Systems-Based Practice and Health Systems Science in Graduate Medical Education: Recommendations for Embracing This Critical Core Competency
Introduction
Rising health care costs, health inequities, and quality and patient safety concerns continue to plague US health care disproportionately compared to similar countries.1-5 Physicians play a vital role in recognizing these challenges and in considering societal factors that influence health.6 For the last 25 years, physicians are supposed to have been trained in Systems-Based Practice (SBP) as 1 of the 6 Accreditation Council for Graduate Medical Education Core Competencies.7 SBP, if mastered, positions physicians to practice high-value care, address population health and health inequities, improve quality of care, and optimize patient safety, thereby playing a role in steering health care systems toward delivering safe, effective, patient-centered, timely, efficient, and equitable care.8,9
Unfortunately, there is a preponderance of evidence highlighting that SBP has not been embraced in physician training and that it remains the so-called “orphan” competency.10,11 Literature demonstrates that residents remain confused about the role of SBP in clinical practice, and program leaders are unsure how best to implement SBP into training.10-12 Continuing to graduate physicians who are not competent in SBP only worsens the challenges already faced by patients in the US health care system.
Over the last 5 years, 2 teams from the American Medical Association’s Reimagining Residency initiative have been investigating how best to implement SBP and health systems science (HSS) in graduate medical education (GME). From our observations, we have found that HSS and SBP are parallel conceptual frameworks; therefore, we integrated the 2 and present them here together.12 Below we present a summary of recommendations, phrased as “do’s and don’ts,” for implementing SBP/HSS into residency training based on our collective expertise, literature reviews, and direct observation of SBP/HSS education within GME programs. We use the learning environment (LE) framework conceptualized by Gruppen et al to propose action items.13 This organizing framework includes the organizational, personal, social, and physical domains (Table), and was developed to address the lack of a health professions education framework that described and categorized factors that affect the learning environment.13 While our recommendations here are specific and based on our recent experiences and expertise, it is important to note that the LE framework could be used during program planning to create opportunities outside of our specific recommendations.
Organizational Domain
The organizational domain encompasses the culture, policies, and curriculum structure within the LE.13
Do
Institutional and program leadership must actively work to establish a culture that emphasizes SBP/HSS integration into daily activities. Our teams frequently learned when trialing SBP/HSS pilots in GME that if the culture of the program did not emphasize SBP/HSS, the pilots failed. Pragmatically, this emphasis can be done in a variety of ways. Conferences could be required to start with a 90-second patient safety moment. For example, an academic half-day conference could begin with a recent story about a resident who prevented a patient safety error, placing emphasis on how the resident recognized the error and the steps the resident took to prevent the error and report it to the health system. Inpatient rounds could begin with a required 15-minute interprofessional team meeting, to include safety issues, to ensure baseline institutional quality and safety standards are emphasized, and to introduce all members of the team to one another. For example, an inpatient internal medicine team may want to start an inpatient service week with a huddle with the medicine floor nursing team in which an initiative for reducing hospital-acquired delirium is outlined. The emphasis may be on ensuring residents check to ensure window blinds are open during the day in patient rooms. Clinic mornings could begin with a “value recommendation” that highlights one area of value-based care that residents should consider while seeing patients that day. For instance, residents in a pediatric clinic may start their clinic week with a brief 30-minute huddle discussing the number of antibiotics prescribed for upper-respiratory tract infections in the past year and reviewing the value-based care evidence for appropriate use of antibiotics. In our experience, the critical piece here is to actively incorporate SBP/HSS into the life of the residency program.
Don’t
We would not recommend relegating SBP/HSS content to lectures or online modules alone. Many times, our teams heard program leadership state that they offered lectures to residents on SBP/HSS topics, only for us to then hear from trainees that they never had any teaching about SBP/HSS. Similar to identifying feedback as such, programs need to call attention to elements of SBP/HSS in the daily operations of patient care to make SBP/HSS implementation successful.
Personal Domain
The personal domain speaks to the elements within the LE that influence professional identity formation, well-being, and personal growth.13
Do
Program leaders should consider residents fully integrated citizens of the institution.14 Recognize the power of residents as change agents who demonstrate ingenuity.15 Share institutional quality metrics, goals, and strategy with trainees. Put them on committees and protect their time to serve on them. For example, place residents on quality improvement committees tasked with preventing hospital-acquired infections so that they may learn how and why quality protocols are developed. Ensure that trainees receive their own individual quality and patient population health metrics and assign them to reflect on the equity and quality of their metrics during semiannual evaluations with program leadership.16 This could be done by developing an equity and quality “dashboard” for all residents in the program so that they may see their own performance and compare to peers. These steps are critical for residents to understand that they are responsible to the larger system of care.16,17
Don’t
The most significant barrier to our study was workload compression, (ie, an increase in work without an equal increase in time to complete it). Even when leaders were supporting residents to work on SBP/HSS projects with our teams, residents struggled to do so because of their overall workload and subsequent lack of well-being. Solving this may require redesigning rotations to allow for time to develop SBP/HSS skills.
Social Domain
The social domain includes all the interpersonal relationships within the LE that influence behavior, including teacher and patient care relationships.13
Do
There is a need for faculty development in SBP/HSS.18 The importance of the relationship between learners and faculty and the clinical imprinting that frequently occurs within this relationship highlights the need to ensure that faculty are competent and appropriately role modeling SBP/HSS skills.19 Many faculty we observed struggled to understand the definition of SBP/HSS. Programs should start with teaching faculty small ways to integrate teaching at the bedside. Review literature in faculty development sessions that highlight the inclusion of structural competency, defined as “understanding of the impact of the social structure on a social group or individual,” into clinical reasoning.20,21 If faculty cannot speak to the importance of SBP/HSS, learners will not prioritize it. Give faculty concrete examples of how to assess SBP/HSS skills so that they can be incorporated into faculty feedback for residents. For example, faculty can give residents feedback on the safety of their transitions of care for a patient, or the quality of their incorporation of high value care principles into their management decisions.
Don’t
SBP/HSS teaching cannot be focused only on the macrosystem. We found that SBP/HSS is much more easily understood by trainees if applied to individual patient cases with whom residents have relationships. Focusing on microsystem/relational teaching in addition to the macrosystem is essential to help trainees understand SBP/HSS.
Physical Domain
The physical domain describes the actual physical space in which trainees learn and practice.13
Do
Program leaders should consider having attendings and learners in the same physical space, for at least some of the clinical day. We noted numerous mental model conflicts between how residents believed attendings were spending their workday and how attendings were actually spending their workday. Many residents falsely stated that they believed SBP/HSS-related work would not have to be done once they became attendings (eg, answering patient messages/questions about health care costs, completing forms for employers, housing, electrical companies, insurance, etc). Attendings noted that this misconception became worse when residents were no longer seated beside them and could see the work they were doing. Allowing residents to see the SBP/HSS work being done by attendings is necessary to set expectations for what their future jobs will require.
Don’t
We found that physical proximity to interprofessional team members, such as social workers, care coordinators, and advanced practice clinicians was essential for building functional teams and coordinating care in general. Numerous programs we observed shared stories in which a redesign of physical space had separated their learners from interprofessional team members to the detriment of patient care. In some cases, separating residents into a private space away from other interprofessional team members was initially thought to be a win, and then was regretted later as it worsened communication and coordination. Program leaders should conscientiously consider the effects of any physical space redesigns that will separate their learners from interprofessional colleagues.
Conclusion
Embracing SBP/HSS within GME is increasingly necessary to ensure physicians can improve and not worsen the system of care in which they care for patients. Program leaders need assistance in determining how to establish SBP/HSS education in their programs. Following the do’s and don’ts presented above could aid GME leaders with implementing this essential content.
Author Notes
