The Transformative Care Continuum: implementing an accelerated pathway that addresses the new roles of the family medicine physician

ABSTRACT

Background

The Transformative Care Continuum (TCC) emerged in 2018 at Ohio University’s Heritage College of Osteopathic Medicine, combining a three-year medical education track with a three-year family medicine residency. TCC aligns evolving family physician roles through the Kern model, AMA’s Master Adaptive Learner model, Health Systems Science Training, and Kirkpatrick’s evaluation model.

Methods

The TCC curriculum emphasizes intensive coaching, clinical encounter video evaluation, reflection, and case-log review. It fosters longitudinal clinical integration, community engagement, and a dynamic learning atmosphere. Students receive rigorous patient-centered communication training and engage in residency-based quality improvement projects, targeting care gap closure and community health in an accelerated 3-year program.

Outcomes

Assessment of TCC graduates demonstrates advanced team communication, leadership, and project management skills, with entrustable professional activities (EPA) scores meeting or surpassing those of traditional program graduates. Projects led by students have yielded notable clinical enhancements, national recognition, and significant philanthropic funding for non-medical determinants of health. Finally, there is an overall increase in scholarly activity and leadership roles within the residency programs that have engaged these students.

Discussion

Lessons reveal intrinsic challenges and heightened academic demands for students and residency programs. Additional educational support for students may be necessary, though costly. Limitations in residency slots and faculty availability as student educators potentially hinder scalability. Ongoing faculty training, cultural support, and early integration of digital systems for curriculum management and evaluation are vital for success. Obtaining patient satisfaction, health outcomes, and program measures remains challenging due to privacy concerns and approval processes between institutions.

Conclusion

Programs like TCC effectively prepare students for family physician leadership and change management roles through tailored learning, longitudinal experiences, health systems training, and addressing critiques of traditional medical education. Continuous feedback and robust communication strategies are essential for program improvement, fostering well-prepared family physicians committed to health system enhancement.

Introduction

Preparing future family physicians to meet new and evolving roles [1] requires corresponding innovation in medical education. For decades, medical educators have experimented with accelerated undergraduate medical education (UME) programs [2]. Examples of early graduation of medical learners include a three-year primary care program at Case Western Reserve University [2] that treated the paid intern year (first year of residency) as the fourth year of medical school. More recently, several medical schools accelerated students’ graduation to participate in caring for COVID-19 patients [3,4]. More broadly, the pandemic heightened appreciation of the current and projected shortages of American physicians, especially in primary care [5], leading Centers for Medicare & Medicaid Services to expand funded graduate medical education (GME) slots and encouraging both UME and GME educators to focus more intensely on competency-based rather than time-based training for medical learners [6].

Existing examples of competency-based medical education from the American Medical Association’s Accelerating Change in Medical Education (ACE) consortium warrant mention [7,8]. The New York University Langone School of Medicine program has graduated students in multiple specialties in three years [9]. Similarly, an Oregon Health Sciences University program aims to graduate students in a time-variable way to meet competency-based rather than time-based milestones [10]. This program is based on graduation on clinical competency rather than on new curricular goals and outcomes. A third program, through The University of California Davis School of Medicine, accelerates student graduation to primary care practice in underserved areas through a tailored curriculum that delivers content unique to primary care through intersessions between the standard core curricular blocks [7,11].

As part of the Accelerating Change in Medical Education (ACE) Consortium, the Ohio University Heritage College of Osteopathic Medicine (OUHCOM), in affiliation with Cleveland Clinic, developed an accelerated, competency-based curriculum for students who choose to pursue family medicine called the Transformative Care Continuum (TCC). This program pre-matches students to their future residency site, where they are fully integrated into the residency program, in addition to the traditional medical school curricular requirements.

The TCC is like and different from existing programs mentioned here in several key ways that will be further explored in this paper. The UC Davis program intersessions achieve similar goals but are intermittent experiences rather than continual, longitudinal ones like the TCC. The NYU program differs from the TCC because the additional training fits into summer sessions to achieve accelerated graduation. NYU students enter any residency at the end of their training and undergo a more traditional match process. This manuscript describes the key features of this new TCC longitudinal curriculum and how it prepares family physicians for their future roles.

Context

Several factors influenced the creation of the Transformative Care Continuum at OUHCOM, including 1) the growing shortage of primary care physicians, 2) the need to provide comprehensive population health services as well as 3) evidence of improved healthcare value and safety outcomes in especially vulnerable communities through adequate numbers of well-trained family physicians [12–17]

Medical errors and health system process errors still account for the third leading cause of death in the USA, behind cardiovascular disease and cancer [18]. In their 2017 study, Abrahamson estimate 251,000 deaths per year from accidents, medical errors, and infection, with the Centers for Disease Control estimating one of thirty-one hospitalized patients developing a severe hospital-acquired infection [19]. System errors are a high cause of mortality and morbidity, and they further are a source of increased cost, inefficiency, and frustration for healthcare workers and patients. This has been the evidence-based impetus to gear curriculum to learning about and impacting functional teams, quality improvement science, and health systems science.

Additionally, Ohio’s worsening deficit of primary care physicians is well documented [20]. The TCC was built upon principles articulated by the Osteopathic Blue Ribbon Commission [21] and the American Medical Association’s Accelerating Change in Medical Education [6]. With Cleveland Clinic’s and OUHCOM’s support, the TCC became an innovation lab for students and educators seeking novel ways to train future family physicians while impacting the healthcare team and system. TCC educators utilized the Taba and Wheeler curriculum development methods [22],evidence-based best practices to address the most underutilized skills with vulnerable populations, and communication skills valued by the specialty. These contextual factors drove the long-term outcomes of the TCC program to include: 1) TCC students match in family medicine, 2) TCC students choose to practice in NE Ohio, and 3) TCC students graduate to practice in underserved areas or with vulnerable populations.

Program concept model

In developing the TCC, we reimagined the medical school experience from application and admission to enrollment, graduation, and residency as one continuum. We designed the curriculum to address common deficits in medical education noted by program directors upon resident matriculation, such as the inability to conduct a safe transfer of care handoff or to ‘participate in an environment of safety’ [23]. The curriculum was developed according to Kern’s six-step model of curriculum development [24]. We created tasks for learners that serve as goal, learning, and evaluation opportunities [25]. These tasks also allow opportunities for failure and the learning that results from planned reflection and ongoing self-assessment.

The TCC program concept model (See Figure 1) illustrates how the program integrates task-oriented components and reflections. Students spend 12 hours per week in various activities in the TCC curriculum. The program’s backbones are the longitudinal integrated clinical patient-centered training (LIC) and health systems science (HSS) components (See Figure 1). The TCC Program Director and health sciences lecturer provide weekly coaching and mentoring (the helices in the diagram) in response to reflective case log entries, reflective essays, and video evaluations. Residency staff and faculty provide weekly task-based feedback covering one to three sub-competencies (360 evaluations) at each clinic or population health session. The interaction between the elements experienced in LIC and HSS enhances and cements learning. For example, learners reflect on and chart social determinants of health and health system errors seen in the longitudinal clinic experiences, addressing critical health systems thinking. Population health and quality improvement projects also utilize skills from patient-centered care, longitudinal clinical leadership, and teamwork skills from the health systems science weekly didactic component. Mentor support and feedback are regularly used to enhance skills and attitude development around the tasks and reflections of students each week.

Figure 1.

Program concept model.

Medical students receive weekly micro competency 360 evaluations on one to three sub-competencies per activity. In addition to the frequent feedback, students are charged with being in and helping create an ‘environment of feedback.’

Program goals and outcomes

The logic model (Figure 2) represents our high-level goals, including recruiting, training, and retaining high-quality primary care physicians who can provide primary care for patients in Northeast Ohio, particularly in vulnerable communities. The institutions aim to find physicians who can serve as leaders to improve systems to work more efficiently and impact health outcomes in vulnerable communities through quality improvement, community engagement, and population health activities. Communities of color suffer from the highest rates of poor health outcomes and reduction in life expectancy compared to their white counterparts [26]. Community location, zip code, or zip code tabulation area (ZCTA) predicts an individual’s life expectancy with social determinants impacting up to 80% of health outcomes [27]; the TCC program seeks to address issues of access, equity, and the risks of social determinants for persons of color (see Figure 2).

Figure 2.

Program logic model.

Figure 2.

(Continued).

Overall, this paper examines the many changes to medical education imagined by one accelerated UME-GME continuum program developed between a medical school and two family medicine residencies. The program seeks to change many elements of the medical education continuum. These include the type of medical students recruited, making the educational continuum continuous, early entry into graduate medical education spaces, the addition of task-based skills and health systems education, individual competency evaluation every week for each student, reflection as an educational tool, promotion of master adaptive learner model, and frequent coaching and mentorship that engages in reconciliation of self-assessment with external assessments. Finally, this program has been evaluated on measures related to students’ success in completing coursework, graduation, and licensing exams in the shortened course.

Methods

This article reviews the program’s curriculum creation, evaluation, and outcomes through mixed methods. The logic model is based on the goals the institutions set forth. We are using the logic model to monitor the program’s success against desired outcomes in student learners, resident learners, future career site/practice outcomes, and health outcomes for the system and faculty and staff in the programs. We are also collecting qualitative feedback via structured reflections and focus groups.

The study population includes eight medical student matriculants per year for the last six years, the residents who were former students, and the faculty, staff, and health system involved in their training. This is the first year of graduates from the residency arm of the trial. We are exploring the preliminary impacts of the clinical care model through qualitative interviews using a group ethnography and surveys with affiliated program teams.

Program resources

The TCC is directed by a full-time physician educator with administrative and teaching time (0.9 FTE), support from two primary care faculty and psychologists, anthropologists, and many other members (0.2 FTE) and one faculty member specializing in health system science and QI (0.4 FTE). A multi-disciplinary faculty, including finance, policy creation, social service agencies, school of business faculty, and governmental and non-governmental agencies, enriches the understanding of TCC students. (See Figure 2).

Program implementation

The inaugural TCC class matriculated to OUHCOM in 2018 with four students pre-matched to Cleveland Clinic Lakewood Family Medicine Residency and four students matched to Cleveland Clinic Akron General Family Medicine Residency. A unique admission process was implemented because the learners would be required to manage more hours, projects, and changes than most medical students in one less year than the traditional 4-year program. The admissions process assessed applicants for 1) evidence of team behavior, 2) comfort with ambiguity, 3) emotional intelligence and behavior 4) resiliency (grit), and 5) commitment to primary care. The first three characteristics were assessed through a bank of novel, program-created, and situational judgment tests developed and pilot-tested by the TCC program creators and eight semi-structured, behaviorally-based interviews. Applicants’ grit and primary care commitment were assessed through personal essays, evidence of challenges faced and overcome, and a series of eight semi-structured behaviorally based interviews as previously noted.

Program activities (Outputs)

TCC students are integrated into the interprofessional team of the family medicine residency clinic practice from their first day of medical school. In addition to the regular OUHCOM medical school curriculum during years one and two of medical school, TCC students engage in 12 additional hours weekly of TCC-specific programming. This includes a half-day of clinical experiences and a half-day of health systems activities at their assigned residencies. They also complete a half-day of other learning activities every week related to primary care core skill development for family doctors, which includes but is not limited to intense patient communications training, mental health screens and how to address common complaints, motivational interviewing, evidence-based medicine, etc. Health systems’ didactics include finance, policymaking, quality improvement, and patient safety. These curriculum activities are more fully outlined in Table 1.

Table 1.

Alignment of TCC educational components to new roles proposed for family physicians.

Role #1: Family physicians are personal doctors for people of all ages and health conditions

Content: Person-centered interviewing skills • Eliciting, valuing and honoring the patient’s story • Cultural-centered care • Systemic racism • Gender-affirming care • Adverse Childhood Experiences (ACEs)• Trauma-informed care• Allyship and advocacy • Vulnerable populations • Health disparities • Health literacy • Clinical Practice Guidelines (CPGs) throughout lifespan • Developmental Disabilities education • Geriatric care including early recognition of cognitive impairment • Social determinants of health (SDOH)

Learning Activities: Gamification of content • Cultural games (Barnga) [28] • Art therapy techniques • SNAP challenge • Clinical experiences with people of all ages from day one of medical school • Humanities Readings: The Spirit Captures You and You Fall Down [29]; Medical Apartheid [30]; Just Mercy [31] • Peer, Patient-oriented Video Evaluation (POVE) • Coached role-plays

Evaluation: POVE (observe and assess person-centered communication) • Validated behaviorally anchored video-evaluation instrument• Self-reflective essays • Competency-based 360 Evaluations

Role #2: Family physicians are a reliable first contact for health concerns and directly address most health care needs

Content: Top 20 Family medicine diagnoses • Top 20 CPGs updated annually• Gender and sexual identity • Aging, neurologic and cognitive assessment • Intimate partner violence • Intellectual and developmental disabilities • Mental health screening • substance use disorder

Learning Activities: • Coached case-based role-plays • Agenda setting and negotiation • Evidence-based screening tools for: Mental health: depression, bipolar and anxiety in primary care; Substance use disorder; Cognitive deficit screening • Elder risk assessment •Family history and Genogram • Journal club •Primary care procedures

Evaluation: Objective Standardized Clinical Evaluation (OSCE) Competency assessment on following topics: Patient-centered negotiation of agenda; Substance Abuse assessment in patients seeking pain treatment; Screen ACEs, Mental Health (MH)and substance use in patients presenting with MH conditions; Recognition of acute problem in chronic disease follow-up; Telehealth and transition of care management; Competency-based 360 Evaluations; POVE; Self-reflective essays

Role #3: Through enduring partnerships, family physicians help patients prevent, understand and manage illness, navigate the health system and set health goals

Content: Introduction to prevention science and USPSTF • Limiting the health impacts of social determinants • Navigation of transitions of care (TOC) • Longitudinal threads on: Systemic Racism; Vulnerable populations; Patient-centered Communication; Evidence-Based Medicine •Strengthening Teams in the Advanced Management of Populations (STAMP) •Care Coordination education by care coordinator faculty

Learning Activities: Participant-observer in transition-of-care patient (TOC) experiences • Critical reflections on patient diagnostic journey • Assigned longitudinal continuity patient panel •Patient educator role •Care Coordinator role

Evaluation: TOC journal self- reflections • Patient case logs focused on SDOH and impacting self-management of illness and navigation through health system• OSCE focused on motivational interviewing• Competency-based 360 Evaluations • POVE

Role #4: Family physicians adapt their care to the unique needs of their patients and communities

Content: Community health needs assessment •Community Practice Playbook •Team-Based Care and communication through Team STEPPS© • Family engagement in health care encounter Electronic Health Record Data Analytic platforms •

Learning Activities: Health System Science education by health policy analyst • Weekly Reflective Journals with weekly mentor feedback, a learning management system ‘conversation’ • Interprofessional Education • Early experiences in roles of other IP • Lean Six Sigma© training • IHI Training Grant-writing Memorandum of understanding (MOU) with community partners [32]

Evaluation: OSCE on recognition of acuity and telehealth hand-offs (based on TEAMSTEPS: ‘I pass the baton’ mnemonic) • Written examination on common primary care exam and illness findings: HEENT; Common orthopedic exams and finding; Heart sounds and pathological findings; Abnormal lung findings and accompanying differential diagnoses • 360 Evaluations Family-centered POVE

Role #5: Use data to monitor and manage their patient populations and use best science to prioritize services most likely to benefit health

Content: • Summer training to address population health project in UDS Webmapper data • Training in Slicer Dicer data management

Learning Activities: Evidence based Medicine (EBM) longitudinal thread considering how to analyze data statistically, use of SORT criteria, the format of Clinical Guideline development • Review of Clinical Guidelines • How to critically appraise journal articles utilizing Oxford criteria and University of Alberta EBM toolkit •Slicer Dicer to conduct a population health QI project • Lean Six Sigma© Yellow Belt Training • IHI Modules [32] • Complete 3 QI/PDSA projects with built in “planned failure” from which to learn

Evaluation: Journal Club leader; open-book, open internet exam; Poster presentations

Role #6: Family physicians are Ideal leaders of health care systems and partners for public health

Content: Longitudinal training threads in systemic racism, health systems science including finance and economics, medical history, ethics, patient safety, quality improvement, professional identity development, teamwork, change management, public policy, EBM and value-based care, and population/Public health • Professional Identity development includes appreciation of IP team and their roles (RN supervisor first year)

Learning Activities: Lean Six Sigma© Yellow Belt Training • IHI Modules [32] • Slicer Dicer to conduct a population health QI project • Complete 3 QI/PDSA projects with built in “planned failure” from which to learn • Creation of a community/population health project • Strength-finders and Working Styles surveys completion and games related to functional teams that utilize best skills balance • Taking roles in IP team • Engagement with other specialties early and often • Root Cause Analysis

Evaluation: Completion of 2 quality improvement projects • Completion of group population health and/or community related project summer year 1 • Completion and plan for continuation of a community-engaged project that will continue throughout residency

Beginning with their orientation boot camp, TCC students are trained in medical assistant functions, including rooming ambulatory patients, measuring vital signs, and administering immunizations. Subsequent training and clinical experiences focus on teaching students to fulfill other medical assistant and scribe roles as well as skills specific to the family physician. Additionally, students are introduced to the Institute of Medicine (IOM)’s six aims for the healthcare system as a foundation for analysis as they are engaged in the orientation program, using it as a lens to evaluate their newly established clinical environments [33].

From the first day of medical school, each TCC student is integrated into their assigned patient panel through whom they learn team-based healthcare and population health management. Students learn how to negotiate the agenda for ambulatory encounters and collect patient history, incorporating frequently neglected psychosocial elements such as life situation assessment (social determinants of health screening tool), screening for adverse childhood experiences (ACEs), and mental health screening. These topics are introduced first through classroom didactics, Socratic discussion, and mentored peer practice, then are applied in the clinical environment.

We utilize a standardized instrument, the Patient-Centered Observation Form (PCOF) [34] adopted from family medicine residency training, for students to give and receive feedback. The PCOF, developed by Mauksch et al. [34], is employed to further students’ learning, foster professional identity development and as a preparation for summative component competency evaluations through Objective Structured Clinical Evaluations (OSCEs). Students meet monthly in pairs with the TCC Program Director to review videotaped patient encounters, perform their self-evaluation, and provide feedback to each other. In these reflective review sessions, they gradually develop their professional identity and hone patient-oriented clinical habits and skills. In addition, attention to self-assessment, self-regulation, and development of prospective skill and behavior goals for the future utilizes the master adaptive learner methods of the AMA.

In exit interviews conducted at the end of medical school by a neutral third-party researcher, a majority of TCC graduates identified the ‘peer, patient-oriented video evaluations’ (POVE), which involves self-evaluation, immediate peer and mentor feedback, as among the most impactful educational activities in their medical education. One recent graduate of the program noted in a recent exit interview,

TCC gave me the skills to be prepared to meet the patients where they are. As a new resident, the nuances of residency can get in the way of truly listening to the patient. Because TCC allowed me to practice patient-centered interviewing skills all 3 years of medical school, those skills were part of my habits at the start of residency. We are also more prepared than our traditionally trained co-residents to partner with patients to find real solutions.

Another aspect of TCC that became habitual is the video POVE. It is a unique experience that we had the privilege of practicing throughout medical school compared to my co-interns not in TCC. They were apprehensive about the practice; however, we know the expectations and believe it is essential in making us better physicians.

In subsequent semesters, we focus on evidence-based medicine as a part of the development of a clinical question and how clinical practice guidelines are formed and maintained. We undertake specific weekly education in evaluating literature for adequacy, clinical relevance, importance, and significance, as well as fit for a patient’s demographics and health status. We develop their reasoning skills and ability to develop a differential diagnosis and clinical questions through Socratic cases, a ‘choose-your-own-adventure’ experience, and clinical precepting with their clinical site mentor. Their first two years conclude with an open book and open internet examination. The test measures their ability to evaluate five complex patient cases with competing health conditions, develop a clinical question, answer it with the best evidence, and defend their choice of reference, explaining their clinical recommendations and rationale on a health condition of which they may have limited prior knowledge or experience.

TCC students learn foundational concepts in Health Systems Science and Quality Improvement Science, followed by mentored opportunities to apply that knowledge in the residency practice and the surrounding community. These sessions are taught by an interprofessional faculty comprised of a health policy analyst, nurse manager, nurse care coordinator, and a clinical pharmacist with expertise and credentials in clinical quality improvement. Students also complete Lean Six Sigma© training in the summer semester between their first and second years and obtain certification from the Institute for Healthcare Improvement in Patient Safety and Quality. Over three years, the TCC students complete at least four projects, each including a formal presentation to their peers and clinical site staff. These projects include clinical quality improvement projects focused on care gap closure with at least one representing a community engagement project utilizing population health data from clinical and public sources. These projects become increasingly sophisticated over the course of the program where the early projects have room for ‘learning from failure’ and precede the Lean Six Sigma© training. The project work culminates with a three-semester community project known as ‘Community Practice’, wherein students work with external, community-based organizations to address common population health challenges like food insecurity, high maternal mortality rates, and social isolation. Students use a Community Practice Playbook, a stepwise program manual we developed to guide students through effective engagement with a community-based organization to improve health outcomes. The program provides students with a curriculum centered on value-based care, incorporating health economics, actuarial science, and best practices in practice transformation. The applicability of this content is underscored by an examination of existing contract value-based achievements, including students’ clinical sites, incorporating real-world conditions for value-based reimbursement as a context for clinical quality improvement projects.

The curriculum of the TCC addresses the six roles suggested for future family physicians [1] while completing their other medical school requirements. Additional details regarding content, activities, and assessment in the TCC are depicted (See Table 1).

Outcomes

Short/mid term outcomes

The students in the first cohort completed their core medical school coursework and passed COMLEX-1, COMLEX-2, and COMLEX-3 examinations. Since that time, a few students from subsequent cohorts have struggled with the traditional pathway course work, COMLEX exams or both. The clinical performance of TCC students in their OMS-3 rotations and PGY-1 rotations suggests no significant deficits in their ability to fulfill the clinical expectations of a rotating third-year medical student or PGY-1 family medicine resident as indicated by rotation evaluations. TCC program graduates demonstrate advanced skills in the monthly root cause analyses conducted on residency practice patients who experience recurrent hospitalization. They have advanced skills in quality improvement (QI) activities and complete two to three QI projects before medical school graduation. As a reference, the American Council for Graduate Medical Education, Residency Review Committee for Family Medicine requires one QI project by each family medicine resident by completion of residency [35].

We have reviewed student and residency stakeholder satisfaction with the TCC program with a mixed-methods evaluation. All students complete an anonymous exit quantitative survey at graduation (Addendum B), followed by a formal ethnographic focus group. Results from the exit survey and focus group suggest that TCC activities are highly rated among all participants who recognize changes in their professional identity compared to their peers. Chief among these experiences is peer, patient-oriented video evaluation, their quality improvement projects, and Community Practice work.

Select student comments from transcribed and deidentified focus groups, below, reveal a growing sense of purpose and belonging as well as skill development important to future roles, one commenting,

TCC teaches us the skills that aren’t taught in the typical medical school curriculum. From our first day, we learn about connection, relationship building and partnership with the patient. We learn the importance of truly understanding our patients and tailoring our care to meet their needs. We also learn how to zoom out and analyze the health care system from a new lens. With these skills, we are training to become physicians who can both understand patients’ needs and make systemic changes in our communities. I feel really lucky to be here for my training. And this was affirmed by several others in the focus group.

Mid- and long-term outcomes

Long-term outcomes directly attributable to the TCC program are difficult to assess. We will not be able to evaluate the cohort’s long-term program outcomes until after the completion of the cohort’s graduate medical education and perhaps until they are in practice for a number of years. In the interim, we report early outcomes, preliminary qualitative observations, and reflections.

Thus far, the first three TCC cohorts have completed their undergraduate curriculum, and the first cohort will complete graduate medical education in June 2024. Preliminary information suggests that seventy-five percent of TCC graduates will practice in northeast Ohio and 2/3 of graduates will practice with underserved populations, including two at federally qualified health centers.

Impact on residency programs

Affiliated family medicine residencies report that TCC program participation enhanced their capacity to educate all learners within and outside the TCC program and more effectively provide healthcare to all their patients. The improvement in team communications associated with early program preparation, in TeamSTEPPS and emphasis on team-based healthcare was highlighted as one of the ways the residency improved those metrics. Quality improvement and Lean Six Sigma© program attendance further elevated their Strengthening Teams in Advanced Management of Populations (STAMP) to address population health goals. By training primary care doctors from medical school through their GME training and providing value-based health care through closure of care gaps, such as colon cancer screening rates, breast cancer screening rates, and diabetes metrics, the programs have demonstrated value care measure increases. Through STAMP, the healthcare team members teach the skills to individualize care and alter population health care outcomes. In the feedback session, the program director from one site stated:

The OUHCOM TCC program has improved our program in a myriad of ways. It has improved our curriculum, giving us the tools, the training, and the time to focus on population health, improving health disparities, and applying effective team science principles. It has enhanced our recruiting, allowing us to attract high-quality individuals who share our commitment to community engagement and quality improvement. It has allowed us to hire more faculty and staff and grow the residency to train more doctors who understand the underserved’s needs [through a cohort expansion from six to eight residents per year.]. It has enhanced our technological ability to provide tele-visits, group visits, and virtual communication, enabling us to adapt to the pandemic more quickly and effectively. It has demonstrated, in a tangible way, Cleveland Clinic Akron General’s mission to improve the health and lives of our people and communities.

Residency clinic nurses and medical assistants were provided the novel opportunity of teaching medical students to serve as medical assistants in the residency clinic, enabling students to appreciate better that role and its importance by ‘working in their shoes.’ The residency nurse managers, clinical pharmacists, care coordinators, and social workers gained experience as interprofessional medical educators. The resident and faculty physicians also taught their future peers the unique culture, workflows, clinical processes, and resources of the residency program, as well as clinical practice. The unique interprofessional synergy that followed was evident in many of the interprofessional quotes. As noted by a nursing staff,

We were told that ’eventually,’ the TCC students would be able to help our practice—and I saw evidence of this phenomenon right away. Our TCC students had the time and dedication to follow up with patients who had not been to our office for a while, and we were concerned about the well-being of these patients. Our nurses were especially grateful to know that these patients on their lists had been reached and that follow-up care had been put in place. On a similar note, our TCC students were able to help with a backlog of high-risk patient check-in phone calls during COVID.

Yet another stated, “As an educator, I have appreciated the calm presence, maturity, and continuity of our TCC students. Because they know the ropes of our practice, I can spend more time focusing on meaningful learning opportunities for them, instead of explaining the day-to-day operations of our practice, as is the case with students who only rotate in our office for 3–6 weeks.”

Many faculty members praised the invigorating nature of having new learners with a passion for treating the underserved and enthusiasm for the practice of medicine:

The OUHCOM TCC program has helped generate a vibrant atmosphere geared toward improving office flow within our practice, enhancing its preventive care measures, in addition to fostering and strengthening relationships between our hospital and the greater Akron community. Our TCC students are passionate about caring for the patients who enter our doors and have a heart for reaching the underserved and under-resourced surrounding neighborhoods. I, for one, can testify that these students motivate me to continue to strive to be a better provider for our patients and our Northeast Ohio family.

Another faculty member said,

In a more personal way, the TCC program has energized me to see medicine anew through the eyes of each new student. We are present for many firsts in their medical education. Their first real patient interaction, first physical exam, first actual ECG, first time admitting someone to the hospital, etc.

Yet another faculty member said,

The TCC has been my immunity to burnout during the COVID pandemic. I could never have envisioned that this would be such a rewarding experience. The continuity we have within our residency clinic with this cohort of medical students have enabled us to push them to meet their competencies earlier and given us the time to teach additional skills such as patient safety and quality, advocacy, and population health. These unique skills have allowed these students to add value to our clinic and residency.

One of our long term goals is to promote a culture of inquiry, learning, and scholarship in family medicine residencies. Figure 3 depicts longitudinal scholarship and leadership by residency faculty and residents from before the beginning of TCC to the present.

Figure 3.

Program scholarly activity from pre-TCC to present.

Our first cohort of TCC-trained family medicine residents is completing their third year of residency. Both residency sites have seen increased faculty and resident scholarly activity, including posters, presentations, grants submitted and received, and submitted and accepted manuscripts. A current challenge to the number of national presentations is a new systemwide policy for the system’s residencies limiting the number of times a resident may be accepted and present. The programs have also noted an increase in leadership roles for faculty and residents. (Figure 3). The ultimate outcomes include improved quality improvement processes and the ability to function as health systems leaders while providing care for a broad range of patients. These outcomes will be tracked going forward into our graduates’ practice years.

Challenges to program implementation

There are many challenges to implementing a complex program such as the TCC. Adequate support from and collaboration between medical school and graduate medical education programs are required. Careful consideration and support for program staffing is critical. The TCC program director is employed full-time. Both the director and the affiliated HSS faculty review reflections, case logs and QI projects, and provide ongoing mentoring and coaching with students on their population health Community Practice projects and clinical care through the POVE. Support for full-time staffing is important and costly because, in this program model, the institution forfeits one year of tuition for the benefit of the students.

Electronic communication systems and file sharing across separate and complex institutions have been challenging. Developing a system to share documents and communication, distributing, and evaluating privacy-controlled educational records, and reviewing controlled patient care videos have been significant hurdles to overcome. Further, data sharing of residency outcomes and practice sites will be important to meeting long-term outcomes. Agreements to share outcomes data prior to beginning the program through formal memorandum of understanding(MOU) and contract agreements may have improved data collection for program evaluation. Agreeing to a shared system of communication would lessen the burden.

Student evaluation design limitations

The evaluation of students follows a competency-based, scheduled weekly evaluation strategy (See Appendix Addendum A). This required student engagement with preceptors to complete and was complex as the learning management system in which the evaluations are embedded do not sync between institutions. Initially, there was no method for obtaining weekly assessments and maintaining the privacy of this information every week. We used paper evaluations kept in a locked box and transported by the TCC program director from each site weekly. Later, we developed an electronic competency system through REDCAP. Finally, evaluations were integrated into our learning management system over the last year. This complex process burdens residency faculty to learn and employ new systems annually. Our electronic evaluation has been developed through multiple iterations. This may also decrease the response rate as faculty tire of new tool integration. The reflective and case log reviews, while valued and offer opportunities for the constant elevation of skills, are similarly time-intensive. This type of mentored feedback will require training many more coaches if this is to be integrated across UME institutions.

Discussion

We described the design and implementation of the undergraduate portion of a longitudinal and accelerated pathway in medical education. We found the program has led to increasing scholarly activity and leadership roles taken by our graduates and at the residency programs overall. There are also demonstrable increases in care gap closures, for instance, in mammography screening, colon cancer screening, and diabetes maintenance screening. The unique features of the TCC that have positively impacted the health system, the students’ learning, and health outcomes for vulnerable patient populations have the potential to improve medical education in general and may offer lessons for quality improvement in healthcare and education. Frequent and individualized feedback is important. Task-based education, in which students have an opportunity to fail and then receive feedback, may move learners forward at a faster pace. Students can learn system thinking as they learn clinical skills, which helps them be empowered to change the systems in which they learn and work rather than succumbing to frustration with ‘the hidden curriculum.’

Clinical skills are best learned in the context of clinical care and can be learned simultaneously as students acquire medical knowledge. In addition to the currently accepted standard of care, students can rapidly evaluate new forms of evidence and apply this information to patient care. Students also come into medical school with passion and drive that is often systematically eliminated through the hidden curriculum. There is an opportunity to reimagine the educational trajectory and the student’s role within it. Further, education can be more deliberate and specifically designed for specific knowledge, skills, attitudes, and behaviors, such as the ability to be patient-centered, systems thinkers who challenge the status quo and advocate for vulnerable populations. These have been suggested for family medicine, and one may wonder, in the shadow of growing artificial intelligence and automation, if other changes to specific training skills may be needed.

Study design limitations and future research

The overlapping complexity of the many elements of the curriculum limits the conclusions we can draw from our program evaluation. Future studies will be focused on residency graduate outcomes and further evaluation of current residents. Obtaining adequate feedback on the undergraduate TCC program’s impact on the residents is difficult because the resident’s time and evaluation fall to GME. A large volume of admission survey data was obtained on TCC students and those interviewed for TCC and trained in the traditional pathway. Future studies will look at admission survey data versus curriculum intervention for impacts on professional identity and practice choices toward primary care and care of vulnerable populations. Maintaining logic model outcomes and survey responses will be important over time, as monitoring the practice placement choices and health outcomes of our graduates’ practices – is a difficult task in terms of privacy and not losing graduates to follow-up. Program design and evaluation also are an iterative cycle; what we learn through this evaluation will be used to improve the program in the future.

Recommendations

The present focus on health systems sciences in medical education provides potential opportunities for simultaneously transforming medical education and healthcare. Integrating competency-based medical education evaluation, coaching practices, and creative adaptation and utilization of the innovative learning environment can produce the characteristics we endeavor to train in future family physicians [1]. Preparing lifelong learners who envision professional education as a continuum begins in medical school and progresses throughout their careers. The alignment of the health professional workforce with societal needs is evaluated through its impact on costs, value, and outcomes. Our intentional alignment of TCC learning activities to desired professional identity outcomes, competency evaluations, and real-world experiences in healthcare improvement – including required quality improvement and community impact projects – will also need to be evaluated in the future for long-term outcomes, such as their maintenance of master adaptive learner skills in meeting new and evolving roles. We have seen evidence of progress toward long-term outcomes by improving health outcomes for vulnerable populations by closing care gaps.

Future areas for study may include evaluation of burnout in these newly trained graduates. While many outside stakeholders initially worried about burnout in these students, many flourished despite the increased workload during their training. We believe there may be a rationale for anticipating a lower burnout rate for TCC graduates’ ability to utilize team-based care and self-efficacy in transforming the healthcare spaces in which they work. Does TCC-type mentoring and task-based education protect against burnout? Does an additional or different professional identity develop from such work through training because of exposure to embedded QI and team-based science? Future steps will explore whether elements of the TCC program could be incorporated into traditional pathways to impact the broader healthcare workforce and what dose-effect may be necessary to achieve similar outcomes in the future.

Conclusions

As suggested in the new roles for primary care physicians, medical knowledge and artificial intelligence increases are poised to both transform medicine and overwhelm practitioners unfamiliar with the rapid transformation of diagnostic and therapeutic strategies. Additional primary care practitioners are urgently needed, and many choose not to enter primary care due to medical education costs. Many students find the knowledge and skills required overwhelming. Training in evidence-based strategies and in judging the efficacy of evidence for specific case presentations must be a central skill taught in medical education. Medical professionals must interface effectively and efficiently to improve patient care and the healthcare system. The adage of two years of individual science disciplines being extensively studied in a run-up to clinical medicine defies the rate and volume of change we see in medicine. Furthermore, focusing on integrating new knowledge, new systems, and how to lead change will be imperative if medicine is to keep up. Accelerated medical pathway programs offer unique opportunities to identify society’s needs, create new training tracks for specific needs in the healthcare system, and rebuild the profession related to the professional identities and practitioners desired while improving educational value. Educational quality improvement can engage society and patient, education, health system care models, and student stakeholders to create a new system of medical education that can nimbly respond to healthcare changes while providing equity in medicine.

Appendices. Addendum A. EPAs are an evidence-based method to plan and develop a curriculum with backward design [36-40]

1. Problem identification and general needs assessment: Need to learn new knowledge, skills, attitudes, and behaviors associated with new roles identified as necessary for health system function. The Blue Ribbon Commission’s report on developing accelerated programs for primary care identified the need for similar novel skills to address environmental and societal challenges not adequately addressed by current health systems or medical education offerings.

2. A targeted needs assessment revealed that health systems science teaching is very limited in medical school and hard to teach in postgraduate environments as postgraduate physician residents try to utilize in practice their foundational medical knowledge. Learning new and unrelated foundational knowledge is difficult, as I witnessed during my own time as a graduate medical education program director. Prepared residents may more readily complete quality improvement and engage in health system leadership as they their foundational health systems science knowledge.

3. goals and objectives: Goals are the competency of all 13 undergraduate EPAs (entrustable professional activities) at a level of emerging + to competent (2.5–3 on a scale of 5), especially those not traditionally addressed by UME (undergraduate medical education)systems, specifically EPAs 7, 8, 9, 11,13. Additionally, engaged the ultimate goal is a community-engaged physician that will comprise a workforce able to address social determinants of health. This will include building a resilient workforce that can address these challenges without workforce burnout, team dysfunction, and team turnover.

   1	Gather a history and perform a phycial examination
   2	Prioritize a differential diagnosis following a clinical encounter
   3	Recommend and interpret common diagnostic and screening tests
   4	Enter and discuss orders/prescriptions
   5	Document a clinical encounter in the patient record
   6	Provide an oral presentation of a clinical encounter
   7	Form clinical questions and retrieve evidence to advance patient care
   8	Give or receive a patient handover to transition care responsible
   9	Collaborate as a member of an interdisciplinary team
   10	Recognize a patient requiring urgent or emergent care and initiate evaluation and management
   11	Obtain informed consent for tests and/or proced
   12	Perform general procedures of a physician
   13	Identify system failures and contribute to a culture of safety and improvement

4. educational strategies, i. task-based learning – giving early learners roles in the health system. ii. Extensive patient-centered communications training. iii. Extensive evidence-based medicine training, including journal club analysis, open book, and open internet test evaluating complex, competing health conditions, and using the best evidence, the highest grade of sources based on SORT criteria.

5. implementation, i. Creative adaptation of the learning environment, training inteprofessional staff to act as faculty to guide students through their health system

6. system.ney. i. Goal and objective-based tasks for video review with self, peer, and mentor feedback and coaching to facilitate patient-centered and motivational communication.ii. Progressive process improvement and team-based project involvement from formation to implementation. iii. Community projects based on vulnerable populations and stakeholders’ engagement with a community partner, health system, and community.

7. evaluation and feedback i. Weekly micro-evaluations assessing 1–3 sub-competencies. ii. Learning objective-based, live, real-patient videotapes with review by self, peer, and mentor feedback. iii. Semester competency reviews with a comparison of self-evaluation and learning plan to SWOT analysis and 360 evaluations to improve self-awareness and assessment over time. iv. Semester review includes program evaluation and suggestions for improvement. v. Final Semester competency includes semester-to-semester comparisons and a plan for learning needs in residency

Addendum B. Program exit survey TCC (Transformative Care Continuum) program evaluation [41]

I feel the TCC portion of the program helped me gain the following skills (that I may not have gained otherwise)

I feel the TCC portion of the program detracted from my learning in the following ways:

The portion of the TCC program that I feel needs work, is excessive. Or over emphasized:

I would recommend the following changes:

Portion of the TCC program that I feel improved my experience, or needs more emphasis:

I would recommend the following changes:

Rate the following Scale of 1 poor … 2 fair … 3 good … 4 Very Good … 5 Excellent

And suggest changes, improvements, stay the same?

HSS 1: Introduction to Systems, Quality and Value, Racism and

1 –––––2 –––––3 –––––4 –––––5

Comments: Great intro to concepts

HSS 2 Intro to Quality improvement, (QI #1, Basic)

1 –––––2 –––––3 –––––4 –––––5

Comments:

HSS 3 Patient Safety, Transitions of Care and Leadership, Lean Six Sigma, IHI, CITI/CREC

(IPC) 1 –––––2 –––––3 –––––4 –––––5

Comments:

HSS 4 Continued quality and value (QI Project 2)

1 –––––2 –––––3 –––––4 –––––5

Comments:

HSS 5 Introduction to the Community Project

1 –––––2 –––––3 –––––4 –––––5

Comments:

LIC 1 Introduction to patient communications, establishment of agenda, Risk factor analysis and culture

1 –––––2 –––––3 –––––4 –––––5

Comments:

LIC2 Continuation on Motivational interviewing, more difficult patient interactions, culture

1 –––––2 –––––3 –––––4 –––––5

Comments:

LIC3 Continuity, Transition of Care, and High-Risk Scenarios

1 –––––2 –––––3 –––––4 –––––5

Comments:

LIC4 Journal Club, and EBM, and emphasis on Family Medicine Clinical Care

1 –––––2 –––––3 –––––4 –––––5

Comments:

LIC5 Clinical Practice guidelines and Team

1 –––––2 –––––3 –––––4 –––––5

Comments:

LIC6 Continuity Experience and Community Project 1

1 –––––2 –––––3 –––––4 –––––5

Comments:

LIC7 Continuity Experience and Community Project 2

1 –––––2 –––––3 –––––4 –––––5

Comments:

Specific Experiences:

POVE 1 –––––2 –––––3 –––––4 –––––5

Comments:

Quality Improvement Science: QI Projects

1 –––––2 –––––3 –––––4 –––––5

Comments:

Lean Six Sigma

1 –––––2 –––––3 –––––4 –––––5

Comments:

IHI 1 –––––2 –––––3 –––––4 –––––5

Comments:

EBM, Journal Club

1 –––––2 –––––3 –––––4 –––––5

Comments:

EBM, Clinical practice Guidelines

1 –––––2 –––––3 –––––4 –––––5

Comments:

Clinical Skills

1 –––––2 –––––3 –––––4 –––––5

Comments:

Communication Skills

1 –––––2 –––––3 –––––4 –––––5

Comments:

CITI/CREC and IRB training/prep

1 –––––2 –––––3 –––––4 –––––5

Comments:

Reflections and Self assessments

1 –––––2 –––––3 –––––4 –––––5

Comments:

Funding Statement

This work was supported by the Josiah Macy, Jr Foundation under Grant B18-01 and American Medical Association under Accelerating Change in Medical Education Consortium Grant, Cohort 2: 19400. The authors also want to thank Cleveland Clinic and The Ohio University Heritage College of Osteopathic Medicine for their enduring support for the innovative work of primary and community-based care in Cleveland, OH.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Assessing the Transformative Care Continuum: A program evaluation: https://www.ohio.edu/medicine/research/ctru/studies.

Ethics statement

The deidentified student and faculty comments as well as deidentified student data were approved and study exempted and reviewed annually by Ohio University IRB