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369 Mary G. Turco, Richard I. Rothstein, and Carl S. DeMatteo chapter 32 Continuing Medical Education in an Era of Health-Care Reform: A Dartmouth Perspective We are now faced with the fact my friends, that tomorrow is today. We are confronted with the fierce urgency of now. In this unfolding conundrum of life and history there is such a thing as being too late. —Dr. Martin Luther King, Jr., quoted in a speech by Jim Yong Kim, president of Dartmouth College Profound changes in society, technology, and the economy of the United States and elsewhere are driving dramatic and persistent transformation of the practice of medicine and, thus, the education of physicians. Predicted challenges for training tomorrow’s doctors are here today. This chapter is a reflection by three members of the Dartmouth Medical School faculty who are Dartmouth-Hitchcock Clinic administrators with responsibility for continuing medical education (CME) on how our particular institution’s broad and varied initiatives, including the development of the new health care delivery science, are in- fluencing the education of physicians across the continuum of their professional lives and medical practice. In this book’s foreword, our colleague C. Everett Koop, MD, framed the present challenge well: how can physicians learn to care for patients ‘‘wisely, safely and right’’ while new knowledge and technology make previous training obsolete, and innovations in management and business make delivery systems outmoded?∞ Stuck in a feefor -service practice model that delivers segmented care, and an antiquated education model that adds reimbursable skills and not value, we need new ways of paying for care, new ways of delivering care, and new ways of educating the health care team. Our argument is that today’s clinicians need twenty-first-century CME that fits twenty-first-century delivery systems. And, to know what to do, our educational system needs to be focused on the model of health care delivery to which we aspire. Reflecting its origins in the New Hampshire hinterlands, the motto of Dartmouth College, a teaching and research institution located in the rural river valley between the White and Green Mountains of New Hampshire and Vermont, is ‘‘vox clamantis in deserto’’—a voice calling in the wilderness.≤ Among the institutions that constitute the whole is Dartmouth Medical School (DMS), founded in 1797 by Nathan Smith, MD, DMS is part of a historic and successful partnership with the Mary Hitchcock Memorial Hospital (1893), the Veterans A√airs Medical Center (VAMC) in White River Junction, Vermont (1938, a≈liated 1946), and the Dartmouth-Hitchcock Clinic (1927). The original Hitchcock Clinic, modeled by its four founders on the Mayo Clinic (where one of them, John Pollard Bowler, MD, had done his Surgical training), became the Dartmouth-Hitchcock Clinic (DHC) in 1999.≥ 370 moving toward the future Today, DHC is one of the largest multispecialty, not-for-profit group practices in the country. Its physicians, like those at Mayo Clinic, are salaried and thus ready to move toward capitation or other non-fee for service reimbursement that would allow professional sta√ to manage patients over time according to the best methods for reaching institutional goals. At Dartmouth, we of course do not have all of the answers. And, like other organizations, we make mistakes and are slow to change. However, we do have a unique and di√erent environment, a research-oriented reform agenda, and important shared philosophies that inform and enable our institutional e√orts to improve. Our objective is to advance past fragmented, sometimes commercially biased and/or ine√ective care and education to well-designed, accountable, and patient-centered care and education. In our twenty-first-century vision of CME, the reflective physician—working inter-professionally—uses data comprehensively, educates herself or himself and patients e√ectively, and practices the art, science, evaluation, and delivery of medicine successfully and compassionately over a lifetime and with every patient. Tomorrow is today. This chapter presents our perspective on how one academic medical center and its partnering organizations are learning and doing in a concerted e√ort to reform clinical care and CME to transform health care in the ‘‘fierce urgency of now.’’ Research-Oriented Reform Open academic discourse in a rural academic medical center can be an adventure, particularly when peers cause what Senior Advising Dean for Dartmouth’s medical students Joseph O’Donnell, MD, calls ‘‘perturbances.’’ Since 1979, DMS faculty member John (Jack) Wennberg, MD, MPH, has been a perturber. Trained in epidemiology as well as internal...

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