Multiple Mission Thinking

Even though most of us understand that the three missions of education, research, and clinical care are the hallmarks of an academic department of Family Medicine, most of us spend the majority of our time heavily invested in one of the three. Even when we are engaged in multiple missions as part of our role as faculty members, we do so consecutively rather than in an integrative fashion. For example, as we prepare a teaching session for students or residents, how often do we think about the potential clinical practice ramifications of what we are teaching, and how often do we raise the potential research questions that are imbedded in every educational session? How many times, in the course of patient care, do we ask ourselves or our colleagues about what we should be teaching learners about this patient, or the research challenges raised by this type of patient? How many times do we engage in an interesting research question without asking how the answer to that question should change our practices or affect our current educational programs?

Our Department is doing very well by most measures, in each of our missions. But to only think about one mission while ignoring the other two is not the way that we will become enriched by the multiple missions. In past years, it seemed acceptable for us to claim a teacher role, or an investigator role or a clinical role, but such thinking is not the future. None of the missions, by itself, is sufficient. Only when we engage in multiple mission thinking will we become the interesting place that will help shape the future of our discipline.

I want to suggest three examples which involve our Department: identifying problem drinkers, the Family Practice Inquiry Network (FPIN), and immunizations.

• Mike Fleming, MD, MPH and his colleagues have worked for over a decade on understanding how interventions with self-identified problem drinkers in clinical practice will result in a decrease in alcoholism and its consequences in a community. Their work has been recognized by the Society of Teachers of Family Medicine in 1998 with its award for the most important research paper of the year, by the NIH through continued funding for ideas which relate to their findings, and recently by Medicare, which based on data from Mike and his colleagues, has made alcohol counseling to identify problem drinkers in the elderly a reimbursable service. Has the identification of patients who would benefit from this successful intervention in one of the most important health issues in our society become part of our Department's clinical practices? Do we include screening for problem drinking as part of our well-adult care, just as we do blood pressure and smoking status? And has this intervention become a part of our contribution to the education of students and residents - will those who graduate from our programs carry this skill and this perspective into their practices because they have learned it from us?
• Our Department is one of the founding departments for the FPIN program, which seeks to apply critical analysis by thoughtful clinicians to the questions that arise from practice. The goal is to provide evidence-based analyses of a topic in a form that is readily accessible to practicing doctors. While there are certainly EBM (evidence-based medicine) proponents and skilled users in all of our residency sites and many clinical practices, have the questions from FPIN become subjects of research for clinician investigators in our Department? Similarly, how much has FPIN and other EBM clinical analyses become a part of how we practice? Do we continue to use things that don't work, or don't use things that may work for our patients? While our students and residents are getting exposed to FPIN and other EBM concepts, are the faculty being models of application of the science of evidence-in-practice or as sources of research questions to create new and perhaps more compelling data about EBM?
• The QI program in the Department has addressed improvement of our immunization practices. As you might imagine, it is not as straight forward as it might seem. The success rates for targeted immunizations in children who turn 2, runs from 54% to 97% in our residency clinics. Are the factors which lead to successful implementation of prevention - why some practices are successful and others are not - something worth researching? How can we emulate the practice that is most successful, and use this "best practice" in all clinics - residency and community? And finally, are we systematically teaching our residents how to be effective in implementing best practices in their future community or academic practice? Do they leave here with training to make their practices effective?

If we can't answer these questions as affirmatively as we would like, it may be because we are not engaging in multiple mission thinking. As a Department, how should our research affect our practice and education, our practice stimulate our research and education, and our education reflect our research and practice?

To find the "three mission best practices", ones that will positively affect teaching, research and practice, we each have to engage in a type of thinking, as one of our colleagues characterized it, that has a "switch" go on in our minds with each patient and learner encounter, that asks,"Is this something that we could study, could teach, and could practice?" The challenge for our Department is to use our strength and diversity to find the best way and then apply it to our "other" missions. Not to do so is squandering our considerable resources, but mostly, it makes each of our missions less exciting and creative than they could be - and shortchanges our students, our patients, and the people around the country who could learn from what we do.