October 1995 Bulletin

Fellowship provides tools for the future

Praises Academy-OREF program

James N. Weinstein, DO, MS, professor of orthopaedics, The University of Iowa College of Medicine, is the most recent recipient of the annual Health Services Research Fellowship, sponsored by the Academy and the Orthopaedic Research and Education Foundation (OREF). The objective of the fellowship is to provide practicing orthopaedic researchers with training in the evaluative clinical sciences so that they may promote and improve musculoskeletal research. Dr. Weinstein began the program at the Evaluative Clinical Sciences Center at Dartmouth College in September 1994 and received his Master's Degree in Clinical Evaluative Sciences in June 1995. Dr. Weinstein's views of his experience at Dartmouth follows.

The educational program is designed to prepare individuals for significant roles in the evolving healthcare system. Participants gain an understanding of the factors that define, determine, and limit the effectiveness and efficacy of healthcare delivery. The curriculum emphasizes outcomes research, clinical decision-making, and health policy research which are the particular strengths of the Center for the Evaluative Clinical Sciences at Dartmouth. Both the core courses and the elective components are designed to impart to the students a solid grounding in the traditions of research in the evaluative sciences, to introduce them to the current research issues and methods of the faculty, and to provide in-depth understanding of research topics. The graduates of the program are prepared to be involved, meaningfully, in original research and applications of research results at levels that have a focus on the effectiveness and efficacy, i.e., they are prepared to carry out "practical research."

The educational program stresses flexibility and individualized guides that enable each student to prepare in subject areas that are appropriate for his or her background and interest. The flexibility is designed to accommodate the needs of mid-career and senior administrators, clinicians, and others who must limit the time away from their home site.

There is a strong emphasis on the interdisciplinary nature of effective research in this field, including the theoretical basis for and practical experiences with ongoing interdisciplinary research. The research projects in which the students participated are designed to meet the needs of the home institution, as well as the academic needs of the students' profession.

New database

I was interested in designing and implementing a database related to various spine diagnoses and treatments. We have seen that current databases designed by nonclinically oriented personnel do not provide the breadth of information our profession needs. We need a database that is designed to look at what we as practitioners and, more importantly, what our patients believe is important in improving the overall quality of care. (Dr. Weinstein's research studies enabled him to help establish an outcome system for the National Spine Network-a database to help assess the effectiveness of spine care at 20 medical centers across the country.)

Associated with the graduate curriculum was a series of short courses for practitioners, policy makers, and administrators. These courses provided introductions and overviews of one or more specific areas, techniques, and/or problems that are covered in the graduate curriculum such as health economics and geographic mapping. These courses represent just part of Dartmouth's emphasis on life-long learning.

The courses also focused on sound methodological principles to extend the students' skills and understanding of the evaluative sciences. The subjects included small area analysis, meta-analysis, epidemiology, biostatistics, functional status measurement, decision analysis, preference research, and policy research.

Each student was expected to become familiar with the methods and theories related to variations and outcomes research, specifically the epidemiology of small-area variations with John Wennberg, MD. Comparative analysis of outcomes for therapeutic alternatives, outcome issues for screening for disease, and the global evaluation of impact of health care on the population also was covered.

Empower patients

Students also became familiar with clinical decision-making, in which patient preferences and shared decision-making were studied, as well as methods of empowering patients with information and thresholds for therapeutic actions.

C. Everett Koop, MD, former U.S. surgeon general, was one of Dr. Weinstein's professors on health policy. In the area of health policy, students discussed physician manpower and other health resource allocation issues, organizational determinants and constraints in health care delivery systems. Environmental determinants and constraints in health care policy were also covered.

I found the program extremely useful and hope to help the Academy and The University of Iowa in many of these areas while serving on the Council for Research and Scientific Affairs, the Committee on Outcome Studies, the Council on Education's Task Force on Value Generation, and Instructional Courses as well as reviewing proposals received by the Academy on cost-effectiveness programs. I will serve as a consultant to The University of Iowa Hospitals and Clinics' Office of Outcomes and Evaluation which has many initiatives underway that will incorporate the practical tools learned while at Dartmouth.

I strongly encourage the orthopaedic community to consider programs like this, and to present these issues to our residents-in-training. I wish to express my deep appreciation for the support of the Academy, OREF, and the North American Spine Society for their sponsorship at Dartmouth.

William K. Payne III, MD, the third recipient of the annual Academy/OREF Health Services Research Fellowship, is currently at the University of Minnesota, focusing on spine research.

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