Article

Concerns and Responses for Integrating Health Systems Science Into Medical Education

Authors:
  • American Board of Medical Specialties
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Abstract

With the aim of improving the health of individuals and populations, medical schools are transforming curricula to ensure physician competence encompasses health systems science (HSS), which includes population health, health policy, high-value care, interprofessional teamwork, leadership, quality improvement, and patient safety. Large-scale, meaningful integration remains limited, however, and a major challenge in HSS curricular transformation efforts relates to the receptivity and engagement of students, educators, clinicians, scientists, and health system leaders. The authors identify several widely perceived challenges to integrating HSS into medical school curricula, respond to each concern, and provide potential strategies to address these concerns, based on their experiences designing and integrating HSS curricula. They identify two broad categories of concerns: the (1) relevance and importance of learning HSS-including the perception that there is inadequate urgency for change; HSS education is too complex and should occur in later years; early students would not be able to contribute, and the roles already exist; and the science is too nascent-and (2) logistics and practicality of teaching HSS-including limited curricular time, scarcity of faculty educators with expertise, lack of support from accreditation agencies and licensing boards, and unpreparedness of evolving health care systems to partner with schools with HSS curricula. The authors recommend the initiation and continuation of discussions between educators, clinicians, basic science faculty, health system leaders, and accrediting and regulatory bodies about the goals and priorities of medical education, as well as about the need to collaborate on new methods of education to reach these goals.

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... Entrepreneurship or self-employment is a viable option for them. In addition to creating wealth for oneself and one's family, entrepreneurship provides an avenue for doctors to contribute to the field of medical innovations directed at patient-centred care (7). To take up entrepreneurship, medical students need to supplement their clinical knowledge business skills (8). ...
... The JSE, developed by Hojat, is a widely employed tool for assessing empathy levels among medical students. Its validity and reliability have been confirmed in a study conducted by Hojat et al. (7). Rahimi and Hashempour adapted the JSE for the Iranian population (17,18). ...
... The Iranian version of the scale demonstrated a Cronbach's alpha of 0.87 for the entire instrument. It comprises 20 items divided into three subscales: "Perspective Taking" (consisting of 10 items with a score range of 10-70), "Compassionate Care" (comprising eight items with a score range of , and "Walking in the Patient's Shoes" (comprising two items with a score range of [2][3][4][5][6][7][8][9][10][11][12][13][14]. This questionnaire includes ten negatively worded items that are reverse-scored. ...
Article
Entrepreneurship is a viable option for young doctors looking for careers beyond patient care. Nascent entrepreneurial behaviour is said to predict future entrepreneurship. To understand whether medical students possess an entrepreneurial spirit, this research aimed to assess nascent entrepreneurial behaviour among students at a private medical school in Malaysia and the sociodemographic factors influencing it. A quantitative approach with a cross-sectional survey design was employed. The data were collected from 318 medical students selected by a disproportionate stratified random sampling technique. The respondents rated their nascent entrepreneurial behaviour on a 13-item selfadministered questionnaire. The responses obtained were analysed using descriptive and inferential statistical tests. Medical students in Malaysia showed moderately low levels of nascent entrepreneurial behaviour. Among the sociodemographic factors, gender and marital status significantly influenced nascent entrepreneurial behaviour among the medical students. The year of study, ethnicity and family income were insignificant. The low level of nascent entrepreneurial behaviour among medical students in Malaysia implies that they are likelier to be job seekers than job creators. Therefore, higher education institutions across the globe need to foster entrepreneurial values in all students, irrespective of their chosen field of study. An understanding of the sociodemographic factors that influence nascent entrepreneurial behaviour will help policymakers plan remedial steps to inculcate an entrepreneurial mindset among medical students.
... [4][5][6][7] Physician leaders and medical educators are promoting health systems science (HSS) integration into education and clinical practice as a catalyst to improve population health. [8][9][10][11] submit your manuscript | www.dovepress.com ...
... 10 The provision of optimal care in complex systems requires an understanding of HSS, the applied science of how care is accessed, delivered, financed, managed, and assessed. 11 HSS conceptualizes how to work in collaborative teams for improved quality, value, and safety in the delivery of patient-and population-centric health services. [8][9][10] HSS aligns with the Quadruple Aim framework for improvement of population health, patient care experiences, work life of providers, and reduction of costs. ...
... The Consortium is promoting the field of HSS as the third pillar of medical education, along with the traditional pillars of biomedical and clinical sciences. [8][9][10][11] Yet, HSS integration into medical education and practice is not without challenges. 11 The difficulty of aligning HSS education with real-world scenarios related to complex delivery systems has been identified. ...
... 6 However, previous studies found that the primary challenges to implement leadership courses include time constraints, overloaded curriculum, limited financing, and the hierarchical structure of the medical field. [7][8][9] Moreover, the absence of agreement and wide range of differences in how leadership is incorporated into medical education. 9 Stakeholders in the United Kingdom have voiced their opinions regarding leadership training at undergraduate medical level. ...
... [7][8][9] Moreover, the absence of agreement and wide range of differences in how leadership is incorporated into medical education. 9 Stakeholders in the United Kingdom have voiced their opinions regarding leadership training at undergraduate medical level. Two thousand member strong body said that the new medical students should be actively trained in leadership skills by their medical school. ...
Article
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Introduction Leaders in healthcare no longer need to hold formal management positions; instead, leadership is perceived to be the responsibility of all healthcare professionals. Despite changes in curricula and teaching design, however, this review of the content taught in medical colleges in Saudi Arabia reveals a lack of leadership and a failure to equip young graduates to compete on the global stage. Medical students need leadership skills for patient care, cooperation, and navigating the complex healthcare system. Clinical management skills in hospitals require these talents also. The complexity of healthcare and the impact healthcare executives have on people’s lives highlight the importance of these skills. Thus, healthcare practitioners must develop non-technical skills like proactivity, motivation, and change management to lead across professional boundaries and negotiate the increasingly complex healthcare landscape. Methods This cross-sectional study combines a quantitative approach with a self-administered questionnaire-based survey. The sampling procedure is a non-probability convenience technique, adapted for 700 male and female undergraduate medical students from four medical colleges. Results Of the students, 75.46% had minimal leadership experience and 22.69% had some leadership experience; 3.02% of 464 students considered themselves highly experienced in leadership. Conclusion As the needs assessment and other relevant factors show, leadership should be introduced as a skilled subject. There will always be a growing demand for competent medical graduates, who are capable of becoming future leaders. Although elementary leadership concepts remain fundamentally the same, curricular development must focus on the needs of society and stakeholders.
... 21 As accountability for clinical care has become married between clinical and corporate entities, it becomes more imperative that clinicians understand the modes of corporate governance and administration becomes more in tune with clinical objectives. 22 The idea that scientific discovery and clinical medicine mastery are enough to impact the health of patients is a limited perspective. The requirements for a healthcare professional to truly impact the health of their patients and the healthcare delivery system lies in their ability to understand the often-complex intersections of system and clinical sciences. ...
... 23 One of the most effective methods used at the Penn State College of Medicine were industry expert lectures from physician leaders and the operations staff in particular. 22 This was, in part, due to the familiarity of seeing physicians being part of the process and showing their own QI projects that they were proud of and had been incredibly successful. When this was paired with operations personnel and their roles in the physician-led projects, it created a connection for students and residents to show the impact that can be made on patient care and their practice environment. ...
Article
Background The complexity of US healthcare has been increasing for many years, requiring clinicians and learners to understand care delivery systems in addition to clinical sciences. Thus, there has been a major push to educate faculty and trainees on healthcare functionality. This comes as hospitals expand into health systems requiring the help of more sophisticated expertise of departments such as operations excellence when problem-solving. As a medical student with a background in operations excellence, medical education leader and clinical administration leader all currently facilitating this transition, we wanted to reflect on the barriers we have experienced in clinical implementation of quality improvement projects and educating learners on the impact of operations excellence principles in their clinical education. Methods The ideas presented in this article were the result of a several collaborative discussion between the authors, on the key challenges to adopting operations excellence principles into health system science education. In an effort to add context to this reflection through the current body of research present, they supplemented a literature review on the topic which included 86 studies published between 2013 and 2021 regarding health systems science and healthcare leadership engagement in the USA. The themes that intersected between the literature review and the discussions were then expanded on in this paper. Results Through this process, we identified four challenges: (1) the difference in thinking styles, which we term, ‘mental model differences’; (2) the strategic nature of process improvement projects and how that collides with physician priorities, or ‘the chess game of stakeholder engagement’; (3) the language and precise methodology, or ‘consistency of language and need for administrative resilience’ and (4) the issue of teaching these concepts or bridging the learning gap.’ Conclusion In an increasingly complex healthcare landscape, physicians and trainee’s need to bridge gaps between the mental models of administrative and clinical workflow.
... Social determinants of health (SDOH), one of the domains within health system science, broadly encompasses factors such as employment, housing, transportation, safety, education, food access and quality, racism and discrimination, and access to and quality of healthcare. 9 Several medical and physician assistant (PA) professional organizations and accrediting bodies have called for education in SDOH, [10][11][12][13][14] and previous work by members of our team has used Delphi methodology to build expert consensus regarding the inclusion of SDOH content in undergraduate medical school curricula, including topics, educational strategies, and timing. 15 However, our extensive review identified a lack of literature describing learner assessment and program evaluation criteria for undergraduate medical education for both medical and PA students (hereafter referred to as "students"). ...
... The Delphi method is an accepted approach to develop expert consensus when there is no or little established evidence and allows for a controlled debate amongst experts. 13 The consensus findings described here are important because of the limited literature describing learner assessment and program evaluation methods for SDOH. There is a strong research base supporting the importance of assessment in shaping both learning and future outcomes. ...
Article
Phenomenon: Assessment and evaluation guidelines inform programmatic changes necessary for educational effectiveness. Presently, no widely accepted guidelines exist for educators to assess learners and evaluate programs regarding social determinants of health (SDOH) during physician and physician assistant (PA) education. We sought to garner expert consensus about effective SDOH learner assessment and program evaluation, so as to make recommendations for best practices related to SDOH education. Approach: We used a Delphi approach to conduct our study (September 2019 to December 2020). To administer our Delphi survey, we followed a three-step process: 1) literature review, 2) focus groups and semi-structured interviews, 3) question development and refinement. The final survey contained 72 items that addressed SDOH content areas, assessment methods, assessors, assessment integration, and program evaluation. Survey participants included 14 SDOH experts at US medical schools and PA programs. The survey was circulated for three rounds seeking consensus, and when respondents reached consensus on a particular question, that question was removed from subsequent rounds. Findings: The geographically diverse sample of experts reached consensus on many aspects of SDOH assessment and evaluation. The experts selected three important areas to assess learners' knowledge, skills, and attitudes about SDOH. They identified assessment methods that were "essential", "useful, but not essential", and "not necessary." The essential assessment methods are performance rating scales for knowledge and attitudes and skill-based assessments. They favored faculty and patients as assessors, as well as learner self-assessment, over assessments conducted by other health professionals. Questions about separation versus incorporation of SDOH assessment with other educational assessment did not yield consensus opinion. The experts reached consensus on priority outcome measures to evaluate a school's SDOH program which included student attitudes toward SDOH, Competence-Based Assessment Scales, and the percentage of graduates involved in health equity initiatives. Insights: Based on the Delphi survey results, we make five recommendations that medical and PA educators can apply now when designing learner assessments and evaluating SDOH programming. These recommendations include what should be assessed, using what methods, who should do the assessments, and how they should be incorporated into the curriculum. This expert consensus should guide future development of an assessment and evaluation toolkit to optimize SDOH education and clinical practice. Supplemental data for this article is available online at https://doi.org/10.1080/10401334.2022.2045490 .
... Medical humanities courses should advocate a student-centered educational philosophy, optimize and conduct subject-specific clinical practice teaching, and enhance students' clinical practice and job competence (Petrou et al., 2021). Outcome-based education (OBE) refers to results-oriented education that uses an opposite approach and provides a targeted and detailed teaching design (Gonzalo et al., 2018). First, schools can invite hospitals and enterprise managers to give special lectures on topics, such as medical humanistic education practices. ...
Article
Full-text available
Medical humanities are the soul of health education. Humanistic education proposes to improve the conscious and practical activities of educated people and promote their humanity, realize personal and social values, cultivate ideal personalities, and develop a trans-cultural humanistic spirit. The development of higher education has considerably strengthened the integration of scientific and humanistic education in China. This study analyzed the up-to-date teaching situation of medical humanities courses in medical schools considering the following aspects: teachers’ team construction, teaching mode, practical teaching, assessment and evaluation systems, and inadequate platforms. Relevant reforms based on life education were proposed, including improving the integrity of the teaching team, building suitable curriculum system and teaching theory, setting proper evaluation standard for both students and teachers, and providing adequate platforms for practice of humanistic medicine. This study aimed to promote the students’ medical humanities literacy, thus providing potential strategy and reference for improving medical humanistic education.
... However, despite interest and availability of existing local L&M training programs covering such topics, only a few physicians take advantage of these learning opportunities in Switzerland [29]. Reasons for non-attendance may include a lack of time, competing priorities, crowded pre-and post-graduate curricula, and a lack of institutional support [42,[46][47][48][49]. Residents spend their time acquiring clinical skills and their exposure to leadership skills generally relies upon role models that have not been themselves trained in such skills and learn and apply through trial and error [43]. ...
Article
Full-text available
Introduction Effective leadership and management (L&M) are essential to the success of health care organizations. Young medical leaders often find themselves ill-prepared to take on these new responsibilities, but rarely attend training in L&M skills. The aims of this study were to evaluate physician’s self-perceived competencies and training needs for L&M, to identify available regional L&M training, and to highlight opportunities, challenges and threats regarding physicians’ training in medical L&M in the French-speaking part of Switzerland. Methods We conducted a mixed methods study in three steps: (1) a survey on perceived L&M competencies and training needs (5 dimensions) to all physicians of a Swiss University Hospital (N = 2247); (2) a mapping of the Swiss French speaking L&M training programs through analysis of hospital websites and interviews; and (3) semistructured interviews with L&M program coordinators about the programs’ strengths and weaknesses as well as the opportunities and challenges to include physicians in such training. We used analysis of variance to compare differences in perceived competences between physicians of different hierarchical status and used Cramer’s V to measure the association’s degree between physicians’ training needs and prior training in L&M and hierarchical status. We analysed semi-structured interviews using thematic analysis. Results Five-hundred thirty-two physicians responded (24%). Physicians perceived themselves as rather competent in most leadership dimensions. More experienced physicians reported a higher sense of competence in all dimensions of leadership (e.g. Working with others: F = 15.55, p < .001; Managing services: F = 46.89, p < .001). Three competencies did not vary according to the hierarchical status: emotional intelligence (F = 1.56, p = .20), time management (F = 0.47, p = .70) and communicating (F = 1.97, p = .12). There was a weak to moderate association between the responders’ self-perceived needs for training and their hierarchal status for all competencies (Cramer’s V ∈ [0.16;0.35]). Physicians expressed a strong desire to seek out training for all competencies, especially for knowing one’s leadership style (82%), managing teams (83%), and managing conflict (85%). Although existing local L&M training programs covered most relevant topics, only a forth of responders had attended any type of training. L&M program coordinators identified several facilitators and barriers to physician attendance on institutional (matching reality and training), relational (managing collective intelligence), and individual levels (beliefs and self-perceived identity). Conclusions French-speaking Swiss hospital physicians clearly express training needs for L&M skills although they only rarely attend such training programs. Reasons for non-attendance to such programs should be explored in order to understand physicians’ low participation rates in these trainings.
... Figure 3 illustrates that although there is relative stagnation in the number of publications using experimental design and in vitro studies, there is consistent uptrend in the number of published studies using evidence synthesis methodologies (i.e., bibliometric studies and other reviews) and qualitative and/or mixed methodologies. This is consistent with the post-Flexnerian wave that highlights the shift of medical education, training, and research from following a purely biomedical perspective to pursuing a holistic and integrative bio-psycho-social perspective in medicine (Gonzalo et al. 2018). Furthermore, as illustrated in Figure 4, there is a steady rise in the number of publications entailing collaborative work from multiple departments in the college emphasizing the shift from working in academic silos to pursuing collaborative research projects. ...
Article
Full-text available
The organ-system integrated (OSI) curriculum was pioneered in the country by the U.P. College of Medicine (UPCM) in 2004. Data on its impact on research productivity was lacking. This study aims to describe the trends in research productivity of UPCM in a time series and the impact of OSI implementation on publication trends. Relevant electronic databases (PubMed, Scopus, and WPRIM) were searched from the earliest indexed record until December 2023. The auto-regressive integrated moving average (ARIMA) time series analysis was used to compare the actual and predicted trends during the OSI implementation using the pre-OSI trend. A total of 2,705 articles were included. Acta Medica Philippina is the journal with the highest number of publications (n = 420, 20.24%). Although there is a considerable rise in the number of publications utilizing evidence synthesis and qualitative design, observational studies remain as the most common design (n = 293, 2021-2023 period). The leading clinical departments are Neurosciences and Medicine. The departments of Biochemistry and Clinical Epidemiology take the lead among basic sciences departments. Despite the glaring uptrend in publications concurrent with OSI implementation, the actual trend is not significantly different from the predicted trend (LR chi2(1) = 0.37; Prob > chi2 = 0.5432). The OSI curriculum did not significantly change the trend of productivity. Medical curriculum designers should revisit strategies dedicated for research competencies. It is imperative to include activities for qualitative and mixed-methods designs. Future studies should consider relevant critical events in the time series forecasting models and the scientific outputs in the grey literature.
... To our knowledge, no previous papers have reported the used of peer or near-peer coaching as a method used for health systems science (HSS) curricula implementation during surgical clerkship, a science which refers to the critical competencies necessary for high-quality healthcare delivery. Real-time implementation of an effective HSS curriculum during clerkship rotations remains a challenge and many undergraduate medical education (UME) programs have struggled to identify ways to incorporate HSS in a way that resonates with students [10][11][12]. This is in part, due to the natural preference of students to place higher prioritization on licensing examination preparation topics/content and faculty's limited time allocation to mentoring students in these topics [11]. ...
Article
Full-text available
Purpose We implemented a near-peer (resident–student) coaching intervention in 2021–2022 to improve clerkship students’ health system science (HSS) learning and application. This study thus sought to identify implementation barriers and potential facilitators of an effective HSS near-peer coaching program for clerkship students from the resident coach’s perspective at a single tertiary-care institution. Methods A mixed-methods study design was employed. Thirty surgical residents volunteered to serve as HSS coaches for rotating third-year medical students during the 2021–2022 academic year. Coaches were asked to complete an exit survey, and a subset was purposefully sampled to complete semi-structured interviews. Transcripts were coded and analyzed with a framework method to identify emergent themes indicative of the barriers and facilitators of effective implementation of this near-peer HSS coaching program. Results A total of 20/30 (67%) resident coaches completed the survey and 50% of these residents ( n = 10/20) completed an interview. Coaches facilitated multiple meetings (ranging from 1 to more than 5 times) with their assigned students over the course of the 3-month surgical rotations. Most coaches who deemed themselves successful in coaching reported early prioritization of setting individualized clerkship goals. Rapport building and strong communication were also important factors identified in facilitating effective near-peer cognitive coaching relationships. Conclusions Our study suggests that, from residents’ perspective, effective near-peer coaching by residents on surgical clerkships requires special emphasis on early goal setting, as well as training and development of coaches in skills, such as feedback delivery, and rapport building to encourage strong resident–student coaching relationships that cater to the individualized needs of the learner.
... Par exemple, dans les réformes liées aux études de santé, les personnes-ressources sont souvent peu nombreuses, car la plupart des enseignants et des formateurs n'ont pas été formés à la pédagogie et aux stratégies de conduite du changement (Fernandez, 2017 ;Pelaccia, 2019). De surcroît, le changement implique fréquemment de nombreux acteurs et la politique institutionnelle associée à la dynamique du changement peut être insuffisante (Bland et al., 2000;Gonzalo, Caverzagie, et al., 2018). Les ressources disponibles ou allouées au changement (sur le plan du financement et des équipements) sont quant à elles fréquemment sous-estimées. ...
Chapter
Paroles d’enseignants... • La réforme nous oblige à transformer notre formation pour l’inscrire dans une approche par compétences. J’aimerais savoir quelle est la meilleure de façon de s’y prendre. • Je me demande parfois si quand on réforme, il faut tout changer, ou si l’on peut se contenter de modifier des aspects ciblés de la formation. • J’aimerais faire bouger les pratiques pédagogiques dans mon établissement, mais je ne sais pas comment faire pour initier un changement auprès de mes collègues. Les questions auxquelles nous répondrons : 21.1 Quelles sont les modalités d’un changement curriculaire ? 21.2 Quelles sont les stratégies de conduite d’un changement curriculaire ? 21.3 Comment conduire un changement curriculaire vers l’approche par compétences ?
... 2 Over time, and despite efforts to redefine and co-construct SBP competencies, there have also been well-documented stumbling blocks. 3,10,14 Checkbox mentalities, focused on satisfying regulatory requirements, have resulted in SBP courses that are disconnected from the practical reality of medical learners, who often struggle with a lack of SBP role models among faculty members. 15 A recent review suggests that, while some promising advances in SBP knowledge and application have been demonstrated, 2 there were also perceptions that SBP teaching has eroded the amount of curricular time available for more medically focused competencies. ...
Article
Systems-based practice (SBP) was first introduced as a core competency in graduate medical education (GME) in 2002 by the Accreditation Council for Graduate Medical Education as part of the Outcomes Project. While inclusion of SBP content in GME has become increasingly common, there have also been well-documented stumbling blocks, including perceptions that SBP has eroded the amount of curricular time available for more medically focused competencies, is not relevant for some practice contexts, and is not introduced early enough in training. As a result, SBP learning experiences often feel disconnected from medical trainees’ practical reality. In this commentary, the authors provide guidance regarding potential changes that may facilitate the evolution of SBP toward an ideal future state where graduates bring a systems science mindset to all aspects of their work. Specific suggestions include the following: (1) expanding the SBP toolbox to reflect current-day health system needs, (2) evolve the teaching methodology, (3) broadening the scope of relevant SBP content areas, and (4) emphasizing SBP as an integrated responsibility for all health care team members. Levers to enact this transformation exist and must be used to influence change at the learner, faculty, program, and clinical learning environment levels. Physicians operate within an increasingly complex health care system that highlights the intersection of health care with complex social, environmental, and relational contexts. Consequently, the role of SBP in both physician work responsibilities and educational requirements continues to expand. To meet this growing demand, GME must adapt how it supports and trains the next generation of systems thinkers, ensuring they understand how levers in the health care system directly affect health outcomes for their patients, and integrate SBP into the foundation of GME curricula in an inclusive, holistic, and unrestrained way.
... The frequency of including SBL for curriculum transformation in under-and postgraduate medical education is increasing. SBL allows for the iteration of training in controlled environments that represent clinical scenarios and facilitates feedback during practice [17][18][19] . For example, Yale ...
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BACKGROUND The social isolation and distancing measures which followed the COVID-19 pandemic promoted clinical telesimulation and virtual simulation as a didactic strategy for training medical students. These strategies have not yet been fully evaluated in terms of impact and acceptability. OBJECTIVE This study evaluates virtual simulation and telesimulation strategies applied during the pandemic from the perspective of students, professors, and experts in clinical simulation. METHODS A qualitative method was applied to 56 medical students studying semiology and 12 professors. The students and professors conducted clinical simulations during in-person classes assisted by information and communication technology (ICT). Follow-up was conducted for 18 months. The intervention focused on tele-simulation and in-person ICT-assisted classes. The measurements focused on students’ perceptions of the practice and of professors relating to developing skills and competence. RESULTS During remote debriefing, students gave simulations an average rating of 6.43/7. Measuring the competence development (generic and specific) showed a rate of 82.2% at different times during the simulation, corresponding to the 80% level of development given by professors’ evaluations in real scenarios. CONCLUSIONS Using a simulation-based didactic strategy in the form of ICT-assisted in-person classes prior to the practical training stage required for medical students was pertinent, efficient, and found to be favourable during the pandemic.
... However, despite interest and availability of existing local L&M training programs covering such topics, only a few physicians take advantage of these learning opportunities in Switzerland [29]. Reasons for non-attendance may include a lack of time, competing priorities, crowded pre-and post-graduate curricula, and a lack of institutional support [42,[46][47][48][49]. Residents spend their time acquiring clinical skills and their exposure to leadership skills generally relies upon role models that have not been themselves trained in such skills and learn and apply through trial and error [43]. ...
Article
Full-text available
Introduction Effective leadership and management (L&M) are essential to the success of health care organizations. Young medical leaders often find themselves ill-prepared to take on these new responsibilities, but rarely attend training in L&M skills. The aims of this study were to evaluate physician’s self-perceived competencies and training needs for L&M, to identify available regional L&M training, and to highlight opportunities, challenges and threats regarding physicians’ training in medical L&M in the French-speaking part of Switzerland. Methods We conducted a mixed methods study in three steps: (1) a survey on perceived L&M competencies and training needs (5 dimensions) to all physicians of a Swiss University Hospital (N = 2247); (2) a mapping of the Swiss French speaking L&M training programs through analysis of hospital websites and interviews; and (3) semi-structured interviews with L&M program coordinators about the programs’ strengths and weaknesses as well as the opportunities and challenges to include physicians in such training. We used analysis of variance to compare differences in perceived competences between physicians of different hierarchical status and used Cramer’s V to measure the association’s degree between physicians’ training needs and prior training in L&M and hierarchical status. We analysed semi-structured interviews using thematic analysis. Results Five-hundred thirty-two physicians responded (24%). Physicians perceived themselves as rather competent in most leadership dimensions. More experienced physicians reported a higher sense of competence in all dimensions of leadership (e.g. Working with others: F = 15.55, p < .001; Managing services: F = 46.89, p < .001). Three competencies did not vary according to the hierarchical status: emotional intelligence ( F = 1.56, p = .20), time management ( F = 0.47, p = .70) and communicating ( F = 1.97, p = .12). There was a weak to moderate association between the responders’ self-perceived needs for training and their hierarchal status for all competencies (Cramer’s V ∈ [0.16;0.35]). Physicians expressed a strong desire to seek out training for all competencies, especially for knowing one’s leadership style (82%), managing teams (83%), and managing conflict (85%). Although existing local L&M training programs covered most relevant topics, only a forth of responders had attended any type of training. L&M program coordinators identified several facilitators and barriers to physician attendance on institutional (matching reality and training), relational (managing collective intelligence), and individual levels (beliefs and self-perceived identity). Conclusions French-speaking Swiss hospital physicians clearly express training needs for L&M skills although they only rarely attend such training programs. Reasons for non-attendance to such programs should be explored in order to understand physicians’ low participation rates in these trainings.
... Implementing HSS course in the medical curriculum is believed to greatly enhance future doctors' attitude and practice. Implementation of the HSS curriculum will be effective once it gets approval by higher education council.We are expecting some of the challenges that were addressed in the literature (Mills LM, 2017, Gonzalo JD, 2018. Some of these short-term ones are faculty development, availability of HSS trained faculty, student perceptivity and enthusiasm especially in the pre-clinical phase, getting feedback for the process and evolving accordingly, and may be other unforeseen challenges. ...
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Background As health systems evolve, medical education needs to adapt education programs that align with healthcare needs. Studies have shown that integrating Health System Sciences (HSS) in the medical curriculum will empower future physicians with additional skills to provide system-based care within a health system. Here, we describe the process and content of the integration of HSS within medical at one Saudi medical school. Methods This experience was conducted at the College of Medicine at Princess Nourah bint Abdulrahman University (PNU), Riyadh/Saudi Arabia. A group of medical educators in the areas of basic, clinical, and medical education made a proposal to integrate HSS within the curriculum. The process started with reviewing literature, similar national and international universities’ experiences, and educational competencies pertaining to HSS developed by Saudi Medical Education Directives Framework. Also reviewing some of the domains, content and skills that already exist in our MBBS curriculum related to HSS for a possible restructuring. The task force with the help of the Program Committee identified potential courses that can be developed or modified to cover the following six core domains of HSS: 1. Population and public health, 2. Health care policy, economics, and management 3. Clinical informatics and health information technology, 4. Value-based care, 5. Health system improvement, and 6. Health care delivery structures and processes. Results The task force recommended rolling out the HSS curriculum longitudinally, in two phases (pre-clinical and clinical). As a result, a new curriculum map was created in which new courses were added and the domains related to HSS already present were enhanced through some restructuring and upgrading. In addition, several teaching/learning activities and assessment methods have been defined. Conclusion We describe systematic process for integrating HSS content at one Saudi medical school, to meet the evolving needs of the health care system. We understand that implementation of these changes is limited by some challenges. However, our experience can be of a significant value for other national medical colleges.
... IPL is a method for preparing students for systems thinking [34] and introducing complexity concepts into graduate and professional education is necessary to drive system changes that address current fragmentation [46,61,83]. Across a number of papers, Gonzalo and colleagues argue for the integration of health systems science, alongside basic and clinical sciences in pre-registration medical education [60,62,120], with acknowledgement that there are challenges [63]. ...
Article
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Background Medical education is a multifarious endeavour integrating a range of pedagogies and philosophies. Complexity as a science or theory (‘complexity’) signals a move away from a reductionist paradigm to one which appreciates that interactions in multi-component systems, such as healthcare systems, can result in adaptive and emergent outcomes. This examination of the nexus between medical education and complexity theory aims to discover ways that complexity theory can inform medical education and medical education research. Methods A structured literature review was conducted to examine the nexus between medical education and complexity; 5 databases were searched using relevant terms. Papers were included if they engaged fully with complexity as a science or theory and were significantly focused on medical education. All types of papers were included, including conceptual papers (e.g. opinion and theoretical discussions), case studies, program evaluations and empirical research. A narrative and thematic synthesis was undertaken to create a deep understanding of the use of complexity in medical education. Results Eighty-three papers were included; the majority were conceptual papers. The context and theoretical underpinnings of complexity as a relevant theory for medical education were identified. Bibliographic and temporal observations were noted regarding the entry of complexity into medical education. Complexity was relied upon as a theoretical framework for empirical studies covering a variety of elements within medical education including: knowledge and learning theories; curricular, program and faculty development; program evaluation and medical education research; assessment and admissions; professionalism and leadership; and learning for systems, about systems and in systems. Discussion There is a call for greater use of theory by medical educators. Complexity within medical education is established, although not widespread. Individualistic cultures of medicine and comfort with reductionist epistemologies challenges its introduction. However, complexity was found to be a useful theory across a range of areas by a limited number of authors and is increasingly used by medical educators and medical education researchers. This review has further conceptualized how complexity is being used to support medical education and medical education research. Conclusion This literature review can assist in understanding how complexity can be useful in medical educationalists' practice.
... IPL is a method for preparing students for systems thinking [34] and introducing complexity concepts into graduate and professional education is necessary to drive system changes that address current fragmentation [46,61,83]. Across a number of papers, Gonzalo and colleagues argue for the integration of health systems science, alongside basic and clinical sciences in pre-registration medical education [60,62,120], with acknowledgement that there are challenges [63]. ...
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Background: Medical education is a multifarious endeavour integrating a range of pedagogies and philosophies. Complexity as a science or theory (‘complexity’) signals a move away from a reductionist paradigm to one which appreciates that interactions in multi-component systems, such as healthcare systems, can result in adaptive and emergent outcomes. This examination of the nexus between medical education and complexity theory aims to discover ways that complexity theory can inform medical education and medical education research. Methods: A structured literature review was conducted to examine the nexus between medical education and complexity; 5 databases were searched using relevant terms. Papers were included if they engaged fully with complexity as a science or theory and were significantly focused on medical education. All types of papers were included, including conceptual papers (e.g. opinion and theoretical discussions), case studies, program evaluations and empirical research. A narrative and thematic synthesis was undertaken to create a deep understanding of the use of complexity in medical education. Results: Eighty-three papers were included; the majority were conceptual papers. The context and theoretical underpinnings of complexity as a relevant theory for medical education were identified. Bibliographic and temporal observations were noted regarding the entry of complexity into medical education. Complexity was relied upon as a theoretical framework for empirical studies covering a variety of elements within medical education including: knowledge and learning theories; curricular, program and faculty development; program evaluation and medical education research; assessment and admissions; professionalism and leadership; and learning for systems, about systems and in systems. Discussion: There is a call for greater use of theory by medical educators. Complexity within medical education is established, although not widespread. Individualistic cultures of medicine and comfort with reductionist epistemologies challenges its introduction. However, complexity was found to be a useful theory across a range of areas by a limited number of authors and is increasingly used by medical educators and medical education researchers. This review has further conceptualized how complexity is being used to support medical education and medical education research. Conclusion: This literature review can assist in understanding how complexity can be useful in their own practice.
... It also developed medical knowledge, skills, and self-perception of the learned materials and skills. While HSS is considered as a third curriculum [79], concerns have been raised about the feasibility of adding class time for HSS to the regular curriculum due to its hectic nature [88]. We present studies where students can develop their HSS competency in EAs. ...
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Background The importance of extracurricular activities (EAs) has been emphasized in medical education. These activities could enhance medical students’ emotional and physical health and afford them developmental opportunities. Despite the growing amount of research related to this theme, few studies review and synthesize the existing literature. This study aims to provide an understanding of the educational implications of EAs in medical colleges and constructs an integrated conceptual framework concerning their types and learning outcomes by literature review. Methods An integrative literature review was conducted following Torraco’s method, with the aim to generate a new framework for the given topic. The authors utilized Scopus and PubMed as databases, using search terms “extracurricular,” “medical,” and “students.” Initially, titles and abstracts were screened to include relevant studies, and the researchers verified the eligibility of the articles by following the inclusion and exclusion criteria. Of the 263 articles identified, 64 empirical studies were selected for further review. Results EAs in undergraduate medical education can be classified into direct extracurricular activities and indirect extracurricular activities, the latter of which is sorted into nine sub-categories. We identified seven main categories regarding the learning outcomes of EAs. In addition to general activities (e.g., pro-social activities, team sports), some distinctive activities such as research have been largely addressed in previous studies. The results of EAs were discussed in relation to academic growth, career development, and psychological experiences. Conclusions This review identified the types and learning outcomes of EAs in the context of medical education, thereby suggesting ways to improve the quality of EAs and maximize their educational effects.
... Following the example of reports on other innovative fellowship programs, 7,9,[11][12][13][14][15] this paper is designed to assist leaders in academic medicine and in health care systems who have recently developed, or are considering initiating, efforts to train physicians and researchers in the emerging field of delivery science. Efforts to increase postdoctoral research training in implementation methods, 10,16 health system science, 17 and delivery science are increasing, including programs facilitated by AcademyHealth and others supported by K12 grants from the Agency for Health Care Research and Quality. However, most delivery science fellowship programs have only been initiated within the past decade, and little systematic knowledge exists about how to optimize the success of delivery science training. ...
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Introduction Learning health systems require a workforce of researchers trained in the methods of identifying and overcoming barriers to effective, evidence‐based care. Most existing postdoctoral training programs, such as NIH‐funded postdoctoral T32 awards, support basic and epidemiological science with very limited focus on rigorous delivery science methods for improving care. In this report, we present the 10‐year experience of developing and implementing a Delivery Science postdoctoral fellowship embedded within an integrated health care delivery system. Methods In 2012, the Kaiser Permanente Northern California Division of Research designed and implemented a 2‐year postdoctoral Delivery Science Fellowship research training program to foster research expertise in identifying and addressing barriers to evidence‐based care within health care delivery systems. Results Since 2014, 20 fellows have completed the program. Ten fellows had PhD‐level scientific training, and 10 fellows had clinical doctorates (eg, MD, RN/PhD, PharmD). Fellowship alumni have graduated to faculty research positions at academic institutions (9), and research or clinical organizations (4). Seven alumni now hold positions in Kaiser Permanente's clinical operations or medical group (7). Conclusions This delivery science fellowship program has succeeded in training graduates to address delivery science problems from both research and operational perspectives. In the next 10 years, additional goals of the program will be to expand its reach (eg, by developing joint research training models in collaboration with clinical fellowships) and strengthen mechanisms to support transition from fellowship to the workforce, especially for researchers from underrepresented groups.
... Therefore, healthcare providers must understand VBC and its application in various situations. 13,14 The adoption of VBC has the potential to transform healthcare delivery, but its uptake among healthcare professionals has been varied. Therefore, understanding the factors that in uence the adoption of VBC is crucial for promoting its wider implementation. ...
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Background: Value-based care (VBC) entails improving the quality and value of healthcare for patients by focusing on costs, quality of healthcare services, and quality of life, holistically. The theory of planned behaviour (TPB) is a psychological model outlining individuals’ intentions and behaviours towards VBC to understand how individuals engage in a specific behaviour. Thus, we developed a questionnaire based on VBC and TPB to collect data from sixth-year medical students and postgraduate trainees to identify and compare factors affecting the intention and application of the VBC principle in patient care between these two groups. Methods: Cross-sectional study (December 2022January 2023) data were collected and analysed using descriptive statistics for personal factors; Spearman rank correlation statistics explored the relationship based on TPB between the score of attitudes towards behaviour, subjective norms, perception of behavioural control, intention to perform behaviour, and application of principles; and a multiple regression analysis was conducted to examine the predictive factors among variables. Results: This study involved 90 participants, 51 (56.67%) postgraduate trainees and 39 (43.33%) undergraduate students. Spearman rank correlation found relationships between each part of TPB, showing a significant difference in behaviour scores between the two groups. In the multiple regression analysis, attitude and perception scores were positive predictors of intention scores, while postgraduate status, perception scores, and perception of family socio-economic status were significant, positive predictors of behaviour scores. A subgroup analysis revealed that perception scores were positive predictors of both intention and behaviour scores for both groups. Furthermore, being a sixth-year student with a family member suffering from a chronic illness was positively associated with higher behaviour scores (β= 6.28, p-value 0.003). In the postgraduate group, attitude scores and perception of family socio-economic status were correlated with intention scores (β= 0.36, p-value 0.018) and behaviour scores (β=4.14, p-value 0.002). Conclusions: TPB is a suitable theoretical basis for examining factors influencing the adoption of VBC. Additionally, the perception of behavioural control significantly affects the intention to perform behaviour related to the application of principles in patient care among sixth-year medical students and postgraduate trainees.
... One set of important barriers is the time and resource constraints placed on medical institutions. Due to numerous existing competencies, medical schools often lack flexibility to include additional content in an already packed curriculum [38,39,40]. The Crimson Care Collaborative at Harvard Medical School, a student-faculty collaborative practice, overcomes this barrier by offering evidence-based education and training sessions focused on chronic disease management, exploring patient priorities, providing focused counseling and education, and assisting patients with self-management goals during clinical visits [41]. ...
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Introduction Chronic diseases account for approximately 70% of deaths in the U.S. annually. Though physicians are uniquely positioned to provide behavior change counseling for chronic disease prevention, they often lack the necessary training and self-efficacy. This study examined medical student interest in receiving chronic disease prevention training as a formal part of their education as part of an effort to enhance their ability to provide guidance to patients in the future. Methods A 23-question, online survey was sent to all undergraduate medical students enrolled in a large medical education program. The survey assessed medical student interest in receiving training related to chronic disease prevention. Survey topics included student awareness of primary prevention programs, perceived importance of receiving training and applied experience in chronic disease prevention, and preferences for how and when to receive this training. Results Of 793 eligible medical students, 432 completed the survey (54.5%). Overall, 92.4% of students reported receiving formal training in physical activity, public health, nutrition, obesity, smoking cessation, and chronic diseases was of “very high” or “high” importance. Despite this level of importance, students most frequently reported receiving no or 1–5 h of formal training in a number of topics, including physical activity (35.4% and 47.0%, respectively) and nutrition (16.9% and 56.3%, respectively). The level of importance given to public health training was significantly greater across degree type ( p = 0.0001) and future specialty ( p = 0.03) for MD/MPH students and those interested in primary care, respectively. Conclusions While medical students perceive chronic disease prevention as an important topic, most reported receiving little to no formal training. To address the growing prevalence of chronic disease across our society, programs schools should place greater emphasis on integrating training in physical activity, nutrition, and obesity-related content into the medical education curriculum.
... There was significant anxiety upon introduction of the curriculum about detracting from opportunities to acquire medical knowledge, and concern that each discipline had unique educational needs such that an institutional curriculum might be harmful [11]. The anxiety abated over time and the HSS curriculum was less frequently discussed at Resident Forum. ...
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Background Physicians must increasingly lead change for improvement in the value of health care for individuals and populations. Leadership, stewardship, and population health competencies are not explicitly part of the Accreditation Council for Graduate Medical Education (ACGME) requirements and are best appreciated in the context of Health Systems Science (HSS). HSS education is best approached at the institutional level, yet almost all graduate medical education (GME) curriculum is at the program level. We describe the process of designing and implementing an institutional HSS GME curriculum in a hospital-based sponsoring institution. Methods A group of diverse stakeholders drafted a curriculum to build competencies in leadership, stewardship, and population health, which was further refined by our Graduate Medical Education Committee (GMEC) and Resident Forum in the academic years 2015–2017. The refined curriculum was implemented at the institutional level of a large urban teaching hospital with over 80 ACGME accredited programs in the 2017–2018 academic year, participation was tracked and impact surveys were conducted. Results All programs participate in at least parts of the curriculum with sustained use. Annual surveys show a progression in assessment of our target competencies and/or opportunities to reflect and provide feedback. The annual program review meeting and GMEC meetings are used to troubleshoot and identify new curricular opportunities. Conclusion This innovative institutional curriculum has been sustained for over four years and we believe that other training institutions with similar goals will find our experience implementing an institutional curriculum translatable to their clinical learning environment.
... In addition to the CanMEDS competencies, and to ensure that physicians' competencies align with evolving health systems, overarching themes focusing on societal needs and future demands are increasingly integrated into medical education. 5 Examples of such themes are patient safety, shared decision-making and value-based healthcare (VBHC). [6][7][8] In the Netherlands, educators undertook action to combine these developments, resulting in the CanBetter project, which started in 2015. ...
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Objectives Stimulating the active participation of residents in projects with societally relevant healthcare themes, such as value-based healthcare (VBHC), can be a strategy to enhance competency development. Canadian Medical Education Directions for Specialists (CanMEDS) competencies such as leader and scholar are important skills for all doctors. In this study, we hypothesise that when residents conduct a VBHC project, CanMEDS competencies are developed. There is the added value of gaining knowledge about VBHC. Design An explorative mixed-methods study assessing residents’ self-perceived learning effects of conducting VBHC projects according to three main components: (1) CanMEDS competency development, (2) recognition of VBHC dilemmas in clinical practice, and (3) potential facilitators for and barriers to implementing a VBHC project. We triangulated data resulting from qualitative analyses of: (a) text-based summaries of VBHC projects by residents and (b) semistructured interviews with residents who conducted these projects. Setting Academic and non-academic hospitals in the Netherlands. Participants Out of 63 text-based summaries from residents, 56 were selected; and out of 19 eligible residents, 11 were selected for semistructured interviews and were included in the final analysis. Results Regarding CanMEDS competency development, the competencies ‘leader’, ‘communicator’ and ‘collaborator’ scored the highest. Opportunities to recognise VBHC dilemmas in practice were mainly stimulated by analysing healthcare practices from different perspectives, and by learning how to define costs and relate them to outcomes. Finally, implementation of VBHC projects is facilitated by a thorough investigation of a VBHC dilemma combined with an in-depth stakeholder analysis. Conclusion In medical residency training programmes, competency development through active participation in projects with societally relevant healthcare themes—such as VBHC—was found to be a promising strategy. From a resident’s perspective, combining a thorough investigation of the VBHC dilemma with an in-depth stakeholder analysis is key to the successful implementation of a VBHC project.
... Curricula that have been developed in HSS within undergraduate medical education focuses on content knowledge and didactics, but less on experiential learning [5]. Although resident physicians are constantly placed in real-life situations that include many cross cutting HSS domains, they are rarely debriefed post-event or viewed through an HSS lens [6]. ...
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Background Health system science (HSS) encompasses both core and cross-cutting domains that emphasize the complex interplay of care delivery, finances, teamwork, and clinical practice that impact care quality and safety in health care. Although HSS skills are required during residency training for physicians, current HSS didactics have less emphasis on hands-on practice and experiential learning. Medical simulation can allow for experiential participation and reflection in a controlled environment. Our goal was to develop and pilot three simulation scenarios as part of an educational module for resident physicians that incorporated core and cross-cutting HSS domains. Methods Each scenario included a brief didactic, an interactive simulation in small-group breakout rooms, and a structured debriefing. The case scenario topics consisted of educational leadership, quality and safety, and implementation science. Learners from four residency programs (psychiatry, emergency medicine, orthopedics, ophthalmology) participated January – March 2021. Results A total of 95 resident physicians received our curricular module, and nearly all (95%) participants who completed a post-session survey reported perceived learning gains. Emotional reactions to the session were positive especially regarding the interactive role-play format. Recommendations for improvement included participation from non-physician professions and tailoring of scenarios for specific disciplines/role. Knowledge transfer included use of multiple stakeholder perspectives and effective negotiation by considering power/social structures. Conclusions The simulation-based scenarios can be feasibly applied for learner groups across different residency training programs. Simulations were conducted in a virtual learning environment, but future work can include in-person and actor-based simulations to further enhance emotional reactions and the reality of the case scenarios.
... Although the foundational principles and knowledge for these competencies are recognized as both necessary and important, curriculum developers struggle with selecting which new topics to teach and when to focus on them during the course of medical training. Medical educators frequently reference the continuum of learning across undergraduate (UME) and graduate medical education (GME), yet calls for education in these topics often fall upon an already full UME curriculum [5], even though some content may be more readily understood and applied in the context of the full patient-care responsibilities associated with GME. ...
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Background Medical educators struggle to incorporate socio-cultural topics into crowded curricula. The “continuum of learning” includes undergraduate and graduate medical education. Utilizing an exemplar socio-cultural topic, we studied the feasibility of achieving expert consensus among two groups of faculty (experts in medical education and experts in social determinants of health) on which aspects of the topic could be taught during undergraduate versus graduate medical education. Methods A modified Delphi method was used to generate expert consensus on which learning objectives of social determinants of health are best taught at each stage of medical education. Delphi respondents included experts in medical education or social determinants of health. A survey was created using nationally published criteria for social determinants of health learning objectives. Respondents were asked 1) which learning objectives were necessary for every physician (irrespective of specialty) to develop competence upon completion of medical training and 2) when the learning objective should be taught. Respondents were also asked an open-ended question on how they made the determination of when in the medical education continuum the learning objective should be taught. Results 26 out of 55 experts (13 social determinants of health and 13 education experts) responded to all 3 Delphi rounds. Experts evaluated a total of 49 learning objectives and were able to achieve consensus for at least one of the two research questions for 45 of 49 (92%) learning objectives. 50% more learning objectives reached consensus for inclusion in undergraduate ( n = 21) versus graduate medical education ( n = 14). Conclusions A modified Delphi technique demonstrated that experts could identify key learning objectives of social determinants of health needed by all physicians and allocate content along the undergraduate and graduate medical education continuum. This approach could serve as a model for similar socio-cultural content. Future work should employ a qualitative approach to capture principles utilized by experts when making these decisions.
... This can create dissonance as we ask students to succeed as individuals, and contribute their time and energy to team goals that may benefit their competitors [22]. Improvements in teamwork education may also be inhibited by a lack of urgency and action on the educators' behalf, possibly related to a lack of expertise amongst educators and institutions in delivering this type of education and inadequate support from programme accreditors [28]. Assessment of teamwork is challenging, but without assessing these skills, we have no indication of whether our students are competent, or our curricula adequate. ...
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The centrality of teamwork in ensuring the effective functioning of institutions across all sectors is undeniable. However embedding teamwork into higher education has been hampered due to a range of deeply entrenched practices associated broadly with the foregrounding of knowledge, beliefs about the place of skills training and routines of assessment. As a result, despite an urgent need to address teamwork, little progress has been made with respect to progressing teamwork education. We have designed and evaluated a novel teamwork module delivered to fourth year undergraduate medical students involving placements, a co‐created piece of work, reflection, and summative peer assessment. This paper aims to investigate whether the module increased students’ insight into teamwork, including their own skills development, and whether their perceptions of teamwork changed. Throughout the evaluation, students played a key role, with four final year medical students working alongside others in the multidisciplinary project team. Five distinct themes emerged from our in‐depth, semi‐structured interviews: (1) importance and meaning, (2) insight into skill development, (3) transferability, (4) peer assessment, and (5) resistance to teamwork education. Themes had positive and negative components, and student perceptions changed in multiple ways after experiencing a longitudinal educational opportunity to develop their teamwork skills. Before practice, students focused on superficial explanations and on where they might improve. In contrast, after practice, students conveyed deeper insights, contextualization, focus on how they might improve, and shared structured reflection.
... The degree and breadth of HSS education programs across the consortium schools generates numerous lessons learned that can inform the work of other educators and medical schools attempting implementation and can help all overcome challenges. Synthesizing results from prior work, Table 3 highlights seven key challenges to HSS education and strategies that schools can deploy to overcome them (Gonzalo et al. 2016;Gonzalo et al. 2017e;Gonzalo, Caverzagie, et al. 2018a;Ehrenfeld and Gonzalo 2019). Issues such as developing core HSS curricula, trainee engagement, faculty development, addressing the hidden curriculum, aligning with health system needs, and showing value from student work all need to be considered at local and national levels when implementing HSS initiatives. ...
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The foundations of medical education have drawn from the Flexner Report to prepare students for practice for over a century. These recommendations relied, however, upon a limited set of competencies and a relatively narrow view of the physician’s role. There have been increasing calls and recommendations to expand those competencies and the professional identity of the physician to better meet the current and future needs of patients, health systems, and society. We propose a framework for the twenty-first century physician that includes an expectation of new competency in health systems science (HSS), creating ‘system citizens’ who are effective stewards of the health care system. Experiential educational strategies, in addition to knowledge-centered learning, are critically important for students to develop their professional identity as system citizens working alongside interprofessional colleagues. Challenges to HSS adoption range from competing priorities for learners, to the need for faculty development, to the necessity for buy-in by medical schools and their associated health care systems. Ultimately, success will depend on our ability to articulate, encourage, support, and evaluate system citizenship and its impact on health care and health care systems.
... 4 Barriers to creating effective infrastructure to teach RCA include lack of faculty funding, time, and expertise to create curriculum or lead patient safety investigations. [5][6][7][8] Similarly, learners also have minimal time, limited schedule flexibility, and competing educational demands. The lack of infrastructure for quality and patient safety education is further complicated by many learners and educators having mixed attitudes and beliefs about quality and patient safety. ...
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Introduction: Root cause analysis (RCA) is a widely utilized tool for investigating systems issues that lead to patient safety events and near misses, yet only 38% of learners participate in an interdisciplinary patient safety investigation during training. Common barriers to RCA education and participation include faculty time and materials, trainee time constraints, and learner engagement. Methods: We developed a simulated RCA workshop to be taught to a mix of medical and surgical specialties from over 11 GME programs and to third-year medical students. The workshop was a single 90-minute session formatted as a gamified mystery dinner including characters and sequentially revealed clues to promote engagement. Participant satisfaction and subjective knowledge, skills, and attitudes were assessed with a pre/post survey. Results: The workshop was completed by 134 learners between October 2018 and October 2019. The short workshop duration and premade simulation allowed a small number of faculty to train a wide variety of learners in various educational settings. Participants' presurvey (124 out of 134, 92%) versus postsurvey (113 out of 134, 84%) responses showed that attitudes about RCA were statistically improved across all domains queried, with an average effect size of 0.6 (moderate effect); 91% of participants would recommend this course to a colleague. Discussion: A 90-minute, gamified, simulated RCA workshop was taught to medical students and multiple GME specialties with subjective improvements in patient safety attitudes and knowledge while alleviating faculty time constraints in case development.
... However, demonstrating long-term educational and patient outcomes from such new curricula is challenging. [7][8][9][10] Most medical schools use a set of core competencies which are not fully aligned with residency programs and the Accreditation Council for Graduate Medical Education (ACGME) Milestones. 11,12 This disjointed continuum creates challenges in assessing the impact of undergraduate medical curriculum on learner outcomes following medical school. ...
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Background The American Medical Association Accelerating Change in Medical Education (AMA-ACE) consortium proposes that medical schools include a new 3-pillar model incorporating health systems science (HSS) and basic and clinical sciences. One of the goals of AMA-ACE was to support HSS curricular innovation to improve residency preparation. Objective This study evaluates the effectiveness of HSS curricula by using a large dataset to link medical school graduates to internship Milestones through collaboration with the Accreditation Council for Graduate Medical Education (ACGME). Methods ACGME subcompetencies related to the schools' HSS curricula were identified for internal medicine, emergency medicine, family medicine, obstetrics and gynecology (OB/GYN), pediatrics, and surgery. Analysis compared Milestone ratings of ACE school graduates to non-ACE graduates at 6 and 12 months using generalized estimating equation models. Results At 6 months both groups demonstrated similar HSS-related levels of Milestone performance on the selected ACGME competencies. At 1 year, ACE graduates in OB/GYN scored minimally higher on 2 systems-based practice (SBP) subcompetencies compared to non-ACE school graduates: SBP01 (1.96 vs 1.82, 95% CI 0.03-0.24) and SBP02 (1.87 vs 1.79, 95% CI 0.01-0.16). In internal medicine, ACE graduates scored minimally higher on 3 HSS-related subcompetencies: SBP01 (2.19 vs 2.05, 95% CI 0.04-0.26), PBLI01 (2.13 vs 2.01; 95% CI 0.01-0.24), and PBLI04 (2.05 vs 1.93; 95% CI 0.03-0.21). For the other specialties examined, there were no significant differences between groups. Conclusions Graduates from schools with training in HSS had similar Milestone ratings for most subcompetencies and very small differences in Milestone ratings for only 5 subcompetencies across 6 specialties at 1 year, compared to graduates from non-ACE schools. These differences are likely not educationally meaningful.
... The need to place greater weight on non-clinical competencies in medical education has been identified [63] as has a need for incorporation of systems sciences [64,65]. A small sample of newly graduated doctors rated each of the 60 attributes and competencies according to their perceived importance and their preparedness to perform in the way described after graduation. ...
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Background Medical education should ensure graduates are equipped for practice in modern health-care systems. Practicing effectively in complex health-care systems requires contemporary attributes and competencies, complementing core clinical competencies. These need to be made overt and opportunities to develop and practice them provided. This study explicates these attributes and generic competencies using Group Concept Mapping, aiming to inform pre-vocational medical education curriculum development. Methods Group Concept Mapping is a mixed methods consensus building methodology whereby ideas are generated using qualitative techniques, sorted and grouped using hierarchical cluster analysis, and rated to provide further quantitative confirmation of value. Health service providers from varied disciplines (including medicine, nursing, allied health), health profession educators, health managers, and service users contributed to the conceptual model’s development. They responded to the prompt ‘An attribute or non-clinical competency required of doctors for effective practice in modern health-care systems is...’ and grouped the synthesized responses according to similarity. Data were subjected to hierarchical cluster analysis. Junior doctors rated competencies according to importance to their practice and preparedness at graduation. Results Sixty-seven contributors generated 338 responses which were synthesised into 60 statements. Hierarchical cluster analysis resulted in a conceptual map of seven clusters representing: value-led professionalism; attributes for self-awareness and reflective practice; cognitive capability; active engagement; communication to build and manage relationships; patient-centredness and advocacy; and systems awareness, thinking and contribution. Logic model transformation identified three overarching meta-competencies: leadership and systems thinking; learning and cognitive processes; and interpersonal capability. Ratings indicated that junior doctors believe system-related competencies are less important than other competencies, and they feel less prepared to carry them out. Conclusion The domains that have been identified highlight the competencies necessary for effective practice for those who work within and use health-care systems. Three overarching domains relate to leadership in systems, learning, and interpersonal competencies. The model is a useful adjunct to broader competencies frameworks because of the focus on generic competencies that are crucial in modern complex adaptive health-care systems. Explicating these will allow future investigation into those that are currently well achieved, and those which are lacking, in differing contexts.
Article
This article describes a framework for the development, implementation, and effect of advanced practice provider (APP) grand rounds. A team of certified registered nurse anesthetists (CRNAs), NPs, and physician associates/assistants (PAs) developed and operationalized a grand rounds initiative in 2019. Since January 2020, 34 live monthly learning sessions have been held in person and virtually. Surveys using Likert-scale questions were provided postattendance to attendees to assess educational growth and opportunities for improvement in future programming. Attendees also were offered an opportunity to give open-ended feedback. Recordings of each presentation were analyzed to identify content alignment with stated academic medical center system goals. Most attendees reported increased projected medical competence, performance, and perceived projected effect on patient outcomes after attending grand rounds. Grand rounds are a novel model for increasing PA, NP, certified nurse-midwife, and CRNA engagement; enhancing evidence-based medical knowledge; and advancing stated academic medical center system goals.
Article
Health systems science (HSS), known as the science of healthcare delivery, is a pillar of medical education. We conducted a needs assessment to investigate clerkship students’ learning expectations and experiences to refine the development and implementation strategy of a health systems science (HSS) curriculum without compromising local clinical workflow. An anonymous paper-based survey was distributed to all 3rd-year medical students during orientation week of the second clerkship ring of the academic year. Survey questions explored three assessment domains: learning and HSS self-efficacy, resource utilization, and career interests. Descriptive statistics and ANOVA were used to analyze the data. A total of 172/197 students (87.3%) completed the survey and 34.8% (60/172) had completed surgery clerkship as their first rotation of the academic year. Most clerkship students lacked explicit understanding of clerkship learning expectations (mean 3.05 [95% CI 2.90, 3.20]) and showed low self-efficacy in navigating themselves through the healthcare system, identifying team expectations/role, and maintaining work–life balance. Students who had completed surgery clerkships reported significantly lower self-efficacy in finding supporting resources (3.75 < 3.99, p = 0.05) and carrying out self-directed learning (3.87 < 4.14, p = 0.03) when compared to other students. Overall, most students (91.2%) favored “individualized coaching support” during clerkship training and preferred seeking help from peers (81.4%) and residents (79.1%). Perceived career enjoyment of residents/faculty was the most frequently cited factor (77.3%) influencing students’ future career interests. Our study suggests that the development of HSS curriculum for clerkship students should focus on enhancing students’ ability to navigate themselves through healthcare systems and identify team expectations/ individual roles in various clinical settings. Strategies such as a new focus on improving the quality of student-to-student service handoff systems, a “clerkship HSS coach”, and providing just-in-time/on-the-go surgical clerkship resources may offer ways to optimally deliver specialty-specific HSS knowledge and skills to clerkship learners, ultimately increasing their levels of HSS efficacy.
Article
Purpose The American Medical Association has recently adopted health systems science (HSS) as the third pillar of medical education to provide comprehensive and holistic patient care. The purpose of this paper is to propose a novel organizational learning perspective in considering how medical schools can facilitate a transformational HSS curriculum change. Design/methodology/approach This is a conceptual paper seeking to present triple-loop learning as a potential approach to HSS curriculum change. Findings Due to its potential for structural accountability and sustainability stemming from the inclusion of diverse voices, the authors argue that HSS curriculum change, guided by the principles of triple-loop learning, is likely to lead to the development of medical curricula that are more adaptive and responsive to the constantly changing health-care landscape. The authors advocate for the deliberate inclusion of stakeholders who have historically been excluded or marginalized in the HSS curriculum change process, such as patients and those in sentinel roles (e.g. nurses, social workers). The authors also suggest an integrated, multilevel transformation that involves collaboration among medical schools, accreditation organizations, licensing boards and health-care systems. Originality/value To the best of the authors’ knowledge, this paper represents the first attempt to apply the theory of triple-loop learning in the context of HSS curriculum change. It highlights how this critical systemic learning approach uniquely contributes to HSS curriculum change, and subsequently to the necessary, larger cultural changes demanded in medical education as a whole.
Article
Purpose: Systems-based practice (SBP) has been a core competency in graduate medical education in the United States since 1999, but it has been difficult to operationalize in residency programs due to its conceptual ambiguity. The authors explored the historical origin and subsequent development of the SBP competency from the perspective of individuals who were influential across critical phases of its implementation and ensuing development. The goal of this study was to elicit the history of SBP from the perspective of individuals who have expertise in it, and to use those findings to inform the current SBP construct. Method: Between March and July 2021, 24 physicians, nurses, educators, and leaders in the field of SBP were individually interviewed about the origin and meaning of SBP as practiced in U.S. medical education using a semistructured guide. Individuals were selected based upon their influence on the origin or evolution of the SBP competency. Data were iteratively collected and analyzed using real-time analytic memos, regular adjudication sessions with the research team, and thematic analysis. Researchers identified themes from participants' perspectives and agreed upon the final results and quotations. Results: Five themes were identified: SBP has many different definitions, SBP was intentionally designed to be vague, systems thinking was identified as the foundation of the SBP competency, the 6 core competencies established in the United States by the Accreditation Council for Graduate Medical Education were developed to be interdependent, and the SBP and practice-based learning and improvement competencies are uniquely related and synergistic. Conclusions: Interview data indicate that since its inception, SBP has been a nuanced and complex competency, resulting in a lack of mutually shared understanding among stakeholders. This deliberate historical examination of expert perspectives provides insight into specific areas for improving how SBP is taught and learned.
Article
Despite the numerous calls for integrating quality improvement and patient safety (QIPS) curricula into health professions education, there are limited examples of effective implementation for early learners. Typically, pre-clinical QIPS experiences involve lectures or lessons that are disconnected from the practice of medicine. Consequently, students often prioritize other content they consider more important. As a result, they may enter clinical settings without essential QIPS skills and struggle to incorporate these concepts into their early professional identity formation. In this paper, we present twelve tips aimed at assisting educators in developing QIPS education early in the curricula of health professions students. These tips address various key issues, including aligning incentives, providing longitudinal experiences, incorporating real-world care outcomes, optimizing learning environments, communicating successes, and continually enhancing education and care delivery processes.
Article
Health systems science (HSS) is recognized as the third pillar of medical education. alongside basic and clinical sciences. Today’s physicians must also be systems thinkers who are able to discern how social, economic, environmental, and technological forces influence clinical decision-making. This study aimed to propose strategies for structuring an HSS curriculum that is tailored to the Korean healthcare and medical education context. First, the authors of this study conducted a survey to identify the present curricular contents of HSS related education at Korean medical schools. Second, a needs assessment was performed to determine the necessity of HSS competencies, as well as the prerequisites for the seamless integration of HSS into the existing curriculum. Third, literature reviews on HSS education at 14 US medical schools and expert consultations was conducted. We would like to propose a set of strategic approaches, classified into two levels: comprehensive and partial restructuring of the current medical curriculum to incorporate HSS. The partial restructuring approach entails a gradual, incremental incorporation of HSS content, while maintaining the current curricular structure. In contrast, a complete overhaul of the curriculum may be ideal to build HSS as the third pillar of medical education, but its feasibility remains relatively limited. The partial reorganization approach, however, has the advantage of being highly feasible. Collaborative efforts between professors and students are imperative to collectively devise effective methods for the seamless integration of HSS into the existing curriculum.
Article
Health systems science (HSS) is an educational framework designed to promote improved care through enhanced citizenship and the training of systems-fluent individuals trained in the science of health care delivery. HSS education in residency builds upon foundations established during medical school, emphasizing practical skills development, and fostering a growth mindset among trainees. The HSS framework organizes elements of system-based practice for radiology trainees, promoting practice-readiness for providing safe, timely, effective, efficient, equitable and patient centered radiological care. This paper serves as a primer for radiologists to understand and apply the HSS framework. Additionally, we highlight radiology-specific curricular elements aligned with the HSS framework, and provide teaching resources both for classroom education and for resident self-study.
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Medical humanities education (MHE) is as essential as basic medical sciences and clinical medicine education. Despite the importance of MHE, MHE curriculum development (CD) has proven to be challenging. This critical review examines the MHE CD at one medical school. The critical review methodology was developed based on Kern’s six step CD model to systematically examine the CD of “Doctoring and Medical Humanities (DMH)” at the Yonsei University College of Medicine. Five review questions were developed related to (1) necessity, (2) direction and purpose, (3) design, (4) operation, and (5) evaluation of CD based on Kern’s model. The review showed that the process of DMH CD mapped to components of Kerns model. The DMH curriculum content selected was closely related to medical practice and aimed to combine the acquisition of understanding and skills by designing a student-participatory curriculum based on clinical cases. Assessment methods that emphasized students’ reflections were actively introduced in the evaluation section. Since the regular committee for DMH continued the work of the special ad hoc committees for DMH CD, the CD was effectively completed. However, the planning and evaluation functions and responsibilities of the DMH committee need to be strengthened. Despite the apparent limitations, the fact that students showed a high satisfaction rate and preferred small group discussions based on clinical cases has significant implications in the instructional design of MHE, where changes in self-awareness and attitude are more important than the acquisition of information. It is necessary to systematically review and study students’ reflection results produced by the changed assessment methods and to develop assessment indicators for MHE that reflect the achievements of the MHE competencies of students.
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Background: Medical education is a multifarious endeavour integrating a range of pedagogies and philosophies. Complexity as a science or theory (‘complexity’) signals a move away from a reductionist paradigm to one which appreciates that interactions in multi-component systems, such as healthcare systems, can result in adaptive and emergent outcomes. This examination of the nexus between medical education and complexity theory aims to discover ways that complexity theory can inform medical education and medical education research. Methods: A meta-narrative systematic literature review was conducted to examine the nexus between medical education and complexity; 5 databases were searched using relevant terms. Papers were included if they engaged fully with complexity as a science or theory and were significantly focused on medical education. All types of papers were included, including conceptual papers (e.g. opinion and theoretical discussions), case studies, program evaluations and empirical research. A qualitative synthesis was undertaken to identify narratives and create a meta-narrative of the use of complexity in medical education. Results: Eighty-three papers were included; the majority were conceptual papers. An overarching narrative established the context and theoretical underpinnings of complexity as a relevant theory for medical education. Temporal observations were noted regarding the entry of complexity into medical education. Complexity was relied upon as theoretical framework for empirical studies covering a variety of elements within medical education including learning theories, curriculum and program development, competency and capability, professionalism and leadership, medical education and program evaluation, faculty development, assessment, learning environments, learning for systems through interprofessional education and simulation training, and learning about systems. Discussion: There is a call for greater use of theory by medical educators. Complexity was found to be a useful theory, albeit by a limited number of authors, and is increasingly being used by medical educators and medical education researchers. This review has further conceptualized how complexity is being used to support medical education and medical education research. Conclusion: This examination of the literature can assist those involved in medical education and medical education research in understanding how complexity can be useful in their own practice.
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Background: The importance of extracurricular activities (EAs) has been emphasized in medical education. These activities could enhance medical students’ emotional and physical health and afford them developmental opportunities. Despite the growing amount of research related to this theme, few studies review and synthesize the existing literature. This literature review aims to provide an understanding of the educational implications of EAs in medical colleges and constructs an integrated conceptual framework concerning their types and learning outcomes. Methods: An integrative literature review was conducted following Torraco’s method, which helped generate a new framework for the given topic. The authors utilized Scopus and PubMed as databases, using search terms “extracurricular,” “medical,” and “students.” Initially, titles and abstracts were screened to include relevant studies, and the researchers verified the eligibility of the articles by following the inclusion and exclusion criteria. Of the 263 articles identified, 64 empirical studies were selected for further review. Results: EAs in undergraduate medical education can be classified into direct extracurricular activities and indirect extracurricular activities, the latter of which is sorted into nine sub-categories. We identified seven main categories regarding the learning outcomes of EAs. In addition to general activities (e.g., pro-social activities, team sports), some distinctive activities such as research have been largely addressed in previous studies. The results of EAs were discussed in relation to academic growth, career development, and psychological experiences. Conclusions: This review identified the types and learning outcomes of EAs in the context of medical education, thereby suggesting ways to improve the quality of EAs and maximize their educational effects.
Article
Introduction: Despite being recognized as a key physician competency, leadership development is an area of improvement especially in undergraduate medical education. We sought to explore the lived experience of leaders who served in elected, representative roles during their time in medical school. Methods: We used a hermeneutic phenomenological approach to uncover the essence of the medical student leader experience. From late 2020 to early 2021, we interviewed 12 medical residents who served in elected leadership roles from 2015 - 2019. Each participant graduated from a different Canadian medical school. We deliberately chose a limited and historic time period in order for participants to be able to reflect on their past experiences while accounting for differences in the medical student leadership experience over time. We then engaged in a reflexive thematic analysis to generate the final themes. Results: We identified the following five themes: (1) living with busyness, (2) the role of faculty mentorship and support, (3) competing demands of leadership, (4) medical student leadership as enriching, and (5) creating better physicians. Though demanding, medical student leadership was found to be rewarding and particularly key in the development of a more well-rounded physician. Furthermore, being well supported by faculty contributed to an overall positive leadership experience. Discussion: In addition to describing the hardships and rewards that make up their experience, this study suggests that medical student leadership can enhance core physician competencies. The findings also support the notion that faculties have an important role to play in supporting medical student leaders.
Article
Purpose: Health systems science (HSS) curricula equip future physicians to improve patient, population, and health systems outcomes (i.e., to become "systems citizens"), but the degree to which medical students internalize this conception of the physician role remains unclear. This study aimed to explore how students envision their future professional identity in relation to the system and identify experiences relevant to this aspect of identity formation. Method: Between December 2018 and September 2019, authors interviewed 48 students at 4 U.S. medical schools with HSS curricula. Semistructured interviews were audiorecorded, transcribed, and analyzed iteratively using inductive thematic analysis. Interview questions explored how students understood the health system, systems-related activities they envisioned as future physicians, and experiences and considerations shaping their perspectives. Results: Regarding future physician identity, most students anticipated enacting one or more systems-related roles, categorized as involving "bottom-up" efforts enacted at a patient or community level (humanist, connector, steward) or "top-down" efforts enacted at an institution or policy level (system improver, system scholar, policy advocate). Corresponding activities included attending to social determinants of health or serving medically underserved populations, connecting patients with team members to address systems-related barriers, stewarding health care resources, conducting quality improvement projects, researching/teaching systems topics, and advocating for policy change. Students attributed systems-related aspirations to experiences beyond HSS curricula (e.g., low-income background; work or volunteer experience; undergraduate studies; exposure to how systems challenges affect patients; supportive classmates, faculty, and institutional culture). Students described future-oriented considerations promoting or undermining identification with systems-related roles (responsibility, affinity, ability, efficacy, priority, reality, consequences). Conclusions: This study illuminates systems-related roles medical students at 4 schools with HSS curricula envisioned as part of their future physician identity and highlights past/present experiences and future-oriented considerations shaping identification with such roles. These findings support practical strategies to support professional identity formation inclusive of systems engagement.
Article
Health system science addresses the complex interactions in health care delivery. At its core, health system science describes the intricate details required to provide high-quality care to individual patients by assisting them in navigating the multifaceted and often complicated U.S. health care delivery system. With advances in technology, informatics, and communication, the modern physician is required to have a strong working knowledge of health system science in order to provide effective, low-cost, high-quality care to patients. Medical educators are poised to introduce health system science concepts alongside the basic science and clinical science courses already being taught in medical school. Due to the common overlap of women's health care subject matter with health system science topics such as interprofessional collaboration, ethics, advocacy, and quality improvement, women's health medical educators are on the forefront of incorporating health system science into the current medical school educational model. In this paper the authors describe the concept of health system science and discuss both why and how it should be integrated into the undergraduate medical education curriculum. It is critical that medical educators develop physicians of the future who can not only provide excellent patient care, but also actively participate in the advancement and improvement of the health care delivery system.
Article
Medical education is increasingly recognizing the importance of the systems-based practice (SBP) competency in the emerging 21st-century U.S. health care landscape. In the wake of data documenting insufficiencies in care delivery, notably in patient safety and health care disparities, the Accreditation Council for Graduate Medical Education created the SBP competency to address gaps in health outcomes and facilitate the education of trainees to better meet the needs of patients. Despite the introduction of SBP over 20 years ago, efforts to realize its potential have been incomplete and fragmented. Several challenges exist, including difficulty in operationalizing and evaluating SBP in current clinical learning environments. This inconsistent evolution of SBP has compromised the professional development of physicians who are increasingly expected to advance systems of care and actively contribute to improving patient outcomes, patient and care team experience, and costs of care. The authors prioritize 5 areas of focus necessary to further evolve SBP: comprehensive systems-based learning content, a professional development continuum, teaching and assessment methods, clinical learning environments in which SBP is learned and practiced, and professional identity as systems citizens. Accelerating the evolution of SBP in these 5 focus areas will require health system leaders and educators to embrace complexity with a systems thinking mindset, use coproduction between sponsoring health systems and education programs, create new roles to drive alignment of system and educational goals, and use design thinking to propel improvement efforts. The evolution of SBP is essential to cultivate the next generation of collaboratively effective, systems-minded professionals and improve patient outcomes.
Article
Introduction Health Systems Science (HSS) teaches students critical skills to navigate complex health systems, yet medical schools often find it difficult to integrate into their curriculum due to limited time and student disinterest. Co-developing content with students and teaching through appropriate experiential learning can improve student engagement in HSS coursework. Methods Medical students and faculty co-developed a patient outreach initiative during the early phases of the COVID-19 pandemic and integrated that experience into a new experiential HSS elective beginning May 2020. Students called patients identified as high-risk for adverse health outcomes and followed a script to connect patients to healthcare and social services. Subsequently, this initiative was integrated into the required third-year primary care clerkship. Results A total of 255 students participated in HSS experiential learning through the elective and clerkship from May 2020 through July 2021. Students reached 3,212 patients, encountering a breadth of medical, social, and health systems issues; navigated the EMR; engaged interdisciplinary professionals; and proposed opportunities for health systems improvement. Discussion and conclusion This educational intervention demonstrated the opportunity to partner with student-led initiatives, coproducing meaningful educational experiences for the learners within the confines of a busy medical curriculum.
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Introduction: The American Medical Association formed the Accelerating Change in Medical Education Consortium through grants to effect change in medical education. The dissemination of educational innovations through scholarship was a priority. The objective of this study was to explore the patterns of collaboration of educational innovation through the consortium's publications. Method: Publications were identified from grantee schools' semi-annual reports. Each publication was coded for the number of citations, Altmetric score, domain of scholarship, and collaboration with other institutions. Social network analysis explored relationships at the midpoint and end of the grant. Results: Over five years, the 32 Consortium institutions produced 168 publications, ranging from 38 papers from one institution to no manuscripts from another. The two most common domains focused on health system science (92 papers) and competency-based medical education (30 papers). Articles were published in 54 different journals. Forty percent of publications involved more than one institution. Social network analysis demonstrated rich publishing relationships within the Consortium members as well as beyond the Consortium schools. In addition, there was growth of the network connections and density over time. Conclusion: The Consortium fostered a scholarship network disseminating a broad range of educational innovations through publications of individual school projects and collaborations.
Thesis
As the U.S. healthcare system undergoes significant transformation, providers who have been traditionally viewed as the nexus of care delivery inside the healthcare system, are struggling to effectively participate in system-wide reform due to challenges related to their ability to navigate the complexities of the system beyond the delivery of individual patient care. In this new era, healthcare providers must become oriented around systems-based practice (SBP) and be more adequately equipped to consider these issues in their patient care decision making. To achieve this goal, they require competencies in contextualizing and operationalizing their role in order to effectively navigate the larger U.S. healthcare system. Medical educators have proposed transforming the health professions school curricula by introducing a “third pillar” of medical education, termed Health Systems Science (HSS) to address knowledge, attitudes, and skills in SBP. The field of HSS is particularly nascent but quickly advancing. While learning about HSS and the U.S. healthcare system is increasingly being acknowledged as an essential part of health professions education, large proportions of graduating health professions students report it is insufficiently addressed in their curricula. Lack of training regarding healthcare systems may put recent health professions school graduates at a disadvantage as they enter their respective professional workforces, often requiring them to spend time and effort learning the health care system as they transition to their role as practicing clinicians. These findings suggest that efforts to amplify the HSS curriculum in health professions education can be an important way to improve student knowledge and confidence regarding health policy and health care systems. To address these challenges, we developed a 6-week HSS massive open online course (MOOC) for interprofessional learners entitled, "Understanding and Improving the U.S. Healthcare System". Learners engage with material predominantly in an asynchronous, learner-determined setting using short-form videos (each ≤ 15 minutes) with a variety of pedagogical techniques. The aim of my dissertation is to understand how HSS can be more readily integrated into health professions education through the use of a MOOC based curriculum. My primary hypothesis is that delivering HSS curriculum in this flexible format provides students with the opportunity to increase objective knowledge of the healthcare system, increase confidence in healthcare system-related knowledge, and become more optimistic about opportunities to improve the healthcare system in the future. In Chapters 1 and 2, I assess associations of exposure to this curriculum with students’ objective knowledge of the healthcare system, confidence in healthcare system-related knowledge, and optimism about opportunities to improve the healthcare system in the future for those who participated in the course and by comparing outcomes to a control group. In Chapter 3, I assess how students applied knowledge they obtained from the HSS MOOC through an analysis of participation in CHAT (Choosing Healthplans All Together), a simulation game designed to provide them with the opportunity to design an insurance plan as an individual and then on behalf of a stakeholder group. In toto, my research contributes to the growing need for health professions schools to identify ways to more effectively integrate HSS into their curricula and evaluate outcomes related to HSS curricular inclusion as HSS education and training has the potential to impact individual and population health by giving future providers a greater ability to contextualize their roles as central stakeholders in the larger U.S. healthcare system.
Article
The term "health systems science" (HSS) has recently emerged as a unifying label for competencies in health care delivery and in population and community health. Despite strong evidence that HSS competencies are needed in the current and future health care workforce, heretofore the integration of HSS into medical education has been slow or fragmented-due, in part, to a lack of evidence that these curricula improve education or population outcomes. The recent COVID-19 pandemic and the national reckoning with racial inequities in the United States further highlight the time-sensitive imperative to integrate HSS content across the medical education continuum. While acknowledging challenges, the authors highlight the unique opportunities inherent in an HSS curriculum and present an elaborated curricular framework for incorporating health care delivery and population health into undergraduate medical education. This framework includes competencies previously left out of medical education, increases the scope of faculty development, and allows for evidence of effectiveness beyond traditional learner-centric metrics. The authors apply a widely adopted six-step approach to curriculum development to address the unique challenges of incorporating HSS. Two examples-of a module on quality improvement (health care delivery) and of an introductory course on health equity (population and community health)-illustrate how the six-step approach can be used to build HSS curricula. The Supplemental Digital Appendix (at http://links.lww.com/ACADMED/B106) outlines this approach and provides specific examples and resources. Adapting these resources within local environments to build HSS curricula will allow medical educators to ensure future graduates have the expertise and commitment necessary to effect health systems change and to advocate for their communities, while also building the much-needed evidence for such curricula.
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Problem Although efforts to integrate health systems science (HSS) topics, such as patient safety, quality improvement (QI), interprofessionalism, and population health, into health professions curricula are increasing, the rate of change has been slow. Approach The Teachers of Quality Academy (TQA), Brody School of Medicine at East Carolina University, was established in January 2014 with the dual goal of preparing faculty to lead frontline clinical transformation while becoming proficient in the pedagogy and curriculum design necessary to prepare students in HSS competencies. The TQA included the completion of the Institute for Healthcare Improvement Open School Basic Certificate in Quality and Safety; participation in six 2-day learning sessions on key HSS topics; completion of a QI project; and participation in three online graduate courses. Outcomes Twenty-seven faculty from four health science programs completed the program. All completed their QI projects. Nineteen (70%) have been formally engaged in the design and delivery of the medical student curriculum in HSS. Early into their training, TQA participants began to apply new knowledge and skills in HSS to the development of educational initiatives beyond the medical student curriculum. Next Steps Important next steps for TQA participants and program planners include further incorporation as faculty advisors and contributors to the full implementation of the longitudinal HSS curriculum; expanded involvement with the Leaders in Innovative Care Scholars student leadership distinction track; continued in-depth evaluation of the impact of TQA participation on patient care, teaching, and role modeling; and the recruitment of the next cohort of TQA participants.
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Educators, policy makers, and health systems leaders are calling for significant reform of undergraduate medical education (UME) and graduate medical education (GME) programs to meet the evolving needs of the health care system. Nationally, several schools have initiated innovative curricula in both classroom and workplace learning experiences to promote education in health systems science (HSS), which includes topics such as value-based care, health system improvement, and population and public health. However, the successful implementation of HSS curricula across schools is challenged by issues of curriculum design, assessment, culture, and accreditation, among others. In this report of a working conference using thematic analysis of workshop recommendations and experiences from 11 U.S. medical schools, the authors describe seven priority areas for the successful integration and sustainment of HSS in educational programs, and associated challenges and potential solutions. In 2015, following regular HSS workgroup phone calls and an Accelerating Change in Medical Education consortium-wide meeting, the authors identified the priority areas: partner with licensing, certifying, and accrediting bodies; develop comprehensive, standardized, and integrated curricula; develop, standardize, and align assessments; improve the UME to GME transition; enhance teachers' knowledge and skills, and incentives for teachers; demonstrate value added to the health system; and address the hidden curriculum. These priority areas and their potential solutions can be used by individual schools and HSS education collaboratives to further outline and delineate the steps needed to create, deliver, study, and sustain effective HSS curricula with an eye toward integration with the basic and clinical sciences curricula.
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Improving healthcare services can all too often become synonymous with the tools of Quality Improvement. Such tools assume that possession of knowledge and skill is likely to improvement. But they miss out a vital ingredient - habit. If the quality of health and social care is to be made better and more reliable then understanding which habits are most associated with improvement and how to acquire them is essential.
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Abstract Cognitive Load Theory (CLT) builds upon established models of human memory that include the subsystems of sensory, working and long-term memory. Working memory (WM) can only process a limited number of information elements at any given time. This constraint creates a "bottleneck" for learning. CLT identifies three types of cognitive load that impact WM: intrinsic load (associated with performing essential aspects of the task), extraneous load (associated with non-essential aspects of the task) and germane load (associated with the deliberate use of cognitive strategies that facilitate learning). When the cognitive load associated with a task exceeds the learner's WM capacity, performance and learning is impaired. To facilitate learning, CLT researchers have developed instructional techniques that decrease extraneous load (e.g. worked examples), titrate intrinsic load to the developmental stage of the learner (e.g. simplify task without decontextualizing) and ensure that unused WM capacity is dedicated to germane load, i.e. cognitive learning strategies. A number of instructional techniques have been empirically tested. As learners' progress, curricula must also attend to the expertise-reversal effect. Instructional techniques that facilitate learning among early learners may not help and may even interfere with learning among more advanced learners. CLT has particular relevance to medical education because many of the professional activities to be learned require the simultaneous integration of multiple and varied sets of knowledge, skills and behaviors at a specific time and place. These activities possess high "element interactivity" and therefore impose a cognitive load that may surpass the WM capacity of the learner. Applications to various medical education settings (classroom, workplace and self-directed learning) are explored.
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Educating physician trainees in the principles of quality improvement (QI) and patient safety (PS) is a national imperative. Few faculty are trained in these disciplines, and few teaching institutions have the resources and infrastructure to develop faculty as instructors of these skills. The authors designed a 3-day, in-person academy to provide medical educators with the knowledge and tools to integrate QI and PS concepts into their training programs. The curriculum provided instruction in quality and safety, curriculum development and assessment, change management, and professional development while fostering peer networking, mentorship, and professional development. This article describes the characteristics, experiences, and needs of a cross-sectional group of faculty interested in acquiring skills to help them succeed as quality and safety educators. It also describes the guiding principles, curriculum blueprint, program evaluation, and lessons learned from this experience which could be applied to future faculty development programs in quality and safety education.
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Many observers have been concerned about a mismatch between the knowledge, skills, and professional values of newly trained physicians and the requirements of current and future medical practice. We surveyed and interviewed Kaiser Permanente's clinical department chiefs for internal medicine, pediatrics, general surgery, and obstetrics/gynecology to ascertain their views of the perceived gaps in the readiness of newly trained physicians. Nearly half of those surveyed reported deficiencies among new physicians in managing routine conditions or performing simple procedures often encountered in office-based practice. A third of the chiefs noted deficiencies in coordinating care for patients. Filling these and other training gaps will require changes at many levels-from residency programs to Medicare reimbursement policies-to better prepare new physicians for the challenges of working in a health care system evolving to emphasize accountability, quality outcomes, cost control, and information technology.
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Although residency programs must prepare physicians who can analyze and improve their practice, practice improvement (PI) is new for many faculty preceptors. We describe the pilot of a PI curriculum incorporating a practice improvement module (PIM) from the American Board of Internal Medicine for residents and their faculty preceptors. Residents attended PI didactics and completed a PIM during continuity clinic and outpatient months working in groups under committed faculty. All residents participated in PI group projects. Residents agreed or strongly agreed that the projects and the curriculum benefited their learning and patient care. A self-assessment revealed significant improvement in PI competencies, but residents were just reaching a "somewhat confident" level. A PI curriculum incorporating PIMs is an effective way to teach PI to both residents and faculty preceptors. We recommend the team approach and use of the PIM tutorial approach especially for faculty.
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Health systems are in the midst of a transformation that is being driven by a variety of forces. This has important implications for medical educators because clinical practice environments play a key role in learning and professional development, and evolving health systems are beginning to demand that providers have "systems-ready" knowledge, attitudes, and skills. Such implications provide a clear mandate for medical schools to modify their goals and prepare physicians to practice flexibly within teams and effectively contribute to the improvement of health care delivery. In this context, the concepts of value-added medical education, authentic student roles, and health systems science are emerging as increasingly important. In this Article, the authors use a lens informed by communities of practice theory to explore these three concepts, examining the implications that the communities of practice theory has in the constructive reframing of educational practices-particularly common student roles and experiences-and charting future directions for medical education that better align with the needs of the health care system. The authors apply several key features of the communities of practice theory to current experiential roles for students, then propose a new approach to students' clinical experiences-value-added clinical systems learning roles-that provides students with opportunities to make meaningful contributions to patient care while learning health systems science at the patient and population level. Finally, the authors discuss implications for professional role formation and anticipated challenges to the design and implementation of value-added clinical systems learning roles.
Article
Purpose: As health systems evolve, the education community is seeking to reimagine student roles that combine learning with meaningful contributions to patient care. The authors sought to identify potential stakeholders regarding the value of student work, and roles and tasks students could perform to add value to the health system, including key barriers and associated strategies to promote value-added roles in undergraduate medical education. Method: In 2016, 32 U.S. medical schools in the American Medical Association's (AMA's) Accelerating Change in Education Consortium met for a two-day national meeting to explore value-added medical education; 121 educators, systems leaders, clinical mentors, AMA staff leadership and advisory board members, and medical students were included. A thematic qualitative analysis of workshop discussions and written responses was performed, which extracted key themes. Results: In current clinical roles, students can enhance value by performing detailed patient histories to identify social determinants of health and care barriers, providing evidence-based medicine contributions at the point-of-care, and undertaking health system research projects. Novel value-added roles include students serving as patient navigators/health coaches, care transition facilitators, population health managers, and quality improvement team extenders. Six priority areas for advancing value-added roles are student engagement, skills, and assessments; balance of service versus learning; resources, logistics, and supervision; productivity/billing pressures; current health systems design and culture; and faculty factors. Conclusions: These findings provide a starting point for collaborative work to positively impact clinical care and medical education through the enhanced integration of value-added medical student roles into care delivery systems.
Article
In 1999, an Institute of Medicine report spurred health care organizations to implement systems-based quality improve ment efforts and tackle patient safety. Simultaneously, the Accreditation Council for Graduate Medical Education asked residency programs to address Practice-Based Learning and Systems-Based Practice competencies. Medical educators now advocate incorporation of these competencies in undergraduate medical education. The authors examine the success of these efforts both from the health care delivery and systems perspective as well as from the perspective of educators as they aspire to engage medical students and residents in these domains. The authors argue that the missing element that prevents health care systems from the full realization of the promise of quality improvement is bidirectional alignment. Included are examples from the literature to demonstrate how medical educators are moving toward alignment of learners with health system quality improvement and safety needs. Finally, the authors explore business and information technology governance literature in support of the hypothesis that bidirectional alignment should be the next step in moving from reactive to proactive systems of care.
Article
Background: Few opportunities exist for early learners to engage in authentic roles on health care teams. In a geriatric optimization clinic for frail high-risk surgical patients, first-year medical and nurse practitioner students were integrated into an interprofessional team as health coaches. Materials and methods: Frail surgical patients with planned operations were referred to a new preoperative optimization clinic to see a geriatrician, occupational, and physical therapists and a nutritionist. A curriculum for health coaching by early learners was developed, implemented, and evaluated in this clinic. Students attended the clinic visit with their patient, reviewed the interdisciplinary care plan, and called patients twice weekly preoperatively and weekly in the first month after discharge. Students logged all calls, completed patient satisfaction surveys 1 wk before surgery and participated in feedback sessions with team members and medical school faculty. Call success rate was calculated, and team communications were recorded and analyzed. Results: Median call success rate was 69.2% and was lowest among medical students (P = 0.004). Students and research assistants contacted or facilitated patient contact with their medical team 84 times. Overall, patients were extremely satisfied with the health coach experience, felt better prepared for surgery, and would recommend the program to others. Conclusions: Early medical and nurse practitioner students can serve the important function of health coaches for frail patients preparing for surgery. Motivated students benefited from a unique longitudinal experience and gained skills in communication and care coordination. Not all students demonstrated capacity to engage in health coaching this early in their education.
Article
To ensure physician readiness for practice and leadership in changing health systems, an emerging three-pillar framework for undergraduate medical education integrates the biomedical and clinical sciences with health systems science, which includes population health, health care policy, and interprofessional teamwork. However, the partnerships between medical schools and health systems that are commonplace today use health systems as a substrate for learning. Educators need to transform the relationship between medical schools and health systems. One opportunity is the design of authentic workplace roles for medical students to add relevance to medical education and patient care. Based on the experiences at two U.S. medical schools, the authors describe principles and strategies for meaningful medical school-health system partnerships to engage students in value-added clinical systems learning roles. In 2013, the schools began large-scale efforts to develop novel required longitudinal, authentic health systems science curricula in classrooms and workplaces for all first-year students. In designing the new medical school-health system partnerships, the authors combined two models in an intersecting manner-Kotter's change management and Kern's curriculum development steps. Mapped to this framework, they recommend strategies for building mutually beneficial medical school-health system partnerships, including developing a shared vision and strategy and identifying learning goals and objectives; empowering broad-based action and overcoming barriers in implementation; and generating short-term wins in implementation. Applying this framework can lead to value-added clinical systems learning roles for students, meaningful medical school-health system partnerships, and a generation of future physicians prepared to lead health systems change.
Article
Purpose: Early workplace learning experiences may be effective for learning systems-based practice. This study explores systems-oriented workplace learning experiences (SOWLEs) for early learners to suggest a framework for their development. Method: The authors used a two-phase qualitative case study design. In Phase 1 (spring 2014), they prepared case write-ups based on transcribed interviews from 10 SOWLE leaders at the authors' institution and, through comparative analysis of cases, identified three SOWLE models. In Phase 2 (summer 2014), studying seven 8-week SOWLE pilots, the authors used interview and observational data collected from the seven participating medical students, two pharmacy students, and site leaders to construct case write-ups of each pilot and to verify and elaborate the models. Results: In Model 1, students performed specific patient care activities that addressed a system gap. Some site leaders helped students connect the activities to larger systems problems and potential improvements. In Model 2, students participated in predetermined systems improvement (SI) projects, gaining experience in the improvement process. Site leaders had experience in SI and often had significant roles in the projects. In Model 3, students worked with key stakeholders to develop a project and conduct a small test of change. They experienced most elements of an improvement cycle. Site leaders often had experience with SI and knew how to guide and support students' learning. Conclusions: Each model could offer systems-oriented learning opportunities provided that key elements are in place including site leaders facile in SI concepts and able to guide students in SOWLE activities.
Article
Purpose: To examine medical student attitudes toward cost-conscious care and whether regional health care intensity is associated with reported exposure to physician role-modeling behaviors related to cost-conscious care. Method: Students at 10 U.S. medical schools were surveyed in 2015. Thirty-five items assessed attitudes toward, perceived barriers to and consequences of, and observed physician role-modeling behaviors related to cost-conscious care (using scales for cost-conscious and potentially wasteful behaviors; Cronbach alphas of 0.82 and 0.81, respectively). Regional health care intensity was measured using Dartmouth Atlas End-of-Life Chronic Illness Care data: ratio of physician visits per decedent compared with the U.S. average, ratio of specialty to primary care physician visits per decedent, and hospital care intensity index. Results: Of 5,992 students invited, 3,395 (57%) responded. Ninety percent (2,640/2,932) agreed physicians have a responsibility to contain costs. However, 48% (1,1416/2,960) thought ordering a test is easier than explaining why it is unnecessary, and 58% (1,685/2,928) agreed ordering fewer tests will increase the risk of malpractice litigation. In adjusted linear regression analyses, students in higher-health-care-intensity regions reported observing significantly fewer cost-conscious role-modeling behaviors: For each one-unit increase in the three health care intensity measures, scores on the 21-point cost-conscious role-modeling scale decreased by 4.4 (SE 0.7), 3.2 (0.6), and 3.9 (0.6) points, respectively (all P < .001). Conclusions: Medical students endorse barriers to cost-conscious care and encounter conflicting role-modeling behaviors, which are related to regional health care intensity. Enhancing role modeling in the learning environment may help prepare future physicians to address health care costs.
Article
To catalyze learning in Health Systems Science and add value to health systems, education programs are seeking to incorporate students into systems roles, which are not well described. The authors sought to identify authentic roles for students within a range of clinical sites and explore site leaders' perceptions of the value of students performing these roles. From 2013 to 2015, site visits and interviews with leadership from an array of clinical sites (n = 30) were conducted. Thematic analysis was used to identify tasks and benefits of integrating students into interprofessional care teams. Types of systems roles included direct patient benefit activities, including monitoring patient progress with care plans and facilitating access to resources, and clinic benefit activities, including facilitating coordination and improving clinical processes. Perceived benefits included improved value of the clinical mission and enhanced student education. These results elucidate a framework for student roles that enhance learning and add value to health systems.
Article
Despite wide consensus on needed changes in medical education, experts agree that the gap continues to widen between how physicians are trained and the future needs of our health care system. A new model for medical education is needed to create the medical school of the future. The American Medical Association (AMA) is working to support innovative models through partnerships with medical schools, educators, professional organizations, and accreditors. In 2013, the AMA designed an initiative to support rapid innovation among medical schools and disseminate the ideas being tested to additional medical schools. Awards of $1 million were made to 11 medical schools to redesign curricula for flexible, individualized learning pathways, measure achievement of competencies, develop new assessment tools to test readiness for residency, and implement new models for clinical experiences within health care systems. The medical schools have partnered with the AMA to create the AMA Accelerating Change in Medical Education Consortium, working together to share prototypes and participate in a national evaluation plan. Most of the schools have embarked on major curriculum revisions, replacing as much as 25% of the curriculum with new content in health care delivery and health system science in all four years of training. Schools are developing new certification in quality and patient safety and population management. In 2015, the AMA invited 21 additional schools to join the 11 founding schools in testing and disseminating innovation through the consortium and beyond.
Article
The current health care delivery model continues to fall short in achieving the desired patient safety and quality-of-care outcomes for patients. And, until recently, an explicit acknowledgment of the role and influence of the clinical learning environment on professional development had been missing from physician-based competency frameworks. In this Perspective, the authors explore the implications of the insufficient integration of education about patient safety and quality improvement by academic faculty into the clinical learning environment in many graduate medical education (GME) programs, and the important role that academic faculty need to play to better align the educational and clinical contexts to improve both learner and patient outcomes.The authors propose a framework that closely aligns the educational and clinical contexts, such that both educational and clinical outcomes are centered around the patient. This will require a reorganization of academic faculty perspective and educational design of GME training programs that recognizes that (1) the dynamic interplay between the faculty, learner, training program, and clinical microsystem ultimately influences the quality of physician that emerges from the training program and environment, and (2) patient outcomes relate to the quality of education and the success of clinical microsystems. To enable this evolution, there is a need to revisit the core competencies expected of academic faculty, implement innovative faculty development strategies, examine closely faculty's current clinical super-vision practices, and establish a training environment that supports bridging from clinician to educator, training program to clinical microsystem, and educational outcomes to clinical outcomes that benefit patients.
Article
This Viewpoint discusses ways academic medical centers can integrate the value-based care taught in residency programs into health system leadership and practices. The Affordable Care Act (ACA) is shifting physician reimbursement from volume to value. Academic medical centers (AMCs) are responsible for educating future physicians so that they will acquire the skills to practice value-based care. However, the linkages between the leaders of health systems and leaders of residency education may be tenuous, primarily because these leaders exist in separate silos in AMCs.
Article
Competency-based medical education (CBME) has emerged as a core strategy to educate and assess the next generation of physicians. Advantages of CBME include: a focus on outcomes and learner achievement; requirements for multifaceted assessment that embraces formative and summative approaches; support of a flexible, time-independent trajectory through the curriculum; and increased accountability to stakeholders with a shared set of expectations and a common language for education, assessment and regulation.
Article
Purpose: The authors performed a review of 30 Accelerating Change in Medical Education full grant submissions and an analysis of the health systems science (HSS)-related curricula at the 11 grant recipient schools to develop a potential comprehensive HSS curricular framework with domains and subcategories. Method: In phase 1, to identify domains, grant submissions were analyzed and coded using constant comparative analysis. In phase 2, a detailed review of all existing and planned syllabi and curriculum documents at the grantee schools was performed, and content in the core curricular domains was coded into subcategories. The lead investigators reviewed and discussed drafts of the categorization scheme, collapsed and combined domains and subcategories, and resolved disagreements via group discussion. Results: Analysis yielded three types of domains: core, cross-cutting, and linking. Core domains included health care structures and processes; health care policy, economics, and management; clinical informatics and health information technology; population and public health; value-based care; and health system improvement. Cross-cutting domains included leadership and change agency; teamwork and interprofessional education; evidence-based medicine and practice; professionalism and ethics; and scholarship. One linking domain was identified: systems thinking. Conclusions: This broad framework aims to build on the traditional definition of systems-based practice and highlight the need for medical and other health professions schools to better align education programs with the anticipated needs of the systems in which students will practice. HSS will require a critical investigation into existing curricula to determine the most efficient methods for integration with the basic and clinical scienc
Article
Objectives: Although a critical component of educational reform involves the inclusion of knowledge of and skills in health systems science (HSS) (including population health, health system improvement and high-value care) many undergraduate medical education programmes focus primarily on traditional basic and clinical sciences. In this study, we investigated students' perceptions of the barriers to, challenges involved in and benefits of the implementation of a HSS curriculum. Methods: In 2014, we conducted 12 focus groups with 50 medical students across all years of medical school. Group interviews were audio-recorded and transcribed verbatim. We used thematic analysis to explore students' perceptions of a planned HSS curriculum, which was to include both a classroom-based course and an experiential component. We then identified themes and challenges from the students' perspective and agreed upon results and quotations. Results: Students identified four barrier-related themes, including (i) medical-board licensing examinations foster a view of basic science as 'core', (ii) systems concepts are important but not essential, (iii) students lack sufficient knowledge and skills to perform systems roles and (iv) the culture of medical education and clinical systems does not support systems education. Students also identified several perceived benefits of a systems curriculum, including acquisition of new knowledge and skills, enhanced understanding of patients' perspectives and improved learning through experiential roles. The major unifying challenge related to students' competing priorities; one to perform well in examinations and match into preferred residencies, and another to develop systems-based skills. Conclusions: Students' intrinsic desire to be the best physician possible is at odds with board examinations and desired residency placements. As a result, HSS is viewed as peripheral and non-essential, greatly limiting student engagement. New perspectives are needed to effectively address this challenge.
Article
In 1990, George Miller published an article entitled "The Assessment of Clinical Skills/Competence/Performance" that had an immediate and lasting impact on medical education. In his classic article, he stated that no single method of assessment could encompass the intricacies and complexities of medical practice. To provide a structured approach to the assessment of medical competence, he proposed a pyramidal structure with four levels, each of which required specific methods of assessment. As is well known, the layers are "Knows," "Knows How," "Shows How," and "Does." Miller's pyramid has guided assessment since its introduction; it has also been used to assist in the assessment of professionalism.The recent emphasis on professional identity formation has raised questions about the appropriateness of "Does" as the highest level of aspiration. It is believed that a more reliable indicator of professional behavior is the incorporation of the values and attitudes of the professional into the identity of the aspiring physician. It is therefore proposed that a fifth level be added at the apex of the pyramid. This level, reflecting the presence of a professional identity, should be "Is," and methods of assessing progress toward a professional identity and the nature of the identity in formation should be guided by currently available methods.
Article
The three-step United States Medical Licensing Examination (USMLE) was developed by the National Board of Medical Examiners and the Federation of State Medical Boards to provide medical licensing authorities a uniform evaluation system on which to base licensure. The test results appear to be a good measure of content knowledge and a reasonable predictor of performance on subsequent in-training and certification exams. Nonetheless, it is disconcerting that the test preoccupies so much of students' attention with attendant substantial costs (in time and money) and mental and emotional anguish.There is an increasingly pervasive practice of using the USMLE score, especially the Step 1 component, to screen applicants for residency. This is despite the fact that the test was not designed to be a primary determinant of the likelihood of success in residency. Further, relying on Step 1 scores to filter large numbers of applications has unintended consequences for students and undergraduate medical education curricula.There are many other factors likely to be equally or more predictable of performance during residency. The authors strongly recommend a move away from using test scores alone in the applicant screening process and toward a more holistic evaluation of the skills, attributes, and behaviors sought in future health care providers. They urge more rigorous study of the characteristics of students that predict success in residency, better assessment tools for competencies beyond those assessed by Step 1 that are relevant to success, and nationally comparable measures from those assessments that are easy to interpret and apply.
Article
In the face of a fragmented and poorly performing healthcare delivery system, medical education in the United States is poised for disruption. Despite broad-based recommendations to better align physician training with societal needs, adaptive change has been slow. Traditionally, medical education has focused on the basic and clinical sciences, largely removed from the newer systems sciences, such as population health, policy, financing, healthcare delivery, and teamwork. In this paper, authors examine the current state of medical education with respect to systems sciences and propose a new framework for educating physicians in adapting to and practicing in systems-based environments. Specifically, authors propose an educational shift from a two-pillar framework to a three-pillar framework where basic, clinical, and systems sciences are interdependent. In this new three-pillar framework, students not only learn the interconnectivity in the basic, clinical and systems sciences, but also uncover relevance and meaning in their education through authentic, value-added, and patient-centered roles as navigators within the healthcare system. Simple adjustments, such as including occasional systems topics in medical curricula, will not foster graduates prepared to practice in the 21st-century healthcare system. Adequate preparation requires an explicit focus upon the systems sciences as a vital and equal component of physician education.
Article
Nearly every medical student and practicing physician aspires to provide the best possible patient-centered care. They went into medicine to do so and are trained to place patients’ wellbeing at the center of their work. What physicians are not trained to do, however, is to engage with and change the powerful systems that shape their ability to provide patient-centered care: funding models, organizational structure, information technology, and others. The messy business of leading change is, more often than not, handled by managers, accountants and legislators, most of whom are adept at looking at the bottom line, but are ill-equipped to understand the reality of providing patient-centered medical care. Physicians can play a key role in delivery system reform, and must now achieve fluency in domains beyond medical knowledge and technical skills.1In this issue of JGIM, Fontaine and colleagues describe six success factors critical to front-line implementation of the patient-centered medi ...
Article
The objective was to determine if a year-long, multispecialty resident and fellow quality improvement (QI) curriculum is feasible and leads to improvements in QI beliefs and self-reported behaviors. The Armstrong Institute Resident/Fellow Scholars (AIRS) curriculum incorporated (a) a 2-day workshop in lean sigma methodology, (b) year-long interactive weekly small-group lectures, (c) mentored QI projects, and (d) practicum-based components to observe frontline QI efforts. Pre-post evaluation was performed with the Quality Improvement Knowledge Application Tool (QIKAT) and the Systems Thinking Scale (STS) using the Wilcoxon matched-pairs signed-rank test. Sixteen residents and fellows started the AIRS curriculum and 14 finished. Scholars' pre and post mean scores significantly improved: STS 3.06 pre versus 3.60 post (P < .01) and QIKAT 1.24 pre versus 2.46 post (P < .01). Most scholars (92%) agreed that skills learned in the curriculum will help in their future careers. A multispecialty QI curriculum for trainees is feasible and increases QI beliefs and self-reported behaviors. © The Author(s) 2015.
Article
Effective quality improvement (QI) education should improve patient care, but many curriculum studies do not include clinical measures. The research team evaluated the prevalence of QI curricula with clinical measures and their association with several curricular features. MEDLINE, Embase, CINAHL, and ERIC were searched through December 31, 2013. Study selection and data extraction were completed by pairs of reviewers. Of 99 included studies, 11% were randomized, and 53% evaluated clinically relevant measures; 85% were from the United States. The team found that 49% targeted 2 or more health professions, 80% required a QI project, and 65% included coaching. Studies involving interprofessional learners (odds ratio [OR] = 6.55; 95% confidence interval [CI] = 2.71-15.82), QI projects (OR = 13.60; 95% CI = 2.92-63.29), or coaching (OR = 4.38; 95% CI = 1.79-10.74) were more likely to report clinical measures. A little more than half of the published QI curricula studies included clinical measures; they were more likely to include interprofessional learners, QI projects, and coaching.
Article
Academic medicine in the United States is at a crossroads. There are many drivers behind this, including health care reform, decreased federal research funding, a refined understanding of adult learning, and the emergence of disruptive innovations in medicine, science, and education. As faculty members are at the core of all academic activities, the definition of "faculty" in academic medicine must align with the expectations of institutions engaged in patient care, research, and education. Faculty members' activities have changed and continue to evolve. Academic health centers must therefore define new rules of engagement that reflect the interplay of institutional priorities with the need to attract, retain, and reward faculty members.In this Commentary, the authors describe and explore the potential effects of the changing landscape for institutions and their clinical faculty members. The authors make a case for institutions to adapt faculty appointment, evaluation, and promotion processes, and they propose a framework for a standardized definition of "faculty" that allows for individual variability. This framework also provides a means to evaluate and reward faculty members' contributions in education, research, and clinical care. The authors propose a deliberate national conversation to ensure that careers in academic medicine remain attractive and sustainable and that the future of academic medicine is secure.
Article
Leaders in medical education have increasingly called for the incorporation of cost awareness and health care value into health professions curricula. Emerging efforts have thus far focused on physicians, but foundational competencies need to be defined related to health care value that span all health professions and stages of training. The University of California, San Francisco (UCSF) Center for Healthcare Value launched an initiative in 2012 that engaged a group of educators from all four health professions schools at UCSF: Dentistry, Medicine, Nursing, and Pharmacy. This group created and agreed on a multidisciplinary set of comprehensive competencies related to health care value. The term "competency" was used to describe components within the larger domain of providing high-value care. The group then classified the competencies as beginner, proficient, or expert level through an iterative process and group consensus. The group articulated 21 competencies. The beginner competencies include basic principles of health policy, health care delivery, health costs, and insurance. Proficient competencies include real-world applications of concepts to clinical situations, primarily related to the care of individual patients. The expert competencies focus primarily on systems-level design, advocacy, mentorship, and policy. These competencies aim to identify a standard that may help inform the development of curricula across health professions training. These competencies could be translated into the learning objectives and evaluation methods of resources to teach health care value, and they should be considered in educational settings for health care professionals at all levels of training and across a variety of specialties.