best practices are disseminated to the field. They can serve as forums for ongoing mentoring and case-based training. They can host expanded practice communities, where professionals from multiple disciplines, specialties, and even locales work together to provide better care to more people.
Given the challenges confronting our health care system— lack of access to care, uneven quality, escalating costs, rising rates of chronic disease, and severe workforce shortages—we must make more expeditious, effective use of the most up-to-date medical knowledge.
It is important to recognize that lack of knowledge is not what hinders us. More medical knowledge has been created in the past 100 years than in the previous 5,000. Over the next 50 years, there will be even more.
Our problem is a serious expertise shortage. Too many clinicians—especially those who care for underserved populations, often isolated from academic medical centers—lack access to updated knowledge and best practices. We do not have continuous learning systems in place to help them keep up with new knowledge. As a result, evidence-based information often does not reach everyday medical practice, and too many doctors, nurses, and other clinicians work without the full benefit of the science that should be available to them.
This is a terrible waste, one I experienced firsthand as a liver disease specialist in New Mexico. Our Albuquerque clinic was the only one statewide with the expertise to treat hepatitis C patients. An estimated 28,000 state residents had the disease, but only some 1,600 had received treatment.
I was deeply frustrated. We knew how to treat hepatitis C. But in New Mexico, that knowledge existed only in Albuquerque and Santa Fe, which meant thousands suffered unnecessarily and even risked death from escalating illness.
This example is far from isolated. Take arthritis, another significant issue in New Mexico. For many primary care clinicians, it is difficult to differentiate the more benign forms of arthritis from rheumatoid arthritis. In New Mexico, primary care clinicians were referring more patients than necessary to specialists. Patients with serious disease faced long delays for specialist appointments, resulting in unnecessarily prolonged suffering and greater expenses.
Arthur Bankhurst, M.D., a rheumatologist in Albuquerque, told me he, too, worried about keeping pace with the need for specialized treatment. Where would we find the additional capacity?
The answer: By sharing our knowledge with our colleagues in the field, as those of us involved in a new model of medical education and care delivery called Project ECHO (Extension for Community Healthcare Outcomes) discovered. We must acknowledge that we cannot train enough specialists quickly enough to meet demand. We need to expand existing capacity by ensuring that all providers are practicing at the top of their competence and reinforcing team-based care as efficiently as possible. We need a system of lifelong learning, knowledge sharing, and mentoring for all clinicians.
Project ECHO is a simple approach that organizes education, training, practice, and research through weekly virtual clinics, or grand rounds. It uses case-based learning, already familiar to clinicians, to extend the learning continuum beyond medical school and residency through the professional life span. The sessions share the specialized knowledge and best practices that exist primarily in academic medical centers with community-based primary care clinicians. We encourage providers to develop an area of expertise to offer specialized services in their own communities.
Although we do not see patients during ECHO clinics, together, university-based specialists and primary care clinicians in the field actually manage patients with highly complex chronic diseases.
The ECHO model offers academic medical centers an enormous opportunity to extend their knowledge and expertise. They no longer reach only a tiny proportion of patients who need help. By leveraging technology to educate and mentor clinicians in the field, they make high-quality treatment available to an exponentially larger number of patients. Clinicians are empowered to do more of what they want to do—provide better care to more people.
Today, Dr. Bankhurst’s expertise benefits many more patients. By working with primary care clinicians like Naomi Clancy, M.D., in the tiny town of Bayard, N.M., Dr. Bankhurst leads a team that treats patients with rheumatoid arthritis more effectively in their own communities. In contrast, patients with more serious disease like lupus gain more immediate access to specialists.
“Through the ECHO program, I can finally access these people,” Dr. Bankhurst said to me. This is the force multiplier effect.
I, too, reap tremendous satisfaction knowing that far more New Mexicans with hepatitis C are getting treatment now than just a few years ago. Today, at 21 centers of excellence across the state, more than 30 primary care clinicians provide treatment to thousands of hepatitis C patients.
And the knowledge pipeline flows both ways. Specialists gain important knowledge by receiving real-time feedback from care teams that are discovering new best practices in community settings. During the H1N1 flu outbreak of 2009, new best practices emerged for treating children with H1N1 and pneumonia. In New Mexico, we immediately convened two series of clinics to train health care clinicians across the state.
By committing to an expanded mission of lifelong learning through models such as Project ECHO, academic medical centers can create knowledge-sharing networks that bring specialists, primary care physicians, nurses, medical students, residents, and others together to practice regionally, nationally, and even globally. Imagine the power, both within and across these networks, and the tremendous good they could achieve.