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The Robert Wood Johnson Foundation Clinical Scholars Change Agents In Medicine For More Than 40 Years Photo: Harold Shapiro
The Robert Wood Johnson Foundation
Clinical Scholars
Change Agents In Medicine For More Than 40 Years
Photo: Harold Shapiro
MissionDevelop physician leaders to improve US health and healthcare with a commitment to service and patients.
Photo: Harold Shapiro
Alumna Tammy Chang (second from
left, Michigan CSP 11-13) and community
partner Zachary Rowe (left) with
community members
About the Program• Founded in 1969; adopted by RWJF in 1972• Oldest RWJF Human Capital program• Long-standing collaboration with US Department of
Veterans Affairs (VA)– RWJF and VA fund stipends and health insurance– RWJF supports research expenses – VA provides in-kind faculty, clinical and research resources
Diversity CommitmentThe Program:• Embraces racial, ethnic, gender, and
disciplinary diversity• Encourages candidates with diverse
backgrounds • Provides all qualified candidates an equal
opportunity to compete for a Clinical Scholar position
Scholar Training Sites and National Program Office
Training Sites:• University of California, Los Angeles• University of Michigan• University of Pennsylvania• Yale University
National Program Office The University of North Carolina, Chapel Hill
DirectorDesmond “Des” Runyan, M.D., Dr.P.H. (former Clinical Scholar, UNC ‘79-’81)
Deputy DirectorKristin Siebenaler, MPA
Program AdministratorKathy Donnald
National Program Office (NPO)• Advise training sites on curriculum development• Provide technical assistance to training sites• Plan and host the annual Clinical Scholars research meeting• Direct nationwide applicant recruitment and program
marketing• Pursue an applicant pool from diverse medical specialty and
racial backgrounds• Oversee the scholar selection process• Engage the Clinical Scholars alumni network• Maximize expertise of the Clinical Scholars national advisory
committee
National Advisory Committee (NAC)
Selected national leaders in health and healthcare committed to helping develop new scholars and leaders
NAC members involved in a wide range of activities: • Curriculum design• Scholar selection• Scholar mentorship• Training site selection • Training site oversight
Key Results: As of August 2013, the program had produced 1,212 scholars. In 2013, 54 Scholars are participating in the program.
Graduates have become directors of major federal, state, and local health agencies and departments; hospital CEOs; leaders in the fields of health services research and health economics; foundation executives; and leaders in academic medicine.
Program Results Report
Authors: Crum R, McKaughan M, & Heroux J
Program Results Report Cont.• Clinical Scholars lead five of seven Pediatric Quality Measures Program
Centers of Excellence created by the federal Agency for Healthcare Research and Quality
• Scholars helped “propel emergency medicine into the mainstream of health care, especially in the academic world,” according to an article in the April 2010 issue of Academic Emergency Medicine.
• Since 2005, Clinical Scholars have taken the lead in community-based participatory research (CBPR).
Authors: Crum R, McKaughan M, & Heroux J
Scholar Experience and Curriculum
Scholar Experience• Unmatched post-residency opportunity for 20
physicians to:– Conduct innovative research in health policy, health
services research, and CBPR
– Work in a leadership role with communities, organizations, practitioners, and policy-makers
– Pursue two years of master’s degree study (degrees awarded)
Scholar Experience, continued• Funding provided for stipends, tuition, travel and research• Protected time for research (20%) and scholarship (80%) • Attend annual national research meeting to present
research and foster networking• Develop skills to serve as an innovative and
accomplished leader in healthcare• Tap into program alumni network
of over 1,200 individuals who serve as resources
Yale Clinical Scholars
Prepare Scholars for External Drivers in Health Care System
• Disparities in access, quality, and outcomes• Spiraling health care costs• Aging of America• Translating research into practice
Core Competencies
• Critically evaluate qualitative, quantitative, clinical, health services, and related research
• Recognize different levels (e.g., molecular, familial, community) of health problems and develop strategies for addressing them at more than one level
• Design scientifically sound and important research
• Identify strategies for data analysis and execute analyses
• Interpret and communicate results with their public health, practice, and policy implications
• Translate research findings into creative interventions to improve health care quality and outcomes
Core Competencies, continued
Approach• Intensive summer orientation• Core curriculum• Seminars and courses• Mentors• Writing group• Leadership training
Photo: Harold Shapiro
Curriculum• The design and conduct of health services research,
clinical epidemiology, and health policy research
• Exposure to other fields of inquiry (e.g. economics, sociology, and law) relevant to study of US Healthcare
• Centerpiece: one or more original research projects
Core Curriculum: Topics•Biostatistics•Population and clinical epidemiology•Health services research•Health policy•Social science•Community-Based Participatory Research•Other analytical methods•Project design and management•Professional development
Seminars and Courses• Weekly seminars: works in progress
• Leadership seminar
• Didactic coursework
• Seminar series
Structured Transition to Faculty• Completing manuscripts from Scholars’ research projects
• Writing grant applications
• Developing mentoring skills
Yale CSP Faculty
Examples of Scholar Publications• Gordon Sun (Michigan CSP 11-13, VA Scholar) and Matthew M. Davis. “The
Patient Protection and Affordable Care Act of 2010: Impact on Otolaryngology Practice and Research.” Otolaryngology – Head and Neck Surgery, 26 January 2012
• Lisa Rosenbaum (Penn CSP 12-14, VA Scholar), "How Much Would You Give to Save a Dying Bird? Patient Advocacy and Biomedical Research." New England Journal of Medicine. 2012 Nov;367(18):1755-9. doi: 10.1056/NEJMms120711
Projects by Recent Scholars
Social Relationships and Depression:
Ten-Year Follow-Up from a National Community Survey of Adults
Alan R. Teo, M.D., M.S. (Michigan 11-13)Portland VA Medical Center, Staff Psychiatrist
Oregon Health and Sciences University, Assistant Professor of Psychiatry
Research Questions1. Does quality and quantity of social relationships predict development of depression?
2.What is the relative impact of type of one’s social relationship on depression risk?
Hypothesis:
Study Sample• Midlife in the United States (MIDUS)• Community-residing adults age 25-75
recruited by random digit dialing
Baseline1995-96
Outcome 2004-06
N = 4,642
1. Quality of social relationships
2. Quantity of social contact
Past-year major depressive episode
Social Relationship Quality Has “Dose-Dependent” Effect on Risk of Depression
Poor QualityGood quality
Using Default Options to Improve Health Care
Value by Reducing the Use of Brand Name
Medications with Generic Equivalents
Mitesh S. Patel, MD, MBA (Penn 12-14, VA Scholar)
Philadelphia Veteran Affairs Medical Center, Philadelphia, PARobert Wood Johnson Clinical Scholars Program,
University of Pennsylvania, Philadelphia, PA
Background• Health care costs in the United States
– Now account for nearly $3 trillion annually– Estimated that 1/3 of health care spending is wasteful and unnecessary
• Improving health care value by reducing low-value services– Brand name medications with existing equivalent generics are a prime
example of a low-value service– In 2009, Medicaid wasted $329 million on brand name medications with
existing equivalent generics– In 2011, UPenn Division of General Internal Medicine found up to 44% of
medications were prescribed as brand name
Study Design• Objective
– To evaluate the impact of an intervention using the electronic medical record (EMR) on the utilization of brand name medications with existing equivalent generics
• Design– Quasi-experimental design with difference-in-differences approach
using internal medicine (IM) as the intervention group and family medicine (FM) as control
• Setting and participants– Ambulatory clinics at the University of Pennsylvania Health System– Attendings and residents from the IM and FM departments between
July 2010 and September 2012
• Intervention– In January 2012, the default in the EMR medication prescriber
was changed for all internal medicine providers from showing brand and generic medications alphabetically to showing only generics, with the ability to opt out and pick the brand if warranted
• Primary outcome measures– Proportion of beta-blockers, statins, and proton-pump inhibitors
with existing generics that were prescribed as brand name
Study Design
Unadjusted Proportions of Brand Name Medications Prescribed
Results - Attendings
Unadjusted Proportions of Brand Name Medications Prescribed
Results - Residents
Results – Multivariate Analyses
AttendingsVariable Coefficient P-value Coefficient P-value Coefficient P-value Coefficient P-valuePost-Intervention x IM Dept -0.091 0.007 -0.162 <.001 -0.101 0.023 -0.035 0.586Pre-Intervention Year 2 x IM Dept -0.02 0.566 -0.052 0.129 -0.042 0.303 0.015 0.824Post-Intervention -0.074 0.002 -0.013 0.663 -0.041 0.251 -0.149 0.004Pre-Intervention Year 2 -0.071 0.006 -0.04 0.074 -0.048 0.159 -0.101 0.085IM Dept 0.109 0.052 0.164 0.001 0.127 0.037 0.027 0.743Constant 0.25 <.001 0.243 <.001 0.14 <.001 0.384 <.001
All Medications Beta-Blockers Statins Proton Pump Inhibitors
ResidentsVariable Coefficient P-value Coefficient P-value Coefficient P-value Coefficient P-valuePost-Intervention x IM Dept -0.008 0.839 -0.139 0.024 0.033 0.549 0.056 0.432Pre-Intervention Year 2 x IM Dept 0.017 0.689 -0.058 0.371 0.045 0.435 0.049 0.454Post-Intervention -0.104 0.007 -0.009 0.871 -0.084 0.103 -0.207 0.001Pre-Intervention Year 2 -0.084 0.033 -0.011 0.852 -0.072 0.189 -0.156 0.008IM Dept 0.002 0.96 0.16 0.005 -0.079 0.104 -0.046 0.515Constant 0.239 <.001 0.157 0.002 0.194 <.001 0.353 <.001
All Medications Beta-Blockers Statins Proton Pump Inhibitors
Summary• Key Findings
– Significant reductions in the use of brand name medications were observed among providers in IM compared to FM for the post-intervention period relative to the pre-intervention period
• Attendings – all medications, beta blockers, and statins• Residents – beta blockers only
– Findings were sustained through nine months of follow-up
• Significance– Default options were an effective methods to reduce the use of a low-
value service– Clinical decision support teams could leverage defaults in EMRs to create
a sustained change in provider behavior– Lessons from behavioral economics could be leveraged in other contexts
to improve health care value
Comorbidity, Age, and Treatment Decision Making in Men with Early-Stage Prostate Cancer
Timothy J. Daskivich, MD, (UCLA 12-14, VA Scholar)Department of Urology
University of California, Los Angeles
To Treat or Not to Treat?• Survival benefits of aggressive treatment (surgery, radiation) for low- and
intermediate-risk prostate cancer are delayed for ~8-10 years after treatment
• Men who die of other causes before 10 years may incur side effects of treatment (erectile dysfunction, incontinence) without garnering any survival benefit
• National guidelines recommend against aggressive treatment for men with less than a 10-year life expectancy
• Despite this, men are often overtreated due to lack of a widely accepted method for determining life expectancy incorporating both age and health status
Bill-Axelson et al, NEJM 2011; Thompson et al, J Urol 2007; Mohler et al, JNCCN 2010; Daskivich et al, Cancer 2011
Study DesignProstate Cancer Outcomes Study: Population-based cohort of men diagnosed with prostate cancer between 10/94-11/95 within six SEER registries: CT, UT, NM, Atlanta, LA County, King County (Seattle).
Follow-up: 14 years
Count of 12 Major Comorbidities AgeD’Amico Tumor Risk Race Type of Treatment
Study Population
Other-Cause Mortality by Comorbidity and Age
Prostate Cancer Mortality by Tumor Risk
Variables
Competing Risks AnalysisMethods
Primary Outcome
Covariates
Secondary Outcomes
Other-Cause Mortality by Age and Comorbidity Count
Age <60 Age >70Age 60-70
10-year Other-Cause Mortality for Charlson 3+
71%40%26%
Daskivich et al. Ann Int Med 2013
Prostate Cancer Mortality by D’Amico Tumor Risk
To Treat or Not to Treat?Probability of 10-year Other-
Cause Mortality
40%
71%
Age and Comorbidity
75 yo
68 yo
DM, HTN, COPD
26%56 yo
Conclusions• A simple count of twelve common comorbidities is strongly
predictive of long-term, other-cause mortality in men with early-stage prostate cancer
• Older men with more than 3 comorbidities had greater than 50% probability of dying of something other than prostate cancer within 10 years of diagnosis
• This information will help older men with multiple medical problems to make more informed treatment decisions and potentially avoid unnecessary overtreatment of low- and intermediate-risk disease
What Drives Frequent Emergency Department Use in an Integrated Health
System? National Data From the Veterans Health Administration
Kelly M. Doran, MD, MHS (Yale 11-13)Instructor, Department of Emergency Medicine and Department of Population Health, NYU School of
Medicine / Bellevue Hospital Center
The Problem
• Small group of patients (frequent users) large share of ED visits and costs
• Prior studies limited in size and scope • Frequent users may not be best defined by a
binary “cut-off” number
Veterans Health Administration 2010• 5,531,379 total patients
930,712 patients with ≥ 1 ED visit Number of ED visits
1: 53.0% 2-4: 38.3% 5-10: 7.6% 11-25: 1.0% > 25: 0.1%
Strongest Correlates of Frequent ED Use• Schizophrenia (OR 1.44 – 6.86)*
• Homelessness (OR 1.41 – 6.60)
• Opioid medication use (OR 2.09 – 5.08)
• Heart failure (OR 1.64 – 3.53)
* OR range for different ED use frequency categories (from 1 to >25 visits/year vs. 0 visits/year) in multivariable analysis, all findings p<.05
Conclusions• Frequent ED use associated with high levels of medical
and psychosocial need – Correlates were consistent across multiple levels of
ED use frequency
• Frequent ED use occurs even in a coordinated health system where patients have access to other care– And use of non-ED VA services was associated with
more, not less, ED use
Alumni Statistics
Clinical Scholar Alumni• More than 1200 alumni located in 41 states + DC, 12 countries• 45 Members of the Institute of Medicine• Academic Medicine
– 8 Medical and Public Health School Deans– >145 Chairs, Vice-Chairs, division chiefs– 193 professors, 139 associate professors, 184 assistant professors
• Government – Federal/International: DHHS, CDC, CMS, House of Representatives,
AHRQ, VA, NIH, WHO, Office of the Surgeon General– State and Local Health Departments
• Hospital CEOs
Distribution of 365 Scholars By Major Specialty 2000-2013
2924
126
915
71
17
338
33
Emergency MedicineFamily MedicineInternal MedicineNeurologyOBGYNPediatricsPsychiatrySurgeryUrologyOther
51 and over26 - 5011 - 256 - 101 - 5
Scholars in Canadian Provinces:(Alberta 2; British Columbia 4; Manitoba 1; Nova Scotia 2; Ontario 9; Quebec 13)
Scholars Outside of US and Canada:(Argentina 1; Australia 1; China 1; Germany 1; Japan 1; Nigeria 1; South Africa 1; Switzerland 1; United Kingdom 3; Zimbabwe 1)
Scholar Distribution by US State (Updated October 2013)
Alumni Feedback
“For anyone who wants to be a catalyst for change in the health and health care of our country, the Clinical Scholars program is an excellent opportunity to do so.” Risa Lavizzo-Mourey, M.D., M.B.A., president and CEO of the Robert Wood Johnson Foundation (Penn CSP 1983-1986)
“There is no other program like the RWJF Clinical Scholars program for physician leaders who want to change America's health care system." -- Comilla Sasson, M.D., M.S., Director of Program Development, and Innovation, American Heart Association & Adjunct Clinical Faculty, University of Colorado School of Medicine
“Community-based work had a formative effect on my development. It’s something I’ve always been committed to, and it’s actually one of the reasons I chose to apply for the [Clinical Scholars] program.” – Nathan Irvin, M.D., instructor in emergency medicine at Johns Hopkins University School of Medicine
Examples of Alumni Publications• Anita Vashi (Yale CSP 11-13, VA Scholar) Justin Fox (Yale CSP 10-12),
Joseph Ross (Yale CSP 04-06), and Cary Gross (Hopkins CSP 97-99). – “Use of Hospital-based Acute Care among Patients Recently Discharged
from the Hospital. JAMA, 23; 309(4):364-71, 2013• Z Song, D Safran, M Chernew, A. Mark Fendrick (Penn CSP 1991-93).
– The Impact of Bundled Payment on Emergency Department Utilization: Alternative Quality Contract Effects After Year One. In press: Academic Emergency Medicine Journal.
• Lenard I. Lesser (UCLA CSP 09-12), Kayekjian, K., Velasquez, P., Tseng, C.-H., Brook, R. H., Cohen, D. A. – “Adolescent Purchasing Behavior at McDonald’s and Subway.” Journal of
Adolescent Health, 2012; 1-5.
Examples of Alumni Awards and Achievements
• Margaret Gourlay (UNC CSP 02-04) won the Top 10 Clinical Research Achievement Award from the Clinical Research Forum for her study on bone density screening for older women.
• Eric Coleman (Washington CSP 95-97, VA Scholar) received a MacArthur “Genius” Award/Foundation fellowship for his leadership in geriatric and chronic disease care.
• Raina Merchant (Penn CSP 07-10), honored for leadership in health care with the first ever RWJF Young Leader’s Award to commemorate the foundation’s 40 year anniversary.
How to Apply
• Physicians who meet the eligibility requirements may may apply online through the website site: http://rwjcsp.unc.edu
• Next application cycle opens November 2013 and closes February 29, 2014 for cohort to start July 1, 2015
