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CHaD's Academic Mission: Teach to Learn

February 18, 2015
Lebanon, NH

CHaD's Academic Mission: Teach to Learn

The Three-legged Stool
CHaD's Academic Mission

What does it mean for the Children's Hospital at Dartmouth-Hitchcock to have an academic mission? Probably more than you would imagine.

"As an academic medical center we have what we call the three legs of the academic stool: clinical care, education and research,' says Leslie Fall, MD, CHaD's Section Chief of Pediatric Hospital Medicine. "We are a teaching hospital, and every physician or advanced health care provider is also on the faculty at Geisel School of Medicine at Dartmouth." This creates a particular synergy, and an environment that is always both teaching and learning. Because of the reciprocity of pedagogy, Fall—who is also a Professor of Pediatrics and Vice Chair for the Pediatric Office of Medical Education and Associate Dean for faculty education at the medical school—says that CHaD "attracts the best physicians, health care providers, students and residents. We are national known as one of the best small pediatric residency training programs in the country." For seven open residency slots, on average CHaD receives 700 applications from across the world.

At CHaD, and throughout the D-H health system, physicians, nurses, and therapists, are in an environment where they are frequently surrounded by learners. "All of us are always learning, and that translates to the best possible care for our patients. It's not just one person's opinion and decision, but often several minds coming together to determine the very best course of treatment for that individual." Although the physician makes the final determination, Fall points out, "We are an elite medical school with an elite residency program. These are bright young people. They can help us reach a more accurate and more rapid diagnosis because they are always asking questions."

"That open discussion is what makes for better care," agrees Kimberly Gifford, MD, pediatric residency program director. "It's a team-based approach. Observers may ask questions that I didn't think of, or prompt me to pause and think more deeply."

Beyond the Walls

An integral part of CHaD's academic mission is working in and with the community, through training such as On Doctoring. As part of the medical school's curriculum, On Doctoring is a two-year course during which learners spend time in community practices throughout the states of New Hampshire and Vermont. "Although some students train here at CHaD, we don't have the onsite capacity for all of them," says Fall, "so we have a very large network of community-based pediatric providers—many are D-H providers—who take students into their office and work side by side with them. These preceptors have been screened for providing excellence in patient care and willingness to donate their time." Because students and residents are in practices throughout the region and across the states, Fall says that a patient is likely to encounter and interact with a CHaD or Dartmouth-Hitchcock provider without ever stepping through our doors.

There are also immersion experiences, says Gifford. "Through the Boyle Community Pediatrics Program, residents can spend a month in a practice within a particular community. While there, they are able to see the interactions with local schools and resources. Beyond medicine we encourage them to get to know the neighborhood, even where people do their grocery shopping. We also have a family faculty, and we match learners with a patient who has a chronic disease. The care that is going to happen is not just in a 20-minute visit, it goes beyond that, right into the community, so residents need to understand the social components and how best to help." Experiences like this, Gifford adds, enhance the awareness of the patient's perspective, which can then be translated to CHaD where patients are coming from many different communities.

There are myriad options for residents to participate in community outreach and advocacy activities. Another long-standing outreach relationship has been with Upper Valley Haven in White River Junction, Vermont. According to Gifford, "For years residents have been supporting Haven families in need. They do free Q & As on health topics; they also provide guidance, educational materials and healthy foods. Also, in support of our advocacy efforts, we've received a grant to have national leaders come here and help residents work on legislative advocacy skills, so that as pediatricians we are well able to help government in making good decisions in regards to the health of children nationwide."

Out into the World

But for CHaD, the academic mission extends far beyond state borders and to more than just students and residents. "Our faculty participates in national and scholarly organizations, interacting with colleagues across disciplines and cultures," says Keith J. Loud, MD, MSc, FAAP, director of CHaD and Chair of the Department of Pediatrics at the Geisel School of Medicine and Dartmouth-Hitchcock Medical Center. "These are opportunities to learn and share best practices and increase knowledge in the field of pediatrics and medicine as a whole." Through these interactions and a "vibrant connection" with Dartmouth Global Health, students, residents and faculty participate in the global health experience, a large part of which is the collaboration with Muhimbili University of Health and Allied Sciences (MUHAS) in Dar es Salaam, Tanzania. "We are about to launch a pilot exchange program as well," say Loud. "So, to talk about all of this is exciting, but it's hard to quantify the degree to which we are locally, regionally and internationally academically active, because it is so much in our DNA; it characterizes everything we do."

One of CHaD's regionally well-received educational offerings is the annual pediatric conference that brings together pediatric health care professional from across New England and surrounding states. "One of the main purposes of the pediatric conference is that we have a mission of teaching, not only at the medical center, but throughout the region," says Maggie Minnock, Director for Planning and Regional Services CHaD. "CHaD has always been way out front in reaching out to the region, and keeping pediatric providers up-to-date and informed."

To Better Understand

Being up-to-date means staying on top of, and often authoring, the latest research—the third leg of the academic stool. Scholarly interests and research studies within CHaD pediatrics cover a wide range of far-reaching topics. But, Loud says, the work being done in the area of pediatric prevention is especially impressive. "Prevention research is an area we excel in. Our staff has done significant work on media influences, risk behaviors, marketing that targets children, obesity, adolescent smoking, and drinking, to name just a few. These behaviors have long-term adverse health effects, but if we can get out in front, and decrease unhealthy trends by understanding what influences them, then we're going to help create a healthier generation. So, the research aspects of our mission have direct benefits to population and long-term health. This is new knowledge, new cures, and new means of prevention."

"CHaD physicians have ongoing research locally and internationally. One current research study is targeting improvements in pediatric clinical care," says Fall, "so our efforts can affect and improve how we provide that care overall. Our research efforts also strengthen CHaD's bonds with the community, because we share research as well. Our residents also help bring us cutting-edge research, because they are continually seeking out that next best thing in medicine and patient care."

"At our recent CHaD summit," says Gifford, "our academic mission, with research being a part of that, was identified as one of our critical service lines. That means that as an institution, as an academic health care system, the importance of this is recognized and supported." Loud agrees: "Having an institution that supports and encourages research is one of the reasons we attract such high-caliber individuals, staff, students and residents."

Back Home Again

Many of the community practitioners that are now training medical students and working with residents, were once students or residents here themselves. Now in private practices within the community, or at other D-H sites, they are well aware of the value these learners bring to their practices and also what they can learn from them. "CHaD and D-H are embedded in the practice of medicine throughout the state and beyond," says Fall. The academic mission is both cyclical and perpetual in nature. "Medicine," Gifford agrees, "is about lifelong-learning. Graduating doesn't mean you know everything; it's about asking the right questions and finding the right answers for patients."  

Part of CHaD's academic mission in support of lifelong-learning includes educational innovations to help learners learn. That is the idea behind Doctor Coach. "It's a model for teaching or coaching, looking at how we teach faculty to teach based on how learners learn best, and that is by being coached." The process encourages self-regulated learning, through reflection, forethought, and performance. With supportive coaching, students are being asked to "identify what they don't know and find a plan to learn it," says Gifford. "We are leaders in this area, and are helping other institutions adopt some of our educational methods, which is really exciting. Leslie and I have done national workshops and visiting professorships to implement Doctor Coach, and it is spreading nationally."

The residency program, Gifford says, is looking toward the future and asking the questions: "How do we better teach population health and value-based health care? How do we change our program to better reflect this? GME [Graduate Medical Education] is also working on these principals. Each of our residency programs has its strengths; I think our CHaD residents are better at population heath—thinking about what the community needs and how can we help them. But if we can take the strengths of each program and pool our collective expertise, we'd be well on our way to becoming leaders in the nation on both population health and high-value health care, and be the best of the best in the country, and our patients will receive the best of the best care."

Why It Matters for Patients

Healthcare is about patient care, and CHaD's academic mission is ultimately to determine and provide the best care possible to pediatric patients. "As an academic medical system, we focus on ensuring that we are all practicing at the highest quality, highest value, and the highest safety of patient care," says Fall. "We move past lifelong-learning to lifelong-competency, adapting and continually improving and being competent in areas like technology. Blending that with medicine, then translating it to hands-on patient care—education, research, and clinical care all woven together. That's what will continue to advance the frontiers of medicine and the health of our patients and the nation."

Residents may have the best perspective on all of what CHaD is and what it can be for our staff and patients, says Gifford. "During rotations they touch every setting within CHaD and they don't have a narrowed or focused perspective. They may be able to think about how patients move through our system and how to make that a better experience for our patients. Physician can get into the mentality of 'this is how we do it,' but to residents it's new, so they ask why do we do it this way? It makes us all think and sometimes we find better answers."

"What our academic mission is bringing to our patients," says Loud, "is the very latest knowledge and information that will hopefully improve their outcomes with greater efficiency and value. Learners also contribute cutting-edge research because they are closer to it being fresh in medical school, or just out of it. They bring an attitude of questioning and knowledge-seeking that consistently pushes us to reassess and challenge old paradigms and ask ourselves how we can do it better.

"Teaching is fundamental to our core. Our students, residents, faculty, and even our volunteers, are out in local, regional and global communities teaching and educating every person we encounter, and with every patient interaction. All of us who work in pediatrics are fundamentally teachers—teachers of families, teachers of patients, and at CHaD and across our pediatric health system, teachers of each other."

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