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Educating for the 21st-Century Health Care System

An Interdependent Framework of Basic, Clinical, and Systems Sciences

Gonzalo, Jed D. MD, MSc; Haidet, Paul MD, MPH; Papp, Klara K. PhD; Wolpaw, Daniel R. MD; Moser, Eileen MD, MHPE; Wittenstein, Robin D. EdD; Wolpaw, Terry MD, MHPE

doi: 10.1097/ACM.0000000000000951
Perspectives
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In the face of a fragmented and poorly performing health care 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, health care delivery, and teamwork. In this article, 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, the 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 health care system. Authors describe the Systems Navigation Curriculum, currently implemented for all students at the Penn State College of Medicine, as an example of this three-pillar educational model. Simple adjustments, such as including occasional systems topics in medical curriculum, will not foster graduates prepared to practice in the 21st-century health care system. Adequate preparation requires an explicit focus on the systems sciences as a vital and equal component of physician education.

J.D. Gonzalo is assistant professor of medicine and public health sciences and associate dean for health systems education, Penn State College of Medicine, Hershey, Pennsylvania.

P. Haidet is professor of medicine, humanities, and public health sciences and director of medical education research, Penn State College of Medicine, Hershey, Pennsylvania.

K.K. Papp is adjunct professor of medicine, Pennsylvania State University College of Medicine, Hershey, Pennsylvania.

D.R. Wolpaw is professor of medicine and humanities, vice chair for educational affairs, Department of Medicine, and director, Kienle Center for Humanistic Medicine, Penn State College of Medicine, Hershey, Pennsylvania.

E. Moser is associate professor of medicine and associate dean for medical education, Penn State College of Medicine, Hershey, Pennsylvania.

R.D. Wittenstein is assistant professor of public health sciences, Penn State College of Medicine, and chief operating officer, Penn State Hershey Health System, Hershey, Pennsylvania.

T. Wolpaw is professor of medicine and vice dean for educational affairs, Penn State College of Medicine, Hershey, Pennsylvania.

Funding/Support: The Systems Navigation Curriculum at the Penn State College of Medicine was developed with financial support from the American Medical Association (AMA) as part of the Accelerating Change in Medical Education Initiative.

Other disclosures: To the authors’ knowledge, no conflict of interest, financial or other, exists for all authors. The views expressed in this paper reflect the views of the authors and do not necessarily represent the views of the AMA or other participants in this initiative.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Jed D. Gonzalo, Division of General Internal Medicine, Penn State Hershey Medical Center–HO34, 500 University Dr., Hershey, PA 17033; telephone: (717) 531-8161; e-mail: jgonzalo@hmc.psu.edu.

In his Commentary “The Woman in the Mirror,” Frank Huyler1 describes his encounter with a homeless, schizophrenic, morbidly obese woman who presents to the emergency department drunk, belligerent, and suffering an acute anterior myocardial infarction. A stent placed several weeks earlier had clotted, due mainly to the absence of an expensive but important medication that prevents clotting. Despite arrangements to obtain the medication for free, the patient could not manage bus fare to pick it up.

After weeks in the hospital and after many hundreds of thousands of dollars were spent, she survived. Then she was discharged back to the street…. Where to start? It’s hard to know. Do we start with examining how society views and treats the mentally ill? Do we start questioning the wisdom of the cardiologist who put a stent into a schizophrenic, alcoholic street person, knowing that compliance with an outrageously overpriced medication would then be vitally important? If the cardiologist had not put in the stent, would we fault him or her for failing to provide the standard of care? Why do we spend $7,000 on a stent, when we do not consider providing the patient with housing and food [or bus fare]?1

Dr. Huyler was writing about the role of the humanities in medicine and medical education, but could have been writing about the U.S. health care system, capable of activating a technologically advanced catheterization laboratory and highly trained specialists to save a patient who really only needed a bus voucher. The evidence for a high-cost, fragmented, and low-performing U.S. health care system is not new.2 To address these insufficiencies, policies such as the Affordable Care Act are prompting health care systems to react, reorganize, and consolidate, creating a practice environment fundamentally different from that of the past. Trends are shifting away from the solo practitioner to care delivered by interprofessional teams.3 Health care outcomes are evolving from individual patient health to the Institute for Healthcare Improvement’s “triple aim” of improving patients’ experiences, promoting population health, and reducing cost.4 With the advancement of electronic medical records, data management systems, and payment systems changes, health care will increasingly focus on proactive management of disease for populations, rather than focusing solely on individual patients. These new directions in health care represent fundamental paradigm shifts for the traditional role expectations of physicians. However, our education remains focused (as in Dr. Huyler’s story) on learning the pathophysiology of atherosclerosis and treatment of coronary artery disease. Something is missing. Where are we providing learners with parallel engagement in the patient experience or systems sciences?

In her seminal challenge in 2013, Catherine Lucey5 called for a reexami nation of medical education and incorporation of “systems sciences” into the medical curriculum. Where to start? What if we located systems education in core educational efforts alongside traditional sciences? What if we provided the tools to understand the diseases of patients like Dr. Huyler’s and then created opportunities for students to work with these patients to identify and address barriers to care? We believe there is an urgent need to reframe the fundamental conceptual model of medical education. In this article, we examine the current state of medical education with respect to systems sciences and propose a new model for educating physicians to practice in today’s health care environment.

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The Three-Pillar Framework of Medical Education

Since the Flexner report, most medical schools have educated students first in the basic sciences, then in the clinical sciences.6,7 Although many schools have challenged this traditional framework by creating early clinical science opportunities and revisiting basic sciences during later years, the general system of education is still based on this dyad. Concurrently, it is increasingly recognized that for future physicians to work in complex health care systems, they will need to have knowledge and abilities related to health care financing, population health, quality improvement, socio-ecological health, informatics, teamwork, leadership, and other areas related to the science of health care delivery.5,8,9 These systems sciences are highly interdisciplinary and distinct from either traditional basic (e.g., physiology, biochemistry) or clinical (e.g., pediatrics, surgery) sciences, necessitating changes that require innovative and integrated pedagogical strategies and a fresh vision for our educational framework.

We believe medical education must align with the needs of the evolving health care system and provide students with opportunities to develop systems science competencies, since proficiency in systems knowledge and skills has become increasingly important to understanding and navigating the growing complexity of the health care system. This transformation will reframe the traditional two-pillar relationship of basic and clinical sciences to an interdependent three-pillar framework of basic, clinical, and systems sciences.5,9 Although some education programs now include systems-based topics in the curriculum, they are finite, isolated, and not an explicitly integrated focus of curriculum reform.10,11 We suggest that although medical schools have assistant- or associate-level dean positions dedicated to basic and clinical sciences, the shift to a three-pillar framework would require similar dean-level positions in systems sciences dedicated to the design and integration of these systems sciences into the curriculum. Additionally, a rebalancing of cognitive and curriculum space to include these systems sciences is required to allow for successful integration. Currently, basic and clinical science learning are contextualized in a variety of doctoring experiences. The shift to a three-pillar framework would require the creation of opportunities to also apply systems sciences outside of the classroom. In short, under the three-pillar model the systems sciences would be offered with the same importance, focus, and attention as the clinical and basic sciences.

Bold changes do not come easily and are not to be taken lightly. A three-pillar framework necessitates an intensive, critical review of the goals and objectives of a school’s educational program. Adding content to an already-overloaded curriculum will not work. Educators need to grapple with fundamental questions about the role of the traditional classroom and the need for large volumes of fact acquisition, when the students will ultimately be practicing in an era of rapidly expanding health informatics and point-of-care resources.12,13 We need to combine well-validated learning principles across the entire curriculum to create a whole that aligns with greater public interest.8 Additionally, the relative lack of representation of systems sciences on board examinations and in residency expectations creates significant barriers to engage students in this new learning agenda. These challenges must be addressed prior to and during implementation of a three-pillar model.14 If we want adaptive educational systems that continuously anticipate societal needs, we need to engage and connect all three pillars with fresh eyes.

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A Systems Curriculum Within a Three-Pillar Education Framework

We present a model for a systems curriculum embedded within a three-pillar educational framework that functions interdependently with the basic and clinical sciences. This systems curriculum has two pedagogical components: a classroom-based conceptual component and a health-system-based experiential component. The conceptual and experiential components are designed to be simultaneous and mutually reinforcing (Figure 1). In the conceptual component, students would learn about and wrestle with issues relevant to health care delivery in organizations, communities, and social networks using the systems sciences, preparing them for practice in systems-based roles. In the experiential component, students would practice using systems concepts to improve patient care in real-world environments across the health care system. This experience-based component should foster students’ awareness of the relevance for learning the fundamental concepts of systems sciences, as well as motivation for such learning.15 Both components should be designed so that students can discover connections between them, subsequently reinforcing their learning in one by participating in the other.

Figure 1

Figure 1

Several authors have suggested content suitable for the conceptual component, including care coordination, patient safety and quality improvement methods, and teamwork.10,11 Although concepts have been proposed and some implemented, there is comparatively little discussion about the way to share a robust experiential component.5,9–11 While various activities may be appropriate, we suggest that the ideal experiential component will fulfill three criteria:

  1. It will allow for an authentic practice experience;
  2. It will allow direct experience with core systems-based practice concepts; and
  3. It will allow students to view the system through the eyes of the patients receiving care within it.

First, authentic practice experiences are critical, as they enhance students’ motivation to participate in both the experiential and conceptual components.15,16 Students performing essential roles in the health care system are more likely to seriously engage in both curriculum components. Second, temporally aligned direct experience will help to anchor and enhance transfer of learned systems-based concepts to real-world practice. Such curricular reinforcement may lead to students applying lessons learned to future clinical practice, as well as cultivation of physicians more likely to adopt the systems-thinking perspectives needed for 21st-century practice.17 Finally, seeing the system through patients’ eyes helps students remain connected to the very populations health care systems are created to serve. Because students are the future practitioners, leaders, and designers of health care systems, we believe an education grounded in patients’ experiences will lead to the development of systems more aligned with patients’ needs.

Returning to Dr. Huyler’s patient, the traditional medical student role might have involved observing complex catheterization lab activities and subsequent hospital care, and case conferences on acute myocardial infarctions and stent management. These can be important student–doctor learning experiences, but they do not qualify as authentic, engaged health care roles because students are “educational bystanders” in care delivery processes. Using the expanded lens to view the skills required of future physicians, we see that patients frequently do not require traditional physician-centric skills, which are perceived as “higher stakes.”9,15,18–20 Rather, patients require “care” in areas not labeled as biomedicine, but classified more broadly into social or systems issues.21 Early depth-focused experiences within health systems provide a high-leverage area for student participation in authentic, meaningful workplace roles. We believe that patient navigation provides students with a participatory role in providing systems-based patient care in a way that parallels and enhances traditional clinical experiences.

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Patient Navigation as an Authentic Systems Science Role

There is a growing literature on student participation in health care systems such as student-run free clinics, emergency medical technician training, and longitudinal integrated clerkships.9,19,20 Although these opportunities could be linked to systems sciences learning, we believe the role of patient navigation is an excellent candidate for the experiential component of a systems curriculum. First implemented in 1990, patient navigation is a strategy that helps bridge gaps in health care delivery, overcome patient and systems-based barriers, reduce delays in diagnosis/treatment, and improve outcomes.22–24 Patient navigation uses outreach workers to help patients maneuver through complex systems to obtain better care. Working with patients and providers in the organization and community, patient navigators connect patients to resources, assist patients in completing care plans, educate patients about medical issues, and/or identify and remove impediments to care.25,26

Creating opportunities for students to serve as patient navigators fulfills the three criteria for an ideal experiential activity. First, many health care systems either lack or are in need of this value-added role, and students are positioned to make meaningful contributions through their authentic practice experiences. Second, patient navigation brings students into direct contact with many systems concepts, including access, financing, community-based services, and systems inefficiencies. Third, patient navigation is inherently patient centered, requiring an understanding of patients’ social contexts and perspectives. Finally, since many models of patient navigation have demonstrated that lay personnel can function effectively as navigators, students can perform navigator duties early in medical school without prolonged training.18

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An Example of a Systems-Based Curriculum: The Pennsylvania State University College of Medicine Systems Navigation Curriculum

In the fall of 2014, we developed and implemented a new curriculum for all medical students at the Pennsylvania State University College of Medicine (PSUCOM)—namely, the Systems Navigation Curriculum (SyNC). This curriculum consists of conceptual and experiential components: (1) the Science of Health Systems Course, and (2) patient navigator experiences. In total, these two components involve an average of three to four hours per week in our students’ first two years of medical school. Both the course (conceptual component) and navigation experiences (experiential component) allow students to develop the knowledge, attitudes, and skills to function effectively amid the complexities of an evolving health care system. SyNC’s goals are that students:

  1. Demonstrate a holistic approach to health care, including psychological, social, and systems-based elements;
  2. Describe and deliver population- and patient-centered care;
  3. Participate as effective members of medical and community-based interprofessional teams;
  4. Demonstrate proactive rather than reactive thinking and decision making; and
  5. Make value-based decisions in medical care.

The Science of Health Systems Course spans the first 17 months of the students’ undergraduate experience and is simultaneous with course work in basic and clinical sciences. Students learn concepts of the science of health care delivery, including financing, population and public health, socio-ecological medicine, high-value care, teamwork, leadership, and evidence-based medicine (Chart 1). They simultaneously apply these concepts in their roles as patient navigators within the health care system.

The year prior to the launch of the program, we embarked on developing a network of patient navigator sites in south central Pennsylvania. We partnered with several health systems with a wide range of clinical sites, including patient-centered medical homes, inpatient discharge programs, a surgical weight loss program, and a state-run tuberculosis clinic, among others. We identified clinical sites that could identify a patient population in need of patient navigation and were willing to collaborate with PSUCOM to build a sustainable network. Patient populations in the network include a spectrum of issues and patient types. For example, several sites include a focus on patients considered to be superutilizers—that is, those with frequent hospital readmissions.27,28 In all settings, students are embedded into interprofessional clinical teams functioning in a nonphysician role and linked with site mentors (e.g., patient navigator, care coordinator) to guide them through patient navigator activities for the duration of one academic year. When students return to the concurrent Science of Health Systems Course, they work in small-group “SyNC Teams” composed of students with heterogeneous experiences across different clinical sites. This intermixing of experiences allows for enriched reflections and discussions about patient-centered issues, expanding the breadth of teams’ discussions. We also believe that given the opportunity to work as a valued member of a health care team and view the role of the doctor from a nonphysician perspective, our students will develop professional identities that incorporate an understanding of meaningful collaboration and alternative perspectives. Students have the opportunity to see firsthand the interdependence of their biomedical, clinical, and systems studies as they play out for the patients they help navigate.

Although we designed SyNC for our undergraduate medical education program, we propose that the three-pillar framework is applicable across health professions educational programs. Many professional programs, including nursing, nurse practitioner, pharmacy, and physician assistant (PA) programs, are beginning to incorporate systems education into their curricula. For example, PSUCOM’s PA program has already recognized the value of the systems science pillar with a full course dedicated to health care delivery and systems; additionally, we have begun to build interprofessional activities as part of the PA and medical school curriculum. Review of the interprofessional competency statements by several authorities (e.g., the Interprofessional Education Collaborative, CanMEDS) reveals competencies for interprofessional practice that are firmly grounded in the systems sciences.29,30 We believe this three-pillar model may represent an important frame shift for education in multiple health professions.

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Conclusion

Systems failures are not always as dramatic as that described in “The woman in the mirror,” but similar stories play out in myriad frustrating ways throughout our health care system. Governmental and health care organizations have begun to address the gaps in focus and the misdirected resource allocations that allow this to happen, though these efforts are frequently uneven and tentative. The medical education community has recognized the problem, but adaptive changes in educational planning and strategies have been slow. There is simply too much baggage in the traditional two-pillar curriculum of basic and clinical sciences for simple adjustments to work. We suggest that, given the rapid changes taking place in the design and organization of health care, medical education too needs to evolve rapidly. The shift from the two-pillar curriculum to a new three-pillar triad of basic, clinical, and systems sciences will better prepare physicians for practice in the 21st century. The three-pillar framework, applied in the PSUCOM SyNC, represents a fundamental frame shift in medical education, one that is a critical step in aligning medical education with the world of practice that students will enter. The transformation to a three-pillar educational framework formed by the interdependence of basic, clinical, and systems sciences can be a powerful engine for fueling how we prepare students to “be the change” that is so clearly needed in our health care system.

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