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Pathways to Discovery

reprinted from Issue 12, Spring 2011 of Frontiers of Medicine (PDF)

Another educational innovation at UCSF is the Pathways to Discovery program, which provides in-depth training that goes beyond the routine practice of medicine to prepare medicine’s future leaders and innovators. The five Pathways – Global Health, Health and Society, Molecular Medicine, Clinical and Translational Research, and Health Professions Education – offer curriculum, intensive mentorship and the opportunity to conduct research and scholarly or community-based projects with real-world impact.

Dr. Arpana Vidyarthi and Dr. Read Pierce lead residents in the Pathways to Discovery’s Health Systems and Leadership track through the main pharmacy at UCSF Medical Center as they follow the trail of a sample prescription for an anti-clotting medication. As part of a quality improvement project, the residents identified vulnerabilities in the prescription and delivery of anticoagu-lants and developed recommendations for improvement, which they presented to UCSF Medical Center leadership.
photo by Noah Berger

“A fundamental precept of the Pathways program is that we want them to be acquiring skills while doing something that’s needed in the world, whether it’s in the lab to answer some fundamental question, or in Zimbabwe or in the Bayview neighborhood in San Francisco,” says Louise Aronson, MD, MFA, who directs the program. “This is about starting to change the world now, and developing the relationships and skills you’ll need to be a leader.”

Some current projects include screening and management of viral hepatitis in Sudan; studying genetic ancestry, socioeconomic status and disease characteristics among Hispanics with systemic lupus; and developing a flow chart and curriculum for appropriately referring elderly patients to community resources.

Now in its third year, Pathways evolved from the former Areas of Concentration and Areas of Distinction programs for medical students and residents. While many other institutions have similar areas of scholarly concen-tration, UCSF’s Pathways program is distinctive because it is open to learners at all levels, including medical students, residents, and fellows, as well as trainees in the schools of dentistry, nursing and pharmacy. Rather than functioning as a standalone elective or advocacy, leadership or research experience, Pathways seeks to provide trainees with long-term professional development, and cultivate health professionals who are not only outstanding clinicians, but become leaders in their fields.

“In order to make a difference in health and health care, we need to address the entire spectrum – from the level of the cell to the level of the individual patient, the community and the country,” says Aronson. “We give people opportunities to succeed as scholars, leaders and advocates throughout the spectrum. Pathways also helps us capitalize on the diversity of who comes to UCSF, helping them figure out, ‘What makes me excited, and where I can really make a difference in the world?’”

Training Leaders

One example of the Pathways is the Health Systems and Leadership Track, one of two options within the Health and Society Pathway. “I fundamentally believe that leaders are bred, not born,” says Arpana Vidyarthi, MD, who co-directs the track with Read Pierce, MD. “Yet there is a tremendous dearth of leadership development training for physicians. We commit decades in structured training to teach clinical skills. But even though our goal is to graduate leaders in medicine, we don’t approach leading and leadership training with the same rigor.”

“The residents in our Pathways Track graduate with a robust understanding of how to improve health care delivery processes,” says Pierce. “They learn techniques that are useful for analyzing organizational problems, identifying possible interventions, and creating pilots to test and then sustain useful change. Historically, clinical training programs have emphasized these skills far less than medical knowledge and biomedical research.”

“The Pathways program was a large part of the reason I came to UCSF,” says Krishan Soni, MD, MBA, now a third-year Medicine resident at UCSF. “Pathways gives you access to amazingly interesting people. Also, it’s a chance to stop and reflect on what we’re doing as residents, whether it’s teaching, clinical care, communicating or leading teams.”

The Health Systems and Leadership Track currently has 12 second- and third-year residents who meet weekly during their outpatient rotations. They bring a wealth of experience – about one-third also have degrees outside of clinical medicine, such as master’s degrees in public health and business administration, and many have worked for finance, consulting and policy organizations.

Building on these talents, they hone personal leadership skills such as the ability to communicate effectively and work with others, make an “elevator pitch,” negotiate, perform a stakeholder analysis, and adapt proposals for multiple audiences and occasions. They also set, pursue and evaluate progress on goals for personal development as leaders during residency. In addition, participants learn about health care policy, and develop a toolkit of quality improvement skills.

Real World Impact

The group uses a public policy school model of applying tools to a client-based project. Last year, the group’s client was the Pacific Business Group on Health (PBGH), a nonprofit coalition of 50 major businesses – including Chevron, Intel and Safeway – which works to improve the quality and affordability of health care for its members. The Health Systems and Leadership cohort was charged with providing a physician perspective on ways to improve the value of health care delivery.

“It was in the midst of the health care debate, and I was very excited to work on something that was relevant and meaningful,” says Soni. “It was a little overwhelming to work on a topic that so many people have been thinking about for so long. However, we conducted research, interviewed very smart people, and drew on our own experience as residents of what we would want to change.”

Their research culminated in a presentation with PBGH’s executive team, followed by a lively discussion. Some of the residents’ recommendations included improving health information technology to reduce the need for different specialists to repeatedly order the same tests; providing financial and technical assistance to physicians to make it easier to implement changes that would provide better value; and developing timely, accurate and relevant “report cards” that physicians could use right away to improve their practices and care of specific patients.

“The UCSF residents’ analysis alerted PBGH leaders to important nuances in structuring shared savings between large employers, insurers and doctors,” says PBGH Medical Director Arnold Milstein, MD, MPH. “It’s an excellent demon-stration of experiential learning for residents about how private sector policy affects health system performance. Society very much needs physicians who can meaningfully contribute to national and regional health policy setting in both the public and private sectors.”

The Health Systems and Leadership Track also has focused on improving quality and safety at UCSF Medical Center. Anticoagulants, or anti-clotting medications, are commonly used in the hospital to prevent clots and treat conditions such as heart attacks, but require precise delivery and careful monitoring to be used safely. Two years ago, residents analyzed vulnerabilities in the anticoagulant delivery system. They wrote a dummy prescription, and physically followed it through the hospital from the pharmacy to the patient, developing a comprehensive map of all the potential things that could go wrong. This year, the group is working on recommendations for reducing “door-to-floor” time – the period between a patient arriving in the emergency department, and being transferred to a hospital room if hospitalization is necessary.

“What we’re seeing in medicine is a tremendous need for physician leaders to embrace and effect change,” says Vidyarthi. “These are 12 incredibly bright residents who choose to spend their elective time in system analysis and developing their own leadership and teamwork ability. We give them mentoring and additional curriculum upon which they can build their skills. Out of this emerges brilliance.”

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