voy uuu ome EXHIBIT 4 EXHIBIT 4 p Be PHYSICIAN EDUCATION Aq] @ TECHNIQUES The workshop identified the following main techniques being employed by the Arthritis Program funded through R.M.P.: - 1. PRECEPTORSHIP- Such efforts involve medical students participating in . local health care deliveries as well as physicians returning to medical schools for specialized rheumatoid training. 2. CLINIC PARTICIPATION- Through these’ tecnniques difficult patients are presented to consultate physicians and others in the local community. The medical problem is discussed in some detail and treatment recommend- ations made. , 3. CONSULTATION- Conventional consultation contacts have evolved from out- reach efforts. h. WEEKLY LECTIVE SERIES- Some programs have employed regular lecture series on specific problems of the treatment or diagnosis of rheumatic diseases. 5. REGIONAL DAY LONG SEMINARS- These seminars are usually conducted at a local site by a panel of rheumatologists of the areas medical centers. 6. MEDICAL CENTER SYMPOSIUMS~- These are more formalized presentations using ‘Out of the area experts of some renown and are usually one or two days in duration. 7. SELF OR PROGRAMMED INSTRUCTION- A few programs have developed self-assesment and programed instruction instruments. This technique is available to individual physicians to apply at their own time and pace. 8. MEDICAL STUDENTS AND HOUSE STAFF PROGRAMS~ There is a conscious attempt in @ many projects to involve medical students and house staff in the rheumatic disease educational programs. o PROBLEMS The following list of problems related to physicians education was enunciated by the workshop group: 1. Local physicians are over-worked and claim no time to participate in programs conducted in medical centers. 2. Treatment of the arthritic patient is a team effort, therefore, training should realistically be conducted on a team basis ( several team teaching programs are being conducted with reasonable success). 3. Programs should be planned to meet the Individual need of the particular . community. Without some degree of tailoring rapport between medical center and community can be lost. lh. There seem to be a insufficiant number of trained rheumatologists in the medical teaching institutions to meet the demands of an extensive out- reach program. 5. Evaluation of the effectiveness of out-reach teaching is at best difficult, no suggestions were offered. @ 6. If out-reach programs are too serviced orientated and patients begin to Q circumvent the local health care system, rapport will be lost. Pr A-] PHYSICIAN EDUCATION page 2 The attempt should be to emphasize education rather than patient service. 7. In areas where distances between population centers are great, experience shows a lethargy amoung local physicians for continuing education effort. Distance also creates a teaching resourse problem. e * 8, Medical school faculty are not all enthusiastic about participating in out-reach clinics. Many feel their responsibilities lie elsewhere, such as research and institutional instruction. EVALUATION The workshop discussed evaluation in broad terms. No concensus was achieved on the best ways to evaluate the programs discussed. In fact, it was generally agreed that such short term efforts could not be evaluated in terms of their effect on patient treatment and physician behavior. It was suggested that where possible all programs maintain and compile cost and "students reached'' data. From this information it may be possible at the end of the R.M.P. program to make judgement concerning the cost effectness of var~ ious teaching techniques. This data could be of great value to those responsible for continued funding. It might also be pertiant to an evaluation of the cost of basic medical education in rheumatoid as apposed to continuing education in rheumatoid. @ The workshop participants heard a report of an assessment of professional educa- tion conducted by the A.R.A. and national Arthritis Foundation. Dr. Evelyn Hess presented some preliminary information which indicates a potential shortage of physicians trained in rheumatology. Their survey indicated few house staff and medical students involved in arthritis centers. it also pointed to the relatively number of post-doctoral fellowships available in rheumatology. Numerically the data would indicate the exsistance of less than 2.5 rheumatoligists per in- stitution surveyed. ( The survey covered 120 teaching and private treatment institutions.) Final results from this survey are expected to be available at the national meeting in June 1975. RECOMMENDATIONS Many suggestions were offered for improvement of physician education by program basis, but several recommendations were offered which relate to the over all task of educating physicians in the area of rheumatic diseases. 1. Educational pregrams should be aimed at the need of the patient and address the physicians problem related to patient need. 2. The guide lines for funding of the R.M.P. Arthritis Initiative were quite ‘restrictive. It is recommended that future funding allow more latitude for program emphasis between out-reach education and education of medical students and house staff. EE I ee NT LT eS a ath as : POET ® srry PHYSIGIAN EDUCATION page 3 A coordinate attempt to gather assess and evaluate data on the various education techniques employed, R.M.P. Arthritis program should be im- plimented. Perhaps the P.A.R. group in coordination in D.R.M.P. could assimilate the appropriate information for such an analysis. The workshop supports continued funding of the Arthritis Center approach and other programs designed for the continuing education of the practicing physician. re eee Fe er Tobe 2 ge ALLIED HEALTH EDUCATION Summary Workshop: A-2 Room: Tower 22 Sunday, Jan. 19, 1975 Edited By: Marjorie C. Becker, R.P.T., Ph.D. Robert Godfrey, M.D. University Hospital Univ. of Kansas School Ann Arbor, Michigan of Medicine Kansas City, Kansas Each project summarized their activities, including educational A.H.P. activities. The potential under the grant initiative, and in any other way, is essentially untapped. The primary method and technique for strengthening the effect of A.H.P. education can most rapidly and efficiently be obtained by a massive A.H.P. training program. We do not want to let rigid certification or licensure to take place @ so that it precludes using manpower and talent at a level that is presently . available. We want to encourage the earliest possible educational inter- action between al] health occupations. We need to correlate or to include the A.H.P. contribution within the A.R.A. central health data basis. Recommendations for future A.H.P. educational activities are: 1. To support Allied Health Professional Section of the Arthritis Foundation 2. Set up a national meeting of Allied Health professionals to share their R.M.P. project outcomes and methodologies, and it was suggested that this might be held in New Orleans, preceding the June meetings, in conjunction with the National Arthritis Foundation meetings. 3. Have each of the twenty-nine project directors assign an A.H.P. coordinator to report specifically on the Allied Health involvement in their projects. This information could be forwarded to the Allied Health Education Workshop participants for some sort of generalization or compilation and distribution. Anticipated outcomes of greater Allied Health Professional Education: 1. We could better assure greater numbers of rheumatic patients @ receiving services from appropriate levels of health professionals. fe caches Sciam ee oo ; © Page 2 ALLIEC HEALTH EDUCATION 2. Therefore, we can increase the total volume of patients serviced. 3. We would enhance better the level of sophistication of the patient so that the patient utilizes the physicians! time and vice versa, which also overcomes physicians’ resistance to his professional education. Unresolved issues that might provide agenda items for future meetings: 1. Who should be doing Allied Health Professional Education? Should discipline train discipline? 2. Who should define criteria for competency, training, and per formance? 3. How should we approach third-party payers for coverage of Allied Health Professional services; and identify other sources of funding for continuing current and proposed projects? - kh. How should we utilize non-physician-Allied Health resources, such as the Arthritis Foundation and other national and local community health resources,for provision of complementary public education, patient education, or simple secretarial services? The Allied Health Education group strongly recommends that Allied Health training, recruitment, and research should be an extremely high priority item when the National Arthritis Act is being considered. SPRL LIT IT FE PE EIT I TT TT ee PET Sere e \-2 PATIENT EDUCATION The participants in this workshop consiste? of orthopedics, R.N.s, Arthritis Foundation personnel and R.M.P. administrators. The expenses and needs for ¢dducation of all varied considerably and it was enlightening to some to know that they were ahead of others. The probleris viewed were: 1. dissemination of educational information and who is responsible or should be for local arthritis centers. 2. The geographical, social, and economical needs of various groups as far as education and how they would feed it to the programs.“. 3. Is there a method to evaluate effect of patient education? 4h. Participants need list to answer patient needs and discuss patient problems. 5. Arthritis Foundation would like to find if anything is available in the way of education for the problems. DEMOGRAPHIC FACTORS Summary Workshop: A-4 Room: 3 Sunday, Jan. 19, 1975 General discussion pursued definition of Demographic data. Basic distinction was made between what should be termed classical Demographic data, e.g., age, race, income, etc., anda broader definition which should include any statistics collected which further programmatic goals, e.g., physical profile, 3rd party payers, community resources, etc. Conclusion was reached that should be termed Slassical Demographic Data, which should be used as an adjuncted to the broader definition of data. By this is meant that the initial. data is used to augment and facilitate the planning process in general. The group as a whole developed a set of classifications and generated a laundry list under each one. The list will appear below with clearifications being given subsequently. 1. Population Data What is normally available through the use of census data and any related national or local resources. . 11. Patient. Data Age Sex Income Occupation Health Insurance Weight Family History ~family rheumatoid -personal history . Smoking Patterns Level of Education Race Urban-Rural Language Spoken Living Arrangement Functional Capacity -diagnosis rheumatoid ~diagnosis other Other Health Care -traditional -nontraditional Mobility Transportation {1}.Provider Data: both physician and AHP"s Practice Arrangements Professional Profile “age -training-speciality -place of education -place of residency -involvement of allied health professionals Physicians Referal Patterns Demographic Factors . Page. 3 lll.Provider Data . American Hospital Guide Issue AMA Directory State and Local Directories State Licenser Boards PSRO's If the above prove unsatisfactory or inadequate it may be desirable to interview the providers themselves. .1t is recommended that this be done in only selective situations and as a last recourse. {V.. Institutions. Data Medical Care Standards, State Agencies State Institutional Licenser Regulatory Authorities V. Community Data Center for National Health Statistics It is suggested that local volunteer resources be explored. Long Term Program Goals In light of the scope of the current projects and recently enacted and hoped for legislation, it is suggested that collective action be taken in order to answer the following three areas. 1. What appropriate mechanism be devised in order to facilitate uniform data collection. ” 2. The present arthritis programs, coupled with new legislation which mandates arthritis initiative suggest collective evaluation of all the funded arthritis projects through a central mechanism. 3. The present public accounting system (PAR) of the regional medical programs provides a resource for centrally collecting and dispersing project data. Further, this activity for PAR is appropriate and consistant with the responsibilities delegated regional medical programs to evaluate operational projects. Consistant with new legislation for help planning and resources developement. This data will be incorporated into national and regional HEW and NIAMMD when appropriate. This will serve as the basis for an ongoing long term evaluation of the arthritis initiative. * A-5 ARTHRITIC SERVICES The arthritic services workshop began by a review of the activities of the participants in the workshop in their particular units. There seemed to be general concensus that an important part of the arthritis service program was decentralization of present services from medical centers and medical clinics out into the respective communities. This was perhaps brought out by 30 per cent of the workshop participants. The exact type of arthritis service was divided into three areas: a. An area of physical treatment. b. An area of social and emotional treatment. c. An area of economic, vocational and educational treatment. A discussion of what constitutes comprehensive arthritis service was held. There seemed to be a wide spectrum as in physician's use of community resources. A discussion was held concerning the use of volunteer organizations, charitable organizations, including the Arthritis Foundation, available community resources such as the Public Health nurse, in order to provide service for the arthritic, “ixed or mobile evaluation and follow-up teams. Considerable variabilty .exsisted among the members of the workshops among the constituents of such a team. These varied from 1) The use of specialized physicians, orthopedists, rheumotologists, physiatrics, and pediatricians with the Allied sersonnel fulfilling a constructive role; 2) teams comprised primarily of Allied Health personnel utilizing a nurse, arthritist specialist, physical therapist, occupational therapist, social service worker and psychologist and nutrition specialists. The teams varied in thrust from teams that were designed primarily to act as demonstration or teaching teams, to.» teams designed primarily to engage in diagnosis and treatment, community resources, fixed or mobile. Medical center or clinic programs. {t was emphasized that there was a need for a centralized resource center, with sophisticated seralogic laboratory support in order to provide the resource and research data necessary to handle complicated patients and often with - specialized clinics for juvenile rheumatoid arthritics, geriatric, lupus. 4) Educational programs. It was felt that patient para-medical and post grant education «were all the important parts of the arthritis service program, but are being discussed under other specific sessions. 5) Vocational need. !t was felt that vocational assistants, ranging from home-bound or sheltered workshops to specialized employment opportunities would be necessary in order tosupport the arthritic in job placements. A discussion was held on the role of Allied Health personnel in the arthritis treatment and service programs. . Consideralbe philosophical differences existed as to what the responsibilities of the nurs¢s practioners and Allied Health personnel should be. Some’ general concensus was reached that there is need for a nurse arthritis specialist to be involved in an evaluation,data collection and treatment situation under the supervision of the physician in charge of the care of the arthritic. Considerable discussion hinged on obtaining funds for a continuation: of arthritis services that are begun under the R.M.P. Grant Program. It was felt that some help would be obtained from charitable, federal and state sources but a majority of the support of the individual Programs would very likely come from fee-for-service charges from both physicisns and Allied Health personnel. SUES SEI So Ge oy iy: Man apa aR RO a aS Rm NRE IreMnCRpeme ERR A=-6 SERVICE DEPLOYMENT As regards the general prodram of existing arthritis services, the first question that was raised was how the majority of rare of arthritis patients is provided, and it was quite clear that this was with the private physician, particularly with the local netina) practitioners, The question was raised as to whether physicians have any idea as what is available to arthritis patients in the area, Many services may be available that the physician is vnaware of, It was also apparent that many services that are avaijabie compete rather than cooperate with one another. The neec here appears to be directory of resources. The uestion was raised as to whose responsibility it is to oversee this directory of reanurces, and, of course, the question was also -xaised as *o sitimate’y who oxcanizes the deployment of the arthritis services that are available. Circumstances that effectively inhibit services: “eploymen* an? use were discussed. Some of these are: one, the physicians are conservative by nature; two, a fear that ~eferrine patients to other clinics or facilities, that these patients will be los* to hem; three, poor educational physicians as to what an arthritis service can offer; and four, suspicien 7f aovernment finance services. Other inhibiting factors of deployment and utilization of services are financial ones, particularly on the part of the patient and the ability of the patient to pay. Tt was felt that more ‘Se shonic be made of insurance carriers to pav out-patient fees, and sin-e +his is undeveloped, this could be a further factor that shoul be develope?. Tt was noted that with the Yational Health Act heine @isensse% in Congress, greater propaganda emphasis in the next sis nonths snoulda be put on the financing and methods of financine in the arthritis field, All areas of concern for arthritis patients show? ba tcoverec, The role of the present region or medical procran in ad4ine to or changing attitudes of local physicians and patents or re*arrals eiven, it was “elt, particularly by physicians in rural armas, that there was a marked impact and that these physicians were becoring much. more familiar with arthritis problems an‘ handling shem with cveater | ease, There was also a better utilization of services. “he use of para-mecdical personnel was discussed, who directs them, what is their role linking the local physician and patient, and the Rheumatolo= gist and patient. The need for early diadnosis and the Ceveloprent o* ALaanostic centers was emphasized, utilizina peripheral facilities for continuation of the program, It was clear that there was 4 ereaak neec for physi- cians and@ patient education as to what can be provider, Some Aiscussion was achieved of the priorities, whether one shouté eencen*rate on quality versus quantitv of care, and it was qenerally falt thak the first priority was to increase the available access to merica” care by arthritis patients. ‘ Aedes TE OLE TI PEE TE EE Te eT " FTE TR YE EET er EET NET eer ree P