Allison’s first-year medical school curriculum includes basic science, clinical science, humanities, and the emerging field of health systems science (HSS).1,2She is learning much of the basic science through online modules, supplemented by faculty-facilitated, small-group peer discussions. Her anatomy “lab” experience is focused on prosections enhanced by virtual resources.3Allison is increasingly interacting with a variety of teachers, including health system leaders, quality improvement experts, health services researchers, community health workers, pharmacists, and nurses.1,2,4Complementing her classroom learning, Allison is immersed in a primary care clinic where she works with a care coordinator and physician to help patients navigate the health system and achieve desired health outcomes.5,6Despite limited exposure to Allison, the physician is the one mentor formally acknowledged as such by the medical school. While critical to Allison’s education, the interprofessional team members are not formally recognized or supported in their roles as educators.
From a distance, the medical school learning environment is not unlike a pond viewed from the shore—a seemingly predictable geography where students navigate learning with the tools we (medical educators) provide them, guided by educators, physicians, and scientists. On closer inspection of the pond, however, a whole new world appears. We see students learning from nonphysician and near-peer role models—that is, we see an informal and hidden curricular world in which our traditional, formal faculty are only a part of a complex ecosystem and changing narrative.7,8
What is going on here? What happened to the studied progression of knowledge and skills captained by physicians and scientists as envisioned by Flexner? Where are the long hours in lecture halls and laboratories, dissecting cadavers and conducting physiology experiments on animals and gram-staining specimens?9 And who are these individuals now teaching our students? Was medical education rescued from the chaos of unregulated and uninformed apprenticeships only to have us return to workplace learning supervised by individuals whose qualifications are unclear?10
Health care is transforming to increasingly focus on the quadruple aim of improving patient care and experience, improving population health, reducing costs, and improving physician well-being.11 These aims are catalyzing a restructuring of medical education to better prepare physicians to function in evolving systems and engage in changing systems of care to improve health.12,13 This mission to better prepare systems-ready physicians requires, in large part, a meaningful focus on HSS education. This “third pillar” of the medical student curriculum integrates with the basic and clinical sciences and includes knowledge and skills related to value-based care, quality improvement, social determinants of health, population health, informatics, and systems thinking.2,4,14 In undergraduate medical education (UME), numerous U.S. medical schools have begun comprehensively restructuring their curricula to address these areas. In graduate medical education (GME), the increased focus on the Accreditation Council for Graduate Medical Education’s systems-based practice and practice-based learning and improvement competencies and ongoing Clinical Learning Environment Reviews are reflective of this transition.15–18 In continuing medical education (CME), there is an awareness of the shifting competencies expected of health care providers and academic faculty, many of which relate to HSS.19–21 Within this movement, it is increasingly apparent that we do not have a sufficient number of trained systems-ready faculty to facilitate student and resident learning of and participation in, among other HSS concepts, quality improvement, interprofessional teamwork, or high-value care.19,20,22–24 At the same time, there is a continued shift in the identity of the profession that is moving away from sovereign physicians toward “collaboratively effective systems physician[s].”25 This shift in professional identity needs to be meaningfully demonstrated by everyone in the educational and clinical communities of practice.4,19–21,25–28 On the basis of our experiences at two U.S. medical schools that are expanding their curricula related to HSS, in this Perspective, we describe the impact of the expanding competencies expected of health care professionals, explore the need for educators in these areas, and offer key implications for medical education.
Starting in 2013, Penn State College of Medicine (PSCOM) and the University of California, San Francisco, School of Medicine (UCSF SOM) initiated several broad curricular transformations to accelerate training of systems-ready physicians, including medical students, residents, faculty, and interprofessional health system professionals and leaders, through the integration of HSS education across the continuum.1,2,5,29 Both schools designed and implemented new classroom-based curricula and experiential learning opportunities within clinical settings, including serving as patient navigators and quality improvement partners in health systems, for first-year medical students.5,30 At PSCOM, all 150 first-year medical students are enrolled in an HSS course, are immersed in a clinical practice site or program to work with interprofessional providers, and extend the work of the clinical site by working with patients to identify barriers to care and implement solutions.31,32 At UCSF SOM, all 150 first-year medical students begin each fall embraced as members of interprofessional clinical microsystems that they work in longitudinally over two years and spend one half-day per week defining and addressing a gap in quality, safety, or value to improve patient care processes or outcomes. As a result, both programs live the realities of shifting educator characteristics and skills because of these new competencies and interprofessional education, by requiring, in both classroom and clinical settings, current-day educators (i.e., residents and faculty) to expand their own skills to teach HSS competencies and a diverse array of health care professionals and leaders to embrace new roles as educators.
Expanding the Definition of Faculty Educator
The shift to a more collaborative, systems-based model of care and aligned goals in education and professional identity formation require the identification and development of qualified educators to design and implement curricula and role model new competencies at all levels of the education continuum, including UME, GME, and CME.14,19,20,25,33,34 These new and evolving roles run the spectrum from classroom instructors, to curricular developers and evaluators, to clinical supervisors and research mentors. Table 1 lists several categories of medical educators and for each category gives examples of the types of new and evolving educator roles and positions within our pioneering programs at PSCOM and UCSF SOM.35
In our own programs, we have found that many students are now ahead of the traditional faculty in HSS knowledge and skills. Similarly, most medical schools and academic health centers (AHCs) now face a conundrum: As medical education embraces a new paradigm, current professionals who role model and educate learners were not educated in this new paradigm.14,36 In addition, the clinical learning environment as a whole currently demonstrates a highly variable landscape of HSS and teamwork, further compromising educational outcomes.36,37 This is the challenge we need to address to ensure a successful culture change that reaches from classroom to bedside.
Clearly, we need to develop and support HSS competencies in our current faculty. But the substance of these competencies, along with the nature of the collaborative professional identity that we are looking for in our learners, mandates that we also need to look for role models outside of the well-worn lane of current-day educators. In medical schools, educators have traditionally been “intraprofessional” (e.g., MDs, DOs, and PhD scientists in preclinical curricula).38 Staff and faculty with degrees in other health professions, such as nursing or social work (i.e., “extraprofessional” in relation to the intraprofessional group mentioned above), have not been traditionally identified as core educators.38 However, considering the emerging HSS competency areas, it is important to include a significantly broadened cohort of professionals—including care coordinators and social workers who address social determinants of health and other factors that impact patient care, teams of experts in quality and health system improvement who collaborate with frontline clinicians to improve care delivery, and system leadership who actively address key issues in health care transformation and value—as core educators.14,36,39 Certainly, traditional physician mentoring remains, and will continue to be, critical to medical student education. Nonetheless, we argue that it is no longer enough. Interprofessional clinicians are now needed to help students expand their perspective of health care delivery, authentically apply teamwork skills and HSS competencies, and develop professional identities as collaborative, systems-thinking physicians.25,40,41
The impact of these shifts on the definition of academic faculty is significant. The term faculty implies a community of teachers and scholars and signifies that there is a fundamental academic component to a person’s professional roles and responsibilities.42 If desired educational outcomes could be accomplished only in traditional biomedical classrooms and physician-centric clinical sites, the familiar MD, DO, and PhD educators might suffice. But we see the beginnings of a cultural and process shift toward the inclusion of a broader range of interprofessional educators in our medical education programs, prompting a reenvisioning of learning environments to include a broad interprofessional cohort of educators as facilitators or leaders. We believe that medical educators need to reconsider how we define faculty and welcome these new faculty colleagues into our community of educators and development programs. Just as our students do, we have much to learn from them.
The Need to Lead Change
One hundred years ago, the Flexner Report10 highlighted the ongoing process of establishing a rigorous scientific foundation for medical education and practice. This reshaping of the profession required an increasing supply of qualified faculty from graduate programs and expanding residency training programs. Widespread efforts to nurture this professoriate resulted in the development of a remarkably broad and robust educational system. Now, on the heels of a “second Flexner report,”43 along with insights into the failings of our systems of care and the resulting accelerated evolution of clinical operations, we believe that today medical education is in a similar period of faculty evolution.43–45 The emergence of HSS is not only a curricular challenge but also a faculty challenge.36 Medical education programs are working to create new curricula while at the same time struggling to educate and train a group of educators skilled in both HSS content and the associated educational pedagogies needed to achieve and sustain this educational transformation. And it is important to note that successful transformation is not the only outcome at risk. AHCs and medical school faculty have a window of opportunity to lead and drive this change, rather than wait for other systems to shape the future of the profession. At times in the past, the medical profession has failed to get out in front of change. We believe that we currently have a window of opportunity to shape, lead, and support the wave of change facing AHCs and medical education.
Implications for Medical Education
Implication 1: The “new” educators we need are already here, working among us in our clinical environments
In our experience, content experts and educators do exist within our health systems and have the experience and expertise to help medical students learn emerging HSS skills.2,20,46 In addition to developing current faculty, we need to include colleagues with expertise who work in our AHCs and our communities as educators. For example, our programs are inviting the participation of interprofessional health care providers, such as nurses, nurse practitioners, physician assistants, care managers, patient navigators, social workers, and health system leaders (Table 1). These invitations have resulted in many examples, including the following, of new and evolving medical educator roles: the director of nursing ambulatory care leading a workshop entitled “Social Determinants of Health and Population Health Improvement” and the quality improvement chief working side-by-side with students to design and implement health system improvement projects. These individuals are employed by our AHCs and affiliated health systems and serve in a broad range of system roles. However, up until recently, they had not been formally asked to participate as teachers for medical students and residents. But the ground has shifted—our health care landscape has changed, so our educational processes and goals are also changing. In addition, residents and practicing physicians are now required to participate in quality improvement.47,48 Thus, the time is right for the alignment of UME and GME as we consider residents as both learners and teachers. As we seek to address these challenges, faculty, residents, and interprofessional colleagues are emerging as critical linchpins in our educational programs. Today, our learners cannot achieve core competencies without the participation of all of these groups.
Implication 2: We can help to develop the educational skills of both current and “new” educators as we create a new and more inclusive curricular scaffold for their efforts
To give medical students the lived reality of interprofessional collaboration in health care today requires both teaching skills and content expertise. We need to collaborate with our new educators to incorporate sound medical education principles and learning science into their educational strategies. Settling for data-heavy slide sets and lectures and neglecting the importance of role modeling in clinical settings are not options. We need to formally engage key faculty in curriculum development challenges and provide clinical faculty with the skills to assess learners on HSS-related concepts and skills.14,36 However, doing these things will likely have implications for interprofessional educators and administrators, nursing leadership, and clinical and quality staff who are busy and may not have been called on before to prepare for, or serve in, integral teaching roles within medical schools. The Liaison Committee on Medical Education requires that medical schools ensure that “all persons who teach, supervise, and/or assess medical students are adequately prepared for those responsibilities” and that they provide resources to enhance faculty’s teaching and assessment skills.49 Altogether, this will require medical schools and health systems to work together to both develop training experiences for new educators and make that training a meaningful part of their professional identities. Efforts to engage frontline educators (both in classroom and clinical settings) will likely require new professional development programs, such as the Teachers for Quality Academy at the Brody School of Medicine at East Carolina University, the Teach for UCSF Certificate Program in quality improvement and patient safety, and the PSCOM Health Systems Science Academy.20,33 Additional models are rapidly emerging and will likely involve the restructuring of medical school programs, professional development opportunities, and continuous quality improvement processes to achieve the ambitious and broad-based outcomes that health care is seeking in education and practice.
Implication 3: We can meaningfully acknowledge and reward our new educators
As the educator cohort expands and diversifies, AHCs must consider how to support efforts of contributing faculty, which potentially includes compensation and formal faculty status. Financial reimbursement and protected time depend on, in part, how each faculty member views his/her role within the AHC and whether he/she is reciprocally viewed as academic faculty. Many medical schools have addressed this compensation and acknowledgment challenge for full-time physician and scientist faculty through some variation on teaching metrics (e.g., educational value units) or funded faculty coaching roles.50 A collaboration between the American Board of Medical Specialties and UCSF SOM is one example of emerging efforts to award maintenance of certification or continuing education unit credits for physicians and health professionals who engage in medical student education related to quality improvement, which is an aim for professional society board recertification in multiple specialties. Other ways to acknowledge teaching efforts may include designation of volunteer faculty affiliation status for community physicians, “thank you” letters that include the clinical team members’ supervisors, and celebratory lunches or awards. Certainly, many schools have taken on the challenge of recognizing community physicians who welcome learners into their practices.41 However, a traditional physician- and scientist-centric framework does not adequately address the need to acknowledge, engage, and sustain a diverse group of interprofessional educators (e.g., care coordinators, nurse managers) who are increasingly key contributors to students’ professional development. Anecdotally, many health care team members describe the tremendous emotional rewards of working with medical students, including a significant increase in job satisfaction and a renewed sense of meaning and professional identity in having the opportunity to teach future physicians as a part of their daily work. Also, some quality improvement experts describe energetic and enthusiastic medical students infusing life into improvement efforts that would otherwise rely on busy clinicians focused primarily on patient care responsibilities. Akin to physician educators, interprofessional educators are busy and cannot be asked to take on significant educational tasks without being provided sufficient time in their job role dedicated to this mission. This will require collaborative planning with community sites, rethinking of educational metrics, and an expansion of our view of time allocation for nonphysicians. That said, anecdotal reports are beginning to emerge around the positive impact of the increasing inclusion of interprofessional educators on additional metrics of interest to health system leaders, including (as mentioned above) students reinvigorating quality improvement work that had been set aside by a busy team and the emerging role of being a teacher of future physicians adding new meaning to the daily work of medical assistants. As medical education broadens its view of the core medical school curriculum to include HSS and expands its view of faculty to include all of those with expertise in those areas, we need to be prepared to invest in, recognize, and reward these new colleagues.
Potential Impacts of Redefining the Professoriate
We envision several positive outcomes of reframing educators’ roles in U.S. medical schools. First, new educators with HSS competencies allow for the cultivation of the next generation of physician leaders so that they are prepared to lead system transformation. These future leaders and change agents will ideally emerge from medical school programs that support a collaborative, systems-oriented mind-set and professional identity formation; promote meaningful learning that is critical to high-quality patient and population care; and expose students to current system leadership, providing them with opportunities to observe health care from a different perspective and participate in scholarly projects. Establishing an early mind-set and professional identity as a future leader and change agent allows learners the opportunity to realize these roles and influence the success of health care transformation.
These shifts in medical education and associated educational relationships can also better align the clinical and education missions of AHCs. New educator roles and skills in classroom and clinical settings can serve a boundary-spanning role in AHCs and help to improve patient health. For example, recent work has described new GME roles that bridge educational programs and health systems, such as director of the clinical learning environment, associate dean for quality improvement, and quality improvement chief resident.37,51 At the UME level, the paradigm shift toward a three-pillar education model that includes HSS has created similar opportunities to develop new roles to lead HSS education efforts (e.g., associate dean for health systems education).4 In both UME and GME, these new education programs and roles are directly aligned with the mission of most AHCs and can help catalyze synergies at the nexus of the clinical and education missions.52
Finally, at the highest level, a medical school program with a shared mental model of education, using expertise from the entire health system, can help facilitate the journey toward becoming a learning organization.24,53
Medical schools are innovating to educate systems-ready physicians, requiring a fundamental reenvisioning of the definition of teachers and educators in and around AHCs. This process of redefining who teaches our students on the basis of emerging competencies will be critical to the success of medical education and health system transformation. It will also require an investment to highlight a combination of expertise in the workplace and education, and a new group of individuals will need to be supported and validated as valued faculty members. From the medical school and health system perspectives, transformational changes in health care are mandating reciprocal changes in the curriculum and professional development of the providers who will support and work in these evolving systems of care. Within this new landscape is a group of individuals with a remarkable range of perspectives and expertise critical to the care of patients and populations. It is time for us to welcome them as faculty.
Acknowledgments: The authors would like to acknowledge the clinicians in collaborating health systems who hosted students for systems educational experiences.
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