Evolving the Systems-Based Practice Competency in Graduate Medical Education to Meet Patient Needs in the 21st-Century Health Care System

Exploring clinician perspectives of systems-based practice: A physician training challenge

INTRODUCTION

Systems-based practice (SBP) has been a competency in US graduate medical education for over 20 years, but it is not well implemented. SBP is loosely defined as physician's responsiveness to the larger system of healthcare. The aim of this study was to describe healthcare professionals' perspectives regarding: (1) their knowledge and beliefs about SBP and (2) their beliefs regarding factors in clinical learning environments (CLE) that facilitate or hinder operationalisation and learning of SBP.

METHODS

Semi-structured interviews were conducted between November 2020 and April 2021 with 42 individuals from four health systems. Participants were healthcare professionals involved in graduate medical education, including physicians and interprofessional clinicians (e.g., nursing staff). Interviews were transcribed and coded using a social constructivist, codebook thematic analysis approach and themes were agreed upon through discussion amongst the research team.

RESULTS

Five themes were constructed: (1) SBP remains a challenge to define, (2) SBP may be intuitively understood, particularly when framed at the microsystem level, (3) SBP aligns with the Health Systems Science framework, (4) SBP learning must be intentionally integrated into the CLE, through training such as onboarding and (5) multidisciplinary settings and work processes are critical to engage in SBP. Workload compression is a barrier to SBP implementation.

CONCLUSIONS

Healthcare professionals highlighted that current CLEs are not designed to prioritise SBP. Graduate medical education programmes may benefit from focusing systems content at the microsystem level and purposefully integrating onboarding procedures, clinical settings and rotations specifically designed to teach SBP into their residencies.

Empowering Health Care Providers: A Collaborative Approach to Enhance Financial Performance and Productivity in Clinical Practice

Background

The combination of inadequate financial training, limited benchmarks, and mindset contribute to many physicians prioritizing revenue below quality, outcomes, and safety. This creates a challenge as hospital administrators aim to motivate clinicians to improve RVU generation and increase revenue.

Recent Findings

Creating physician/administrator teams that defines and explores the gap between observed and expected financial performance in parallel with appreciating the physician's practice preferences can create new opportunities for billing. The proposed 3 phase approach emphasizes nonjudgmental communication, education and partnership. The most common and effective opportunities for improvement include billing optimization, scheduling and system infrastructure modifications.

Implications for Practice

As reimbursement decrease, balancing revenue generation with physician satisfaction has become paramount. Promoting data drive bidirectional communication can lead to identifying previously unrecognized billing opportunities where change is driven by providers rather than by 1-dimensional institutional goals.

Artificial Intelligence in Endourology: Maximizing the Promise Through Consideration of the Principles of Diffusion of Innovation Theory

Introduction: Diffusion of Innovation Theory explains how ideas or products gain momentum and diffuse (or spread) through specific populations or social systems over time. The theory analyzes primary influencers of the spread of new ideas, including the innovation itself, communication channels, time, and social systems. Methods: The current study reviewed published medical literature to identify studies and applications of artificial intelligence (AI) in endourology and used E.M. Rogers' Diffusion of Innovation Theory to analyze the primary influencers of the adoption of AI in endourological care. The insights gained were triaged and prioritized into AI application-related action items or "tips" for facilitating the appropriate diffusion of the most valuable endourological innovations. Results: Published medical literature indicates that AI is still a research-based tool in endourology and is not widely used in clinical practice. The published studies have presented AI models and algorithms to assist with stone disease detection (n = 17), the prediction of management outcomes (n = 18), the optimization of operative procedures (n = 9), and the elucidation of stone disease chemistry and composition (n = 24). Five tips for facilitating appropriate adoption of endourological AI are: (1) Develop/prioritize training programs to establish the foundation for effective use; (2) create appropriate data infrastructure for implementation, including its maintenance and evolution over time; (3) deliver AI transparency to gain the trust of endourology stakeholders; (4) adopt innovations in the context of continuous quality improvement Plan-Do-Study-Act cycles as these approaches have proven track records for improving care quality; and (5) be realistic about what AI can/cannot currently do and document to establish the basis for shared understanding. Conclusion: Diffusion of Innovation Theory provides a framework for analyzing the influencers of the adoption of AI in endourological care. The five tips identified through this research may be used to facilitate appropriate diffusion of the most valuable endourological innovations.

Implementation of High-Value Care for Physical Therapy Residents Through Systems-Based Practice Curriculum Development: Case Report

BACKGROUND AND PURPOSE

Systems-based practice is a core competency for physical therapy residents, best acquired through experiential learning. Peer health professions are further along than physical therapy in implementing curricula that support systems-based practice. Clinical and practice data in residency programs could provide for education in high-value care (HVC) as a foundation for systems-based practice. Our purpose was to develop and assess a HVC curriculum incorporating reflective practice to help residents achieve competency in systems-based practice.

CASE DESCRIPTION

The Logic Model, which evaluates key components needed for success and sustainability, was used to identify resources for a curriculum in HVC. Two orthopedic physical therapy residents and 5 faculty mentors participated in didactic and mentoring sessions. A practice dashboard for each clinician was developed to facilitate resident-mentor discussions. Focus group input was used to refine the curriculum. The validated Systems Thinking Scale, the Quality Improvement Knowledge Application Tool Rubric, and the American Physical Therapy Association Residency Core Competency Score were used to assess residents' progress and to make comparisons to prior years' residents.

OUTCOMES

The residents demonstrated increases in systems thinking and quality-improvement knowledge and improvements in clinical outcomes and practice efficiencies. Three themes emerged from semistructured interviews: challenges to HVC, current approach in HVC, and future-oriented thinking in HVC in practice.

DISCUSSION AND CONCLUSION

This study demonstrates that HVC activities and a personalized clinical dashboard in a physical therapy residency program can facilitate experiential learning of systems-based practice, a core competency for value-centered, inclusive practice.

Supporting Care Transformation Through a Comprehensive Graduate Medical Education Curricular Program in a Department of Internal Medicine

BACKGROUND

The imperative to train physicians in skills required to lead care transformation is increasingly recognized, yet few Graduate Medical Education (GME) programs exist to meet this need.

AIM

Describe the development, outcomes, and lessons learned from a novel GME care transformation curricular program.

SETTING

Department of Internal Medicine (IM) at Dell Medical School at The University of Texas, Austin.

PARTICIPANTS

Between 2020 and 2023, 33 IM residents and fellows completed training with participation in the Care Transformation program.

PROGRAM DESCRIPTION

Department leadership developed a comprehensive educational and experiential program that included (1) Dell Medical School-wide Distinction in Care Transformation curriculum; (2) Primary Care Residency track with care transformation projects; (3) participation in the national Veterans Affairs Chief Resident in Quality and Safety program; and (4) Hospital Medicine Fellowship in Quality and Safety.

PROGRAM EVALUATION

Each trainee led a care transformation project spanning a variety of topics and settings. Graduates who responded to a follow-up survey (22 of 33 graduates) reported they used skills learned through the program in their current roles and these experiences better prepared them for fellowship and/or faculty positions.

DISCUSSION

The Care Transformation program provides real-world experiences and skillsets that are increasingly valuable in modern healthcare delivery.

Systems-Based Practice: Expert Perspectives on the Origin and Evolution of an Ambiguous Competency

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.

Systems-Based Practice in Graduate Medical Education: Evolving Toward an Ideal Future State

ABSTRACT

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.

Breaking Down Silos Between Medical Education and Health Systems: Creating an Integrated Multilevel Data Model to Advance the Systems-Based Practice Competency

ABSTRACT

The complexity of improving health in the United States and the rising call for outcomes-based physician training present unique challenges and opportunities for both graduate medical education (GME) and health systems. GME programs have been particularly challenged to implement systems-based practice (SBP) as a core physician competency and educational outcome. Disparate definitions and educational approaches to SBP, as well as limited understanding of the complex interactions between GME trainees, programs, and their health system settings, contribute to current suboptimal educational outcomes elated to SBP. To advance SBP competence at individual, program, and institutional levels, the authors present the rationale for an integrated multilevel systems approach to assess and evaluate SBP, propose a conceptual multilevel data model that integrates health system and educational SBP performance, and explore the opportunities and challenges of using multilevel data to promote an empirically driven approach to residency education. The development, study, and adoption of multilevel analytic approaches to GME are imperative to the successful operationalization of SBP and thereby imperative to GME's social accountability in meeting societal needs for improved health. The authors call for the continued collaboration of national leaders toward producing integrated and multilevel datasets that link health systems and their GME-sponsoring institutions to evolve SBP.

Examining the nexus between medical education and complexity: a systematic review to inform practice and research

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.

Exploring the Critical Driving Forces and Strategy Adoption Paths of Professional Competency Development for Various Emergency Physicians Based on the Hybrid MCDM Approach

The implementation of competency-based medical education (CBME) focuses on learners' competency outcomes and performance during their training. Competencies should meet the local demands of the healthcare system and achieve the desired patient-centered outcomes. Continuous professional education for all physicians also emphasizes competency-based training to provide high-quality patient care. In the CBME assessment, trainees are evaluated on applying their knowledge and skills to unpredictable clinical situations. A priority of the training program is essential in building competency development. However, no research has focused on exploring strategies for physician competency development. In this study, we investigate the professional competency state, determine the driving force, and provide emergency physicians' competency development strategies. We use the Decision Making Trial and Evaluation Laboratory (DEMATEL) method to identify the professional competency state and investigate the relationship among the aspects and criteria. Furthermore, the study uses the PCA (principal component analysis) method to reduce the number of components and then identify the weights of the aspects and components using the ANP (analytic network process) approach. Therefore, we can establish the prioritization of competency development of emergency physicians (EPs) with the VIKOR (Vlse kriterijumska Optimizacija I Kompromisno Resenje) approach. Our research demonstrates the priority of competency development of EPs is PL (professional literacy), CS (care services), PK (personal knowledge), and PS (professional skills). The dominant aspect is PL, and the aspect being dominated is PS. The PL affects CS, PK, and PS. Then, the CS affects PK and PS. Ultimately, the PK affects the PS. In conclusion, the strategies to improve the professional competency development of EPs should begin with the improvement from the aspect of PL. After PL, the following aspects that should be improved are CS, PK, and PS. Therefore, this study can help establish competency development strategies for different stakeholders and redefine emergency physicians' competency to reach the desired CBME outcomes by improving advantages and disadvantages.

Cultivating patient-centered care competence through a telemedicine-based course: An explorative study of undergraduate medical students' self-reflective writing

Background

The COVID-19 pandemic has encouraged adaptations of learning methods in clinical clerkship. There have been limited reports on the merits of involving medical students in telemedicine. This study, therefore, aims to investigate students' reflection on what they learned and identify the challenges and benefits of doctor-patient interaction through their experience in a telemedicine-based course.

Methods

A 4 week telemedicine-based course for medical students to participate in telemonitoring of COVID-19 patients undergoing self-isolation was conducted. This is a qualitative study using an interpretive phenomenology design to investigate students' self-reflection on their experiences in monitoring COVID-19 patients. Students were asked to reflect on their experience upon completion of the course through 750-1,000 words essays. A thematic analysis which considers units of meaning based on students' experiences was completed.

Results

Our study identified four main themes gathered from students' experiences related to the telemedicine-based course: communication and education, professionalism and professional identity formation, system-based practice, and patient-centered care.

Conclusion

The course was part of an integrative effort involving multiple parties to tackle the burden on the nation's healthcare system during the pandemic. Telemedicine is part of future medical practice which supports the medical curriculum adaptability along with attempts to develop future-proof medical doctors through various clinical learning experiences.