Introduction
Health care will continue to get better and better in Europe and the United States, but its costs will increase. In parallel, the expectations of both the individual and society are changing clearly concerning the profi le of physicians and the desired results of the system.
While the last 20 years have seen a steeper increase in health care costs world- wide than ever before, this has also resulted in marked improvements of outcome variables such as longevity and quality of life in patients with frequent diseases, such as cardiac problems or cancer. To limit the steadily increasing expenses for the health system, efforts have been made to improve the effi ciency of the expenses, for instance by decreasing length of hospital stay and shifting man- agement and care of many diseases to ‘outpatient’ systems. As a consequence, the following questions must be asked:
- How should we adapt the training of health professionals, funding and ac- counting systems to meet the expectations of the population?
- How can societal demands be satisfi ed in a consumer-driven system?
In the present chapter, some elements enabling us to meet the new objectives are presented
Training the Physician for a New Role in Tomorrow’s Health Care:
Reforming the Medical Curriculum and Introducing the Bologna System
Why?During the late eighties and early nineties, a wind of change blew through a number of medical schools in the US and in Europe. The main reasons for the desperate need for a profound reform are summarized in the Robert Wood John- son Foundation National Program Project report [1]:
• “Traditional medical school curricula required students to absorb imprac- ticable amounts of scientifi c information in lecture format for the fi rst two years, in preparation for standardized tests that grade their abilities in basic science. They received little practical experience in working with patients and were so busy with classes and tests that they had little time to think and proc- P. M. Suter
ess what they were learning. Only in the third and fourth years did medical students have a chance to meet patients and apply what they had learned to clinical situations.
• Similarly, once students were into the third and fourth years of medical school, their experience was almost exclusively on the clinical side. Therefore, much of the basic science they learned in the fi rst two years was forgotten, lost in the whirl of clinical rotations.
• The relevance of teaching basic sciences needed re-examination. At issue was the following question: Is it necessary for medical students to absorb the entire range of basic scientifi c knowledge, which is expanding exponentially year after year? Or would it be more productive to have them learn how to access such information easily when necessary in the course of clinical prac- tice?
• Reorganization of basic sciences to take account of entirely new sciences, such as molecular biology and medical informatics, was long overdue. For many years, basic science education had been broken down into discipline-based departments such as cell biology or pharmacology. Innovations like prob- lem-based learning and organ-based teaching, which integrate basic science with patient problems, had been largely stymied by the power of department heads.
• As medical schools started becoming major sites for biomedical research, and as their associated teaching hospitals have become the locus for cutting- edge medical care, teaching took a back seat to the research and clinical mis- sions.”
In addition to the necessary changes in organization of the curriculum, more autonomy of the students and newer pedagogic methods, a major shift in favor of expanded time for human and social science, the so-called soft sciences [2]
became necessary.
How?
Recognizing these shortcomings and new demands, including for instance the scientifi c evidence linking biological, behavioral, psychological and social vari- ables to health, illness and disease, the ongoing reforms have focused on the following:
• enforcement of human psychological and social sciences during the whole curriculum [2, 3];
• enhanced responsibility for students to organize their training and knowl- edge acquisition, by the problem-based-learning system;
• increased attention paid to clinical skills;
• earlier clinical contact and student-patient interaction;
• training for effi cient communication;
• teaching of physician role and behavior
• more attention given to health policy and economics;
• learning practice skills and ‘savoir-être’.
The Introduction of the Bologna System in all European Universities:
An Additional Opportunity?
In 1988, the Ministers of Education of 29 European countries edited the “Bolo- gna Magna Charta Universitatum”. In this framework, the major objectives and changes needed to improve the university system of the continent were defi ned, including:
• a call for independence and autonomy of the universities
• a defi nition of the curriculum for:
• better compatibility, and
• increased comparability, for a
• greater student mobility between universities.
To achieve these goals, the Charta proposed the introduction of a
• quality insurance for teaching, research and management
• uniform 3-level system:
– fi rst level: Bachelor 3 years – second level: Master 2 – 3 years – third level: Doctorate 2 – 3 years
• defi nition of the workload for the student by the introduction of a common
‘European Credit Transfer System’ (ECTS), whereby 1 ECTS corresponds to 30 hours, one full year of university study to 1800 hours and hence 60 ECTS;
therefore the Bachelor degree corresponds to 180 ECTS, and the Master to 120–180 ECTS.
For the medical curriculum, the Bologna system adds an interesting opportu- nity to include the essential elements of the reform, to increase comparability between different countries and systems, and to ensure and improve quality as- pects of formation and training.
In essence, the Bologna system is an occasion to improve training of tomor- rows’ physicians, which cannot be missed (Fig. 1).
How to Adapt Funding and Medical Education?
To defi ne a good model for tomorrow’s medical education funding system, we will have to consider the essential changes planned for the next decade (Table 1).
These include the following:
• a reshaped curriculum of medical education (Bologna system) to select and train doctors;
• a reorganized postgraduate training system, to provide professional compe- tence preferentially in domains where this is most needed;
• a quality-based pre- and post-graduate teaching system, with transparent fi - nancing, controlling and examination basis, leading to better international comparability, exchange and recognition;
• a performance controlled research promotion and improvement system - including national and European institutional coordination and fi nancing agencies.
Fig. 1. Schematic representation of the Bologna system applied to the medical curriculum.
Changes from and to the Bachelor and Master in Medicine are possible also during the stud- ies, provided that the necessary credits are obtained and documented in the student fi le. Du- ration and ECTS: Bachelor 3 years / 180 ECTS, Master 2-3 years / 120-180 ECTS, Doctorate 2-3 years.
Table 1. Funding of teaching and research
Funding Today – costs supported by 2015
Medical School Federal + state, tuition Federal + state, tuition + grants according to need + results Postgraduate Trainee (working hours) Trainees
+ teacher + state according to specifi c + institutions needs for domains
+ results
Continuous Trainee, institution, industry - Idem - but also recognition for education ± recognized accreditation
Quality control
Incentives for quality
Research Institutions (University, Idem - but more specifi c short / long hospital, foundations, industry) term support according to quality based on expert evaluation control + performance indicators or standards of institution Basis for academic career
New Funding and Accountability for Health Care
When a system for an expensive area has to be reinvented, all important stake- holders must be involved to fi nd a possible consensus or at least a compromise.
Today, health spending per capita or in % of gross domestic product varies wide- ly among developed countries (Table 2) [4].
The level of these expenses is not necessarily related to results or outcome.
However, looking at a larger number of countries, including developing and poorer areas, a certain association between health expenditures and life expect- ancy at birth can be seen (Fig. 2) [5].
In countries where there is less than 1000 US$ of total health expenditure per head, life expectancy seems lower. On the other hand, no signifi cant difference for life expectancy is evident for expenditures between 1500 and 3700 US$. This could suggest that in the latter, richer countries, effi ciency of health expendi- tures are variable in terms of their effect on longevity.
Although longevity is frequently used as a simple variable to assess the effects of a health care system and its costs, this is not very satisfactory overall if we want to compare the most developed areas of the world, offering high standard care (Fig. 2). A better defi nition of health care outcome must include in addi- tion infant and maternal mortality and potential years of life lost to common diseases below the age of 70. Such an approach was explored by Herzlinger and
Table 2. Health spending in 2002. From [4] with permission
Country Health spending per capita PPP $* % of gross – Domestic product
USA 5267 146
Switzerland 3445 112
Canada 2931 96
Germany 2817 10.9 ×
France 2736 97
Netherlands 2643 91
Sweden 2517 92
Australia+ 2504 91
Italy 2166 85
United Kingdom 2160 77
Japan+ 2077 78
PPP $ * indicates purchasing power parity international dollars
+ Data are for 2001
× Nr high because the former East Germany contributed proportionally less gross domestic product to the unifi ed Germany than added health expenditure
Parsa-Parsi [6]. These authors noted that the most favorable outcomes resulted from a consumer-driven program. This could suggest that an appropriate shar- ing of responsibilities and fi nancial efforts between patient public funds (= tax- es), insurer and health care providers is important for a favorable cost/effi ciency relationship [4].
As indicated in Table 3, this type of more precise analysis seems to indicate an advantage for a consumer-driven system [6].
Consequences for Intensive Care Medicine
Intensive care medicine is a complex area in terms of clinical tasks and con- straints, collaboration with other health professionals and caregivers, interac- tion with hospital administrative, technical and other support services, and also concerning its relation with academic institutions. These institutions are responsible for the pregraduate and (in part) postgraduate teaching, but also for basic medical as well as clinical research. The multiple interactions of all part- ners and stakeholders in this fi eld are not unique; these can be found in similar but not identical forms for other medical specialities.
Three main areas can be considered relevant for designing new models in funding and accountability (Table 4). Such new models should be built on the following conditions:
• the existence of a general service agreement, for the department/division of intensive care medicine, established with the partners and stakeholder most involved;
• a job description for the intensivist, cosigned by the main actors and revised regularly, including the tasks in clinical work, teaching, research and admin- istrative duties;
• defi nition of budgets, distinguishing clinical and academic parts.
Fig. 2. Relation between total health expenditure per head and longevity for a number of de- veloping and rich countries. It seems that health-expenditure above 1000 dollars per head (1997 fi gures) does not result in substantial further benefi t in terms of longevity. From [5]
with permission
The funding system of the future should be based on future possibilities and needs for specifi c training and more precisely defi ned tasks for the ICU phy- sician. Dynamic career construction based on enlarged formation possibilities will open promising developments for intensivists, and provide better coverage of the main needs of hospital, ICU and university (Table 4).
The specifi c challenges of intensive care medicine may in part vary from one country to the other. Special consideration has to be given to an effi cient han- dling of procedures and specifi c needs of other departments [7]. For staffi ng and career planning, the presence of the ‘hospitalist’ track [8] may play an important role.
The ICU as many other domains has felt increased competition with other units for income, increased costs, and a demand for a more business-like ap- proach to operation. Its role in the hospital and the health care system in gen- eral is not always well defi ned, nor are its academic missions. Again, a ‘general service agreement’ (‘convention d’objectifs’) can help to defi ne better tasks and duties, and the means required to do this.
Bekes et al. have recently described a real business model for critical care medicine as a product line [7]. They present a plan in the context of a specifi c hospital context and its board of trustees, based on the concept of a product line.
It is shown that such a product line can be profi table for the hospital.
Table 3. Potential years of life lost to diabetes and myocardial infarction, life expectancy, and infant and maternal mortality – Canada, Switzerland, United Kingdom, and Germany. From [6] with permission
Canada Switzerland United Germany
Kingdom
Potential years of life lost per 100 000 population aged < 70 y, 1997
All causes 3803.3 3619.3 3951.5 4164.4
Diabetes 50.8 27.7 28.9 42.9
Acute myocardial infarction 184.9 122.6 248.4 239.5 Malignant neoplasm of colon 76.0 63.0 79.5 90.6 Malignant neoplasm of breast 211.2
(among women only)
Malignant neoplasm of prostate 27.0 25,7 28.9 27.9 (among men only)
Infant mortality 5.3 4.6 5.8 4.5
per 1000 live births, 1999 Maternal mortality
per 100 000 live births, 1998 3.8 3.8 7.0 5.6 Life expectancy, y
Total population at birth, 1999 79.9 79,7 77.4 77.7 Disability-adjusted total 72.0 72.5 71.7 70.4 population at birth, 1997/1999
Men at age 65 y, 1997 16.3 16.5 15.1 15.2
Unlike other parts of the health system, the approach by Bekes et al. brings the ICU (and other sectors such as the emergency department) into focus as an essential part of the hospital. This can also mean that expansion of this line can only be achieved by increasing referrals from other hospitals, or offering new services requiring ICU beds, such as cardiology or liver transplantation.
Accountability of ICU services has to go primarily through hospital structure and university requirements of teaching and research. General health system discussions and funding models are therefore not applicable separately. From the patient’s standpoint however, emergency and ICU services are typically part of the duties which should be taken care of by the state, its government and thereby the tax payer.
References
1. National Program Report. Preparing physicians for the future (PPF): A program in medi- cal education. At: http://www.rwjf.org/reports/npreports/prephysicians.htm Accessed July 2005
2. Anonymous (2004) The soft science of medicine. Lancet 363:1247
3. Cuff PA, Vanselow NA (2004) Enhancing the Behavioral and Social Science Content of Medical School Curricula. US Institute of Medicine. At: http://www.nap.edu/books/
030909142X/html Accessed July 2005
Table 4. Critical care activities relevant for funding and accountability Today General mixture of – clinical tasks
– management
– teaching
– research
Tomorrow Clarifi cation of main activities, early identifi cation of different career possibilities and specifi c training
Medical school Options (opportunity = Bologna), e.g.
– clinical track
– research track
– MPH, MBA, etc
Postgraduate – enlarged possibilities for more than 1 medical specialty board
– MD/PhD ± clinical training – PhD ± medical horizon – MBA / management
Continuous education: – according to activities in the ICU defi ned by curriculum, specifi c capacities and service needs
– management, economics in health care, etc
4. Reinhart UE (2004) The Swiss health system. Regulated competition without managed care. JAMA 292:1227–1232
5. Richards T, Tumwine J (2004) Poor countries make the best teachers. BMJ 329:1113–1114 6. Herzlinger RE, Parsa-Parsi R (2004) Consumer-driven health care. Lessons from Switzer-
land. JAMA 292:1213–1220
7. Bekes CE, Dellinger RP, Brooks D, Edmondson R, Olivier CT, Parrillo JE (2004) Critical care medicine as a distinct product line with substantial fi nancial profi tability: The role of business planning. Crit Care Med 32:1207–1214
8. Wachter RM (2004) Hospitalists in the United States – Mission accomplished or work in progress? N Engl J Med 350:1935–1936
