Reframing undergraduate medical education in global health: Rationale and key principles from the Bellagio Global Health Education Initiative.

Global health education (GHE) continues to be a growing initiative in many medical schools across the world. This focus is no longer limited to participants from high-income countries and has expanded to institutions and students from low- and middle-income settings. With this shift has come a need to develop meaningful curricula through engagement between educators and learners who represent the sending institutions and the diverse settings in which GHE takes place. The Bellagio Global Health Education Initiative (BGHEI) was founded to create a space for such debate and discussion and to generate guidelines towards a universal curriculum for global health. In this article, we describe the development and process of our work and outline six overarching principles that ought to be considered when adopting an inclusive approach to GHE curriculum development.

Development of a Tool to Measure Student Perceptions of Equity and Inclusion in Medical Schools.

Importance: Creating an inclusive and equitable learning environment is a national priority. Nevertheless, data reflecting medical students' perception of the climate of equity and inclusion are limited. Objective: To develop and validate an instrument to measure students' perceptions of the climate of equity and inclusion in medical school using data collected annually by the Association of American Medical Colleges (AAMC). Design, Setting, and Participants: The Promoting Diversity, Group Inclusion, and Equity tool was developed in 3 stages. A Delphi panel of 9 members identified survey items from preexisting AAMC data sources. Exploratory and confirmatory factor analysis was performed on student responses to AAMC surveys to construct the tool, which underwent rigorous psychometric validation. Participants were undergraduate medical students at Liaison Committee on Medical Education-accredited medical schools in the US who completed the 2015 to 2019 AAMC Year 2 Questionnaire (Y2Q), the administrations of 2016 to 2020 AAMC Graduation Questionnaire (GQ), or both. Data were analyzed from August 2020 to November 2023. Exposures: Student race and ethnicity, sex, sexual orientation, and socioeconomic status. Main Outcomes and Measures: Development and psychometric validation of the tool, including construct validity, internal consistency, and criterion validity. Results: Delphi panel members identified 146 survey items from the Y2Q and GQ reflecting students' perception of the climate of equity and inclusion, and responses to these survey items were obtained from 54 906 students for the Y2Q cohort (median [IQR] age, 24 [23-26] years; 29 208 [52.75%] were female, 11 389 [20.57%] were Asian, 4089 [7.39%] were multiracial, and 33 373 [60.28%] were White) and 61 998 for the GQ cohort (median [IQR] age, 27 [26-28] years; 30 793 [49.67%] were female, 13 049 [21.05%] were Asian, 4136 [6.67%] were multiracial, and 38 215 [61.64%] were White). Exploratory and confirmatory factor analyses of student responses identified 8 factors for the Y2Q model (faculty role modeling; student empowerment; student fellowship; cultural humility; faculty support for students; fostering a collaborative and safe environment; discrimination: race, ethnicity, and gender; and discrimination: sexual orientation) and 5 factors for the GQ model (faculty role modeling; student empowerment; faculty support for students; discrimination: race, ethnicity, and gender; and discrimination: sexual orientation). Confirmatory factor analysis indicated acceptable model fit (root mean square error of approximation of 0.05 [Y2Q] and 0.06 [GQ] and comparative fit indices of 0.95 [Y2Q] and 0.94 [GQ]). Cronbach α for individual factors demonstrated internal consistency ranging from 0.69 to 0.92 (Y2Q) and 0.76 to 0.95 (GQ). Conclusions and Relevance: This study found that the new tool is a reliable and psychometrically valid measure of medical students' perceptions of equity and inclusion in the learning environment.

Patient-centered care: achieving higher quality by designing care through the patient's eyes.

Patient centered care requires that health care organizations and health care professionals actively understand what patients value. Fortunately, there are methods for gaining that understanding. But, they need to be adopted much more widely, and patients need to be treated as full partners in their care.

A call to action: next steps to advance diagnosis education in the health professions.

OBJECTIVES: Improving diagnosis-related education in the health professions has great potential to improve the quality and safety of diagnosis in practice. Twelve key diagnostic competencies have been delineated through a previous initiative. The objective of this project was to identify the next steps necessary for these to be incorporated broadly in education and training across the health professions. METHODS: We focused on medicine, nursing, and pharmacy as examples. A literature review was conducted to survey the state of diagnosis education in these fields, and a consensus group was convened to specify next steps, using formal approaches to rank suggestions. RESULTS: The literature review confirmed initial but insufficient progress towards addressing diagnosis-related education. By consensus, we identified the next steps necessary to advance diagnosis education, and five required elements relevant to every profession: 1) Developing a shared, common language for diagnosis, 2) developing the necessary content, 3) developing assessment tools, 4) promoting faculty development, and 5) spreading awareness of the need to improve education in regard to diagnosis. CONCLUSIONS: The primary stakeholders, representing education, certification, accreditation, and licensure, in each profession must now take action in their own areas to encourage, promote, and enable improved diagnosis, and move these recommendations forward.

Opportunities for diversifying and enriching our article mix.

As 2020 comes to a close, the Israel Journal of Health Policy Research (IJHPR) will soon be starting its tenth year of publication. This editorial compares data from 2012 (the journal's first year of publication) and 2019 (the journal's most recent full year of publication), regarding the journal's mix of article types, topics, data sources and methods, with further drill-downs regarding 2019.The analysis revealed several encouraging findings, including a broad and changing mix of topics covered. However, the analysis also revealed several findings that are less encouraging, including the limited number of articles which assessed national policy changes, examined changes over time, and/or made secondary use of large-scale survey data. These findings apparently reflect, to some extent, the mix of studies being carried out by Israeli health services researchers.As the senior editors of the IJHPR we are interested in working with funders, academic institutions, the owners and principal users of relevant administrative databases, and individual scholars to further understand the factors influencing the mix of research being carried out, and subsequently published, by Israel's health services research community. This deeper understanding could then be used to develop a joint plan to diversify and enrich health services research and health policy analysis in Israel. The plan should include a policy of ensuring improved access to data, to properly support information-based research.

Innovation and The Israel Journal of Health Policy Research.

The Israel Journal of Health Policy Research (IJHPR) is a peer-reviewed, on-line, open access journal, sponsored by Israel's National Institute for Health Policy Research. We believe that it is both an innovative platform and a platform for innovation. Within just 2 years of its launch in 2012, the IJHPR was accepted into the prestigious Web of Science - primarily because of its innovative positioning as a journal that is simultaneously national and international. This positioning has contributed to annual growth of over 20% in both submissions and publications and to the IJHPR being ranked among the top half of public health journals, just 6 years after its launch date.The IJHPR has also served as a platform for numerous innovations, including: Sharing with the international community information about Israeli innovations in public health, health policy, health care delivery, and more.Enhancing the impact of empirical studies by Israeli scholars via commentaries by leading scholars from abroad - including 18 commentaries from scholars based at Harvard and one commentary by a Nobel laureate in economics.Developing a new genre of articles for Israel, namely, broad policy analyses focused on major challenges facing Israeli health care.Creating dynamic, constantly growing, article collections in such fields as digital health, pharmaceutical policy and health care equity, to highlight areas of excellence as well as important issues in Israeli health care and health policy.Disseminating to a wide audience the essence of major Israeli health policy workshops and conferences.We feel that the IJHPR has significant potential to contribute more, and in new ways, in the years ahead. We look forward to your suggestions for innovative enhancements of the IJHPR.

Competencies for improving diagnosis: an interprofessional framework for education and training in health care.

Background Given an unacceptably high incidence of diagnostic errors, we sought to identify the key competencies that should be considered for inclusion in health professions education programs to improve the quality and safety of diagnosis in clinical practice. Methods An interprofessional group reviewed existing competency expectations for multiple health professions, and conducted a search that explored quality, safety, and competency in diagnosis. An iterative series of group discussions and concept prioritization was used to derive a final set of competencies. Results Twelve competencies were identified: Six of these are individual competencies: The first four (#1-#4) focus on acquiring the key information needed for diagnosis and formulating an appropriate, prioritized differential diagnosis; individual competency #5 is taking advantage of second opinions, decision support, and checklists; and #6 is using reflection and critical thinking to improve diagnostic performance. Three competencies focus on teamwork: Involving the patient and family (#1) and all relevant health professionals (#2) in the diagnostic process; and (#3) ensuring safe transitions of care and handoffs, and "closing the loop" on test result communication. The final three competencies emphasize system-related aspects of care: (#1) Understanding how human-factor elements influence the diagnostic process; (#2) developing a supportive culture; and (#3) reporting and disclosing diagnostic errors that are recognized, and learning from both successful diagnosis and from diagnostic errors. Conclusions These newly defined competencies are relevant to all health professions education programs and should be incorporated into educational programs.

The IJHPR's growing scientific impact.

The Israel Journal of Health Policy Research (IJHPR) was launched in 2012, with a mission that included fostering intensive intellectual interactions among health policy scholars in Israel and abroad. Now, as the journal approaches the end of its seventh year of publication, we can all be proud that this component of our mission is increasingly being realized.As of the end of November 2018, the Web of Science included 404 articles published by the IJHPR. These IJHPR articles had generated 1023 citations via 847 citing articles. Just over 70% of those citing articles were in journals other than the IJHPR, with the vast majority of those being in non-Israeli journals. The authors of the citing articles were most often based in institutions in the US (35%), Israel (33%), England (9%) or Canada (7%).Looking to the future, we hope that the IJHPR will receive even more submissions from authors based in Israel or other countries that are well-designed data-based studies; thoughtful, comprehensive policy analyses; or important integrations of a body of knowledge. In all instances, these should be relevant to Israeli health policy and health care. We hope that many, ideally most, will also be relevant to scholars, policymakers and professionals in other countries.

Fundamental reform of payment for adult primary care: comprehensive payment for comprehensive care.

Primary care is essential to the effective and efficient functioning of health care delivery systems, yet there is an impending crisis in the field due in part to a dysfunctional payment system. We present a fundamentally new model of payment for primary care, replacing encounter-based imbursement with comprehensive payment for comprehensive care. Unlike former iterations of primary care capitation (which simply bundled inadequate fee-for-service payments), our comprehensive payment model represents new investment in adult primary care, with substantial increases in payment over current levels. The comprehensive payment is directed to practices to include support for the modern systems and teams essential to the delivery of comprehensive, coordinated care. Income to primary physicians is increased commensurate with the high level of responsibility expected. To ensure optimal allocation of resources and the rewarding of desired outcomes, the comprehensive payment is needs/risk-adjusted and performance-based. Our model establishes a new social contract with the primary care community, substantially increasing payment in return for achieving important societal health system goals, including improved accessibility, quality, safety, and efficiency. Attainment of these goals should help offset and justify the costs of the investment. Field tests of this and other new models of payment for primary care are urgently needed.

Adoption of patient-centered care practices by physicians: results from a national survey.

BACKGROUND: Little is known about the extent to which primary care physicians (PCPs) practice patient-centered care, 1 of the Institute of Medicine's 6 dimensions of quality. This article describes the adoption of patient-centered practice attributes by PCPs. METHODS: Mail survey; nationally representative physician sample of 1837 physicians in practice at least 3 years postresidency. RESULTS: Eighty-three percent of PCPs surveyed are in favor of sharing of medical records with patients. Most physicians (87%) support team-based care. But, only 16% of PCPs communicate with their patients via e-mail; only 36% get feedback from their patients. Seventy-four percent of PCPs still experience problems with availability of patients' medical records or test results; less than 50% have adopted patient reminder systems. Thirty-three percent of physicians practicing in groups of 50 or more have adopted 6 to 11 of the 11 patient-centered care practices targeted in the survey compared with 14% of solo physicians. CONCLUSION: Although some patient-centered care practices have been adopted by most PCPs, other practices have not yet been adopted as broadly, especially those targeting coordination, team-based care, and support from appropriate information systems.

Changes in the Health Professions: A Commentary.

Increased life expectancy in the United States has been accompanied by a concomitant increase in the prevalence of chronic conditions in persons of all ages, especially older Americans. This necessitates new ways of organizing and conducting medical practice, and this affects the roles and interactions of health professionals. Physicians and other health professionals require appropriate training and more efficient workplaces to enhance their functioning and reduce burnout. Additional factors influencing the success of health professionals in further advancing the health and well-being of Americans are health information technology and ensuring that all have access to care.

Long-term solution to malpractice crises: reduce harm to patients.

Physician executives need to lead the charge and actually reduce harm to patients. Simply capping malpractice awards or changing the rules of litigation is not enough.

Keys to a high-performance health system for the United States.

Five keys to better performance in the U.S. healthcare system are: Coverage of the uninsured, reduction in cost shifting, and administrative simplification. More primary care and less specialty care. Interoperable health IT. Mass customization of care. Delivery of near perfect care.

A 2020 vision of patient-centered primary care.

Patient-centered care has received new prominence with its inclusion by the Institute of Medicine as 1 of the 6 aims of quality. Seven attributes of patient-centered primary care are proposed here to improve this dimension of care: access to care, patient engagement in care, information systems, care coordination, integrated and comprehensive team care, patient-centered care surveys, and publicly available information. The Commonwealth Fund 2003 National Survey of Physicians and Quality of Care finds that one fourth of primary care physicians currently incorporate these various patient-centered attributes in their practices. To bring about marked improvement will require a new system of primary care payment that blends monthly patient panel fees with traditional fee-for-service payment, and new incentives for patient-centered care performance. A major effort to test this concept, develop a business case, provide technical assistance and training, and diffuse best practices is needed to transform American health care.

Measure, learn, and improve: physicians' involvement in quality improvement.

Payers, accreditors, and consumers are using quality improvement (QI) methods, but little is known about whether physicians do so. The results from this 2003 national physician survey indicate that most do not. Physicians do not routinely use data for assessing their performance and are reluctant to share those data. They infrequently participate in redesign activities. Physicians in larger and salaried groups are more likely to be engaged in QI. The science of QI has been "institutionalized" but not yet "professionalized."Accelerating physicians' adoption of and participation in QI requires building the infrastructure to support quality and paying attention to professionalism, knowledge, and skills.

Malpractice reform must include steps to prevent medical injury.

In the current malpractice insurance crisis, physicians have focused their advocacy and energy primarily on rapidly increasing liability premiums; problems in access to care; and demands for legal reform, especially caps on damages. An even more important focus, however, is prevention of injury and improvement of patient safety. Physicians largely control patient care and can play a critical role in systematically reducing injury. Reforms should go beyond liability issues; they should also harness and enhance physicians' ability to act. More visible efforts by physicians to reduce harm, better communication with patients and others, and true evidence of improved patient safety should reduce patient anger and litigiousness. Individually and collectively, physicians can and should ensure that "doing no harm" comes first in the malpractice debate.

High performance team-based care for persons with chronic conditions.

Care for patients with complex chronic conditions such as diabetes requires a coordinated and collaborative team working in partnership with the patient. Israel has taken important steps forward with the development of structured diabetes follow-up by Clalit Health Services, including several measures of diabetes care in the National Program for Quality Indicators in Community Healthcare, and efforts to develop health information exchange and measures of continuity between hospital and community-based care. Achieving even better results will require purposeful development of health care teams to meet the needs of patients with single and multiple chronic conditions, including robust interprofessional education programs for the next generation of health professionals, and developing partnerships between the teams and the patients.