Mission - RWJF Clinical Scholars

The Robert Wood Johnson Foundation Clinical Scholars

Change Agents In Medicine For More Than 40 Years

Photo: Harold Shapiro1MissionDevelop 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 membersAbout the ProgramFounded in 1969; adopted by RWJF in 1972Oldest RWJF Human Capital programLong-standing collaboration with US Department of Veterans Affairs (VA)RWJF and VA fund stipends and health insuranceRWJF supports research expenses VA provides in-kind faculty, clinical and research resources

Diversity CommitmentThe Program:Embraces racial, ethnic, gender, and disciplinary diversityEncourages candidates with diverse backgrounds Provides all qualified candidates an equal opportunity to compete for a Clinical Scholar positionScholar Training Sites and National Program OfficeTraining Sites:University of California, Los AngelesUniversity of MichiganUniversity of PennsylvaniaYale University

National Program Office

The University of North Carolina, Chapel HillDirectorDesmond 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 developmentProvide technical assistance to training sitesPlan and host the annual Clinical Scholars research meetingDirect nationwide applicant recruitment and program marketingPursue an applicant pool from diverse medical specialty and racial backgroundsOversee the scholar selection processEngage the Clinical Scholars alumni networkMaximize 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 designScholar selectionScholar mentorshipTraining 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 ReportAuthors: Crum R, McKaughan M, & Heroux JProgram 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 JScholar Experience and CurriculumScholar ExperienceUnmatched 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 masters degree study (degrees awarded)Scholar Experience, continuedFunding provided for stipends, tuition, travel and researchProtected time for research (20%) and scholarship (80%) Attend annual national research meeting to present research and foster networkingDevelop 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 ScholarsPrepare Scholars for External Drivers in Health Care System Disparities in access, quality, and outcomesSpiraling health care costsAging of AmericaTranslating research into practiceCore CompetenciesCritically evaluate qualitative, quantitative, clinical, health services, and related researchRecognize different levels (e.g., molecular, familial, community) of health problems and develop strategies for addressing them at more than one levelDesign scientifically sound and important researchDES: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

DES:ApproachIntensive summer orientationCore curriculumSeminars and coursesMentorsWriting groupLeadership training

Photo: Harold ShapiroDES: Introduce Joanne

CurriculumThe 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: TopicsBiostatisticsPopulation and clinical epidemiologyHealth services researchHealth policySocial scienceCommunity-Based Participatory ResearchOther analytical methodsProject design and managementProfessional developmentJOANNE:Seminars and CoursesWeekly seminars: works in progress

Leadership seminar

Didactic coursework

Seminar series

JOANNE:Structured Transition to FacultyCompleting manuscripts from Scholars research projectsWriting grant applicationsDeveloping mentoring skills

Yale CSP FacultyMORRISExamples of Scholar PublicationsGordonSun (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 2012Lisa 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 ScholarsSocial 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 PsychiatristOregon Health and Sciences University, Assistant Professor of Psychiatry

Research Questions Does quality and quantity of social relationships predict development of depression?What is the relative impact of type of ones social relationship on depression risk?

Hypothesis:Study SampleMidlife in the United States (MIDUS)Community-residing adults age 25-75 recruited by random digit dialing

Baseline1995-96Outcome 2004-06

N = 4,642Quality of social relationshipsQuantity of social contact

Past-year major depressive episode

Social Relationship Quality Has Dose-Dependent Effect on Risk of Depression

Poor QualityGood qualityUsing Default Options to Improve Health Care Value by Reducing the Use of Brand Name Medications with Generic EquivalentsMitesh 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, PABackgroundHealth care costs in the United StatesNow account for nearly $3 trillion annuallyEstimated that 1/3 of health care spending is wasteful and unnecessary

Improving health care value by reducing low-value servicesBrand name medications with existing equivalent generics are a prime example of a low-value serviceIn 2009, Medicaid wasted $329 million on brand name medications with existing equivalent genericsIn 2011, UPenn Division of General Internal Medicine found up to 44% of medications were prescribed as brand name

Study DesignObjectiveTo evaluate the impact of an intervention using the electronic medical record (EMR) on the utilization of brand name medications with existing equivalent genericsDesignQuasi-experimental design with difference-in-differences approach using internal medicine (IM) as the intervention group and family medicine (FM) as controlSetting and participantsAmbulatory clinics at the University of Pennsylvania Health SystemAttendings and residents from the IM and FM departments between July 2010 and September 2012

InterventionIn 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 warrantedPrimary outcome measuresProportion 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 - ResidentsResults Multivariate Analyses

SummaryKey FindingsSignificant 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 periodAttendings all medications, beta blockers, and statinsResidents beta blockers onlyFindings were sustained through nine months of follow-up

SignificanceDefault options were an effective methods to reduce the use of a low-value serviceClinical decision support teams could leverage defaults in EMRs to create a sustained change in provider behaviorLessons 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 CancerTimothy J. Daskivich, MD, (UCLA 12-14, VA Scholar)Department of UrologyUniversity 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 treatmentMen who die of other causes before 10 years may incur side effects of treatment (erectile dysfunction, incontinence) without garnering any survival benefitNational guidelines recommend against aggressive treatment for men with less than a 10-year life expectancyDespite this, men are often overtreated due to lack of a widely accepted method for determining life expectancy incorporating both age and health statusBill-Axelson et al, NEJM 2011; Thompson et al, J Urol 2007; Mohler et al, JNCCN 2010; Daskivich et al, Cancer 2011Study 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 yearsCount of 12 Major Comorbidities AgeDAmico Tumor Risk Race Type of TreatmentStudy PopulationOther-Cause Mortality by Comorbidity and AgeProstate Cancer Mortality by Tumor RiskVariablesCompeting Risks AnalysisMethodsPrimary OutcomeCovariatesSecondary OutcomesOther-Cause Mortality by Age and Comorbidity Count

Age 70Age 60-7010-year Other-Cause Mortality for Charlson 3+71%40%26%Daskivich et al. Ann Int Med 2013Prostate Cancer Mortality by DAmico Tumor Risk

To Treat or Not to Treat?Probability of 10-year Other-Cause Mortality40%71%Age and Comorbidity

75 yo

68 yoDM, HTN, COPD26%

56 yoConclusionsA 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 diseaseWhat Drives Frequent Emergency Department Use in an Integrated Health System? National Data From the Veterans Health AdministrationKelly M. Doran, MD, MHS (Yale 11-13)Instructor, Department of Emergency Medicine and Department of Population Health, NYU School of Medicine / Bellevue Hospital CenterThe 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 numberVeterans Health Administration 20105,531,379 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 UseSchizophrenia (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 p145 Chairs, Vice-Chairs, division chiefs193 professors, 139 associate professors, 184 assistant professorsGovernment Federal/International: DHHS, CDC, CMS, House of Representatives, AHRQ, VA, NIH, WHO, Office of the Surgeon GeneralState and Local Health DepartmentsHospital CEOs

MORRISDistribution of 365 Scholars By Major Specialty 2000-2013Check distribution51 and over26 - 5011 - 256 - 101 - 5Scholars 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 MedicineCommunity-based work had a formative effect on my development. Its something Ive always been committed to, and its 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 PublicationsAnita 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, 2013Z 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 McDonalds and Subway. Journal of Adolescent Health, 2012; 1-5.

Examples of Alumni Awards and AchievementsMargaret 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 Leaders Award to commemorate the foundations 40 year anniversary.

How to ApplyPhysicians 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, 2015Contact UsE-mail: rwjcsp_admin@med.unc.eduPhone: 919-843-1351Website: http://rwjcsp.unc.edu