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

Gonzalo, Jed D. MD, MSc1; Wolpaw, Daniel R. MD2; Cooney, Robert MD3; Mazotti, Lindsay MD4; Reilly, James B. MD, MS5; Wolpaw, Terry MD, MHPE6

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doi: 10.1097/ACM.0000000000004598
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Abstract

In 1999, the Accreditation Council for Graduate Medical Education (ACGME) made the bold and prescient move of establishing systems-based practice (SBP) as 1 of 6 core competencies in its organizing vision of resident education. 1 The SBP competency was a critical articulation of a previously underrepresented domain in medical education, reflecting a clear recognition of growing evidence that health care delivery and systems directly affect patient outcomes and need to be addressed in medical education. 2–6 The SBP competency requires “Residents to demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care,” and delineates 6 subcompetencies focusing on collaboration, cost, advocacy, and health system improvement (see Box 1); examples include incorporating social determinants of health into clinical workflow and decision making or implementing a high-value care curriculum. Since that time, medical practice has continued to evolve, adding important focus to systems-based areas such as team-based care; collaborative leadership; technology; population health; and the social, organizational, and economic determinants of health. 7–11

From largely aspirational beginnings, SBP has made significant progress in definition and application. 3–6 Since the early 2000s, nearly all U.S. graduate medical education (GME) programs have established curricula in patient safety (PS) and quality improvement (QI). 12 More recent ACGME SBP milestones highlight critical systems learning goals and are increasingly integrated into resident work processes. 13,14 Despite these advances, the full potential of SBP as a meaningful driver in the GME learning space has not been realized. 15 In recent years, the ACGME’s Clinical Learning Environment Review (CLER) has identified significant gaps in resident education in multiple SBP-related areas, including PS, QI, care transitions, and health care disparities. 16,17 In contrast to the significant strides that have been made in other ACGME competencies, 20 years after its creation SBP remains an important idea without significant traction, struggling to become an equal partner for trainees and faculty alike. 4,5,18,19 Variability in interpretation and application of the SBP competency and milestones, both within and across GME programs, has impeded the development of a cohesive approach to teaching, monitoring, and assessing learners and GME programs. Systems-based competencies are often relegated to isolated pockets across the education continuum depending on local context, including curricular priorities and available expertise. 20–22 This inconsistent, patchwork pattern of implementation affects both professional development and patient outcomes. The immense promise and opportunity of SBP is likely to remain aspirational in the absence of an organized strategy that clarifies, prioritizes, and integrates these principles and perspectives in the clinical learning environment (CLE).

The catastrophe of COVID-19 has likely only accelerated the stuttering developmental trajectory of SBP. The pandemic has forced medical and public health professionals to move beyond disease management and directly take on complex challenges without precedent in modern health care. We have been compelled to address how and why our patients arrived at this point, how our systems have responded (both good and bad responses), and how we can work together to change the narrative of the next pandemic. It has taken a global health care tragedy to move SBP out of the shadows and into a central role in how we think about and address illness and the needs of patients and populations. During the height of the initial surge, one critical care physician observed, “If you try to treat the virus with an ICU mentality [rather than a public health/epidemiology perspective], you will fail. Most papers speak about ICU care—when you see an article about ICU care, throw it in the garbage.” 23 As we work to transition to a postpandemic world, we need to remember and reengage the ways of seeing and thinking that transformed a critical care physician into a citizen of a larger health care landscape. The pandemic has made it clear that SBP can no longer be treated as a marginalized competency and needs to be the primary lens through which we focus our traditional knowledge and skills.

Our efforts to accelerate increasing the footprint of SBP began in 2018 when we assembled a network of medical educators from 4 U.S. academic health organizations (Geisinger Health, Kaiser Permanente, Allegheny Health, and Penn State Health) representing diverse approaches to systems of care and health systems education, to explore how SBP must evolve to better meet the needs of patients and health systems. Based upon these experiences, in this article we articulate 5 key priority areas required for the evolution of SBP and highlight key strategies and a potential path forward. Our goal is to catalyze an ongoing dialogue between medical education and health systems to advance a shared vision for SBP and improve patient health.

Evolution of the SBP Competency

While SBP outlines a high-priority, systems-based performance domain, its realization has been challenged by several limitations, all of which can inform improvement areas. First, although a systems-based competency, SBP was not originally established in partnership with sponsoring health systems. As a result, there is a persistent gap between the goals of GME and of health systems. Second, during the initial design and implementation phases of the competency, a comprehensive conceptual framework for the content and skills of SBP had not been developed, resulting in ambiguity and diversity in the approach to implementation. Individual GME programs most often pursued fragmented educational efforts with variable connections to medical centers and health systems. To date, most efforts have focused on QI/PS, which, though important, represent only parts of the larger SBP competency. 11 The last decade has seen the development of a more comprehensive and unifying framework for systems-based education and care delivery: health systems science (HSS). 7–11 Third, a trainee’s achievement of competence in SBP is dependent upon CLEs. 4,16,17 An effective and supportive CLE is critical to patient outcomes, the well-being of the medical workforce, and trainee learning and socialization into the profession. 4,24 However, the CLE is a complex environment influenced by health system operating principles, faculty expertise, and trainee engagement. Consequently, any interventions aimed at advancing the principles and practice of SBP must consider the role of health systems in creating opportunities for learning and practicing SBP (i.e., affordances), the importance of faculty development along with the validation of faculty contributions to SBP, and the need for collaboration and alignment with GME programs. 25 These limitations to the evolution of SBP highlight the complexity of the challenge and also provide a roadmap for a way forward. Below we examine 5 priority areas that need to be addressed to effectively advance SBP over the next decade. We outline each area, provide a brief description of the current state and/or challenges, and propose improvement strategies. Table 1 highlights these changes in each area from current to envisioned status, while Table 2 addresses how each SBP subcompetency could be evolved in relation to each of the following priority areas.

T1
Table 1:
Priority Areas for Evolving the SBP Competency Over the Next 10 Years
T2
Table 2:
Mapping Accreditation Council for Graduate Medical Education SBP Competency and Subcompetencies to Priority Areas for Evolving Systems-Based Practice

Priority area 1: Comprehensive systems-based content

As a new foundational science of systems-based concepts, HSS has been established for medical education, research, and clinical operations, and directly informs the evolution of SBP. 7,26,27 Supported by the American Medical Association’s Accelerating Change in Medical Education Initiative, the comprehensive HHS framework has been adopted by many medical schools as a “third pillar” of medical education along with biomedical and clinical sciences. 7–11,28 Defined as “the principles, methods, and practice of improving quality, outcomes, and costs of health care delivery for patients and populations within systems of medical care,” HSS encompasses 12 distinct learning areas, including population health, interprofessional collaboration, clinical informatics, value-based care (including PS), health system improvement, and systems thinking. 7–11 In our prior work, which mapped the SBP competency, milestones, the related practice-based learning and improvement competency, and other GME frameworks to the more comprehensive HSS framework, we highlighted important gaps. 11 In coming years, we anticipate SBP content will move toward a comprehensive framework more aligned with HSS as the foundation for education and assessment.

Priority area 2: The professional development continuum

There has been increasing focus on gaps and poor alignment in the progression of learners from undergraduate medical education (UME) to GME and into the role of practicing physician and continuing medical education (CME). 29 In UME, medical schools have adopted locally contextualized frameworks such as core competencies and the Association of American Medical Colleges’ Core Entrustable Professional Activities for Entering Residency. 30–32 Programs in GME, on the other hand, adhere to national accreditation standards of competencies and milestones. At the practicing physician level, very few commonly accepted frameworks exist. In the case of SBP or HSS, there is little in the way of expectations outside of hospital privileging requirements and obtaining the CME credits necessary for licensing. The lack of a unified framework across the professional development continuum to guide educational advancement compromises systems-based learning and readiness for practice. Implementing a comprehensive, aligned, and developmental SBP curriculum can enhance progression along the professional development continuum while simultaneously optimizing health outcomes.

Priority area 3: Teaching and assessment methods for SBP

Despite escalating efforts to weave HSS into UME and the presence of SBP in GME, educational programs continue to focus largely on biomedical and clinical sciences. 7,19–21 Efforts to address SBP tend to be tethered mostly to PS/QI (e.g., improvement projects, reporting safety events, etc.), with some increasing attention to social determinants of health and high-value care. 33–36 These efforts, however, can often be approached in a pop-up manner, more like a “to-do” list rather than a coordinated design. Trainee assessments in SBP largely follow this checklist approach. Deficiencies in knowledge, skills, or attitudes in SBP may be noted, but are rarely linked to competency-based advancement or remediation. Reasons for this suboptimal linkage are complex and include CLEs that are not designed to assess trainees’ SBP competence, insufficient workplace-based assessments, and teaching faculty who never learned these areas and feel unprepared to mentor or assess trainees. 19,20 Trainees will respect what we inspect, and currently, most GME programs are not significantly inspecting SBP. We view this as an opportunity. With health systems increasingly prioritizing systems-based outcomes that are significantly influenced by the contributions of GME trainees, and with programmatic oversight such as CLER, there are emerging opportunities to strengthen the alignment, teaching, and assessment of these SBP outcomes. In coming years, a robust library of SBP workplace-based assessments and significant focus across and within GME programs will be required to effect meaningful change.

Priority area 4: CLEs in which SBP is practiced and learned

Students, residents, physicians, and all clinicians live, work, and grow as professionals within CLEs. The 4 components of CLEs are personal (one’s engagement and identity formation), social (role modeling and interactions with others), organizational (culture, curricula, infrastructure), and physical/virtual (space to promote learning, online resources). 24,37 The CLE is the location that nurtures the knowledge, attitudes, and behaviors relating to SBP and an individual physician’s role as a systems citizen (see below). 38–42 For nearly a decade, CLER has evaluated CLEs of U.S. residency programs and identified significant gaps in an academic health system’s ability to facilitate resident education in multiple SBP-related areas, including PS, QI, and care transitions. 16,17 Any effort to realize the potential of SBP must focus on the development of supportive CLEs. Without this pairing of curricular intent and applied day-to-day practice, SBP will remain added-on, formal “classroom” work that lacks meaning or authenticity. 18 Current-day CLEs involve overlapping partnerships between medical schools and numerous external stakeholders, including physicians, hospitals, health systems, and universities (to name a few), all of which can both enable and impede change within learning environments. In the context of forward-looking health systems actively innovating clinical care to achieve the quadruple aim of medical training and education programs seeking to advance learners’ professional development to align with this goal, we see an opportunity in coming years to gain a deeper understanding of the attributes and affordances of high-functioning CLEs. 4,43–45 We anticipate that leveraging the transparency of the CLE’s positive attributes and potentially linking CLER with accreditation can better align health systems and GME programs to foster a cycle of continuous collaborative improvement in CLEs.

Priority area 5: Professional identity as systems citizens

The last priority area addresses the necessary shift in professional identity from the traditional “sovereign physician” to a systems citizen who embodies the mindset, knowledge, and behaviors of SBP along with expertise in all other competency areas. 38–42,44,45 A notion originally articulated by Senge, systems citizens build genuine partnerships across boundaries, see patterns of interdependency, discern how a system is functioning, and connect with others to engage in a process aimed at achieving outcomes. 38,39 When applied in GME, the concept of systems citizen identity translates to residents who take on the rights and responsibilities of citizens in a transformed CLE—they become fluent in the language of teams, knowledgeable across the full spectrum of SBP and HSS, and apply systems thinking skills in the process of collaborating, advocating, learning, caring, and leading. They not only care for individual patients but also know how to perform in developing systems of care, embodying the motivation to grow and contribute to the evolution of the health care system itself. 44–47 Up to this point, physicians have largely been on the receiving end of this seismic shift from independent professional to moving part in a large, compartmentalized system. 45–47 Recapturing the motivation and engagement to actively contribute as citizens of a transformed CLE “country” will require the training, assessment, and implementation of an evolved SBP. Trainees come to the field of medicine to make a difference—we need to make that possible in the health care systems of today and tomorrow.

How Can We Address These Priorities?

Addressing the 5 priority areas we have articulated to hasten the evolution of SBP represents a series of complex adaptive challenges. Technical fixes in the form of standardized coursework or resident activities are at best intermediate endpoints, and at worst distractors from our real goals. With the example of the COVID-19 pandemic fresh in our experience, educators and health system leaders must come to consensus on the depth and breadth of the outcomes and impacts that should be valued, as well as the necessary processes and outputs to reach those outcomes. This will involve accessing the full range of stakeholder inputs, embracing the compelling framework of HSS, innovating and co-creating in the CLE, and developing our current faculty while we educate our future faculty. Bringing clarity to SBP will require innovation at multiple levels, from national platforms (e.g., advanced work in SBP milestones, CLER program, accreditation expectations) to systems thinking in local workplace environments. Here we articulate 4 ways in which medical education and health systems can accelerate the evolution of SBP.

Embracing complexity with systems thinking

The evolution of SBP must be viewed as a complex adaptive challenge rather than a technical one, and requires embracing a systems thinking mindset. Systems thinking is at the heart of SBP and HSS; it describes behaviors and ways of approaching problem solving and change that are open-minded, reflective, and founded on well-established strategies of critical analysis. 10,47,48 For example, challenges and failures that occur in health care delivery must be viewed as opportunities for both individual and system learning and growth. While there is content and skill embedded in the SBP learning agenda, professional development in this area relies on the ability to navigate uncertainty and innovate collaboratively in the face of the complex landscapes of clinical care for both individual patients and populations. Facilitators and barriers to successful SBP in GME programs and CLEs must address both the culture and assessment of learning. Readiness for practice, which clearly includes SBP, must be viewed through the rigorous lens of systems thinking rather than the binary and limited perspective of right or wrong decisions or answers.

Facilitating change through coproduced processes and outcomes

Operationalizing SBP in local environments cannot be done reactively or opportunistically. The structure and process of change should be intentionally developed among all stakeholders, including medical educators, trainees, and health system leaders. 49–52 Any formal change proposals need to embrace the tenets of coproduction as the “interdependent work of educators and health system leaders to make better use of each other’s assets, resources, and contributions to achieve better outcomes for education and healthcare.” 50 Although SBP may be viewed as an education outcome, it is at the core a patient care and workforce outcome that will require co-investment by all stakeholders in U.S. academic health systems to be fully realized. Unlike UME, where forward-looking educators and administrators may have significant leverage to innovate, GME is embedded in practice environments that reflect the needs of diverse stakeholders: health systems, departments, local and national GME administrations, education leadership, residents, and patients, including those who seek our care and those who need our care. Any viable path forward requires recognizing, validating, and empowering each of these groups under a shared vision, shifting from our embedded model of institution-centered thinking to a continuous process of coproduction in a shared platform. Investing in the right process to address current and future complex challenges will in the long run outperform any defined plan, no matter how enlightened.

Creating new roles to drive alignment of system and educational goals

From a structural perspective, an organization that can successfully link education and health care delivery goals is more likely to accomplish paired advances in both learning and patient care. Supporting and advancing this linkage will require insightful leadership and likely new dedicated roles. Our 4-institution network has invested in developing one of these new structural roles at each site—a GME Clinical Systems Accelerator (CSA), which extends the Bridging Leader role described in the literature. 53,54 The CSA is an individual (or small team of individuals) who translates SBP concepts into practice within CLEs. They bring the design work directly to GME programs and CLEs by developing working partnerships and design thinking pods to bridge the gap between theory and practice. This new work process can allow for the dedicated thinking needed to identify opportunities for frontline stakeholders to create and innovate in a landscape where systems, patient care, and education coexist in the same health care delivery ecosystem. It is likely the COVID-19 pandemic stress test, with associated insights into effective leadership strategies and critical new roles, will be important to these developmental efforts.

Using empathy and design thinking to propel improvement efforts

From a process perspective, new methods for performing the work within local environments with diverse stakeholder groups are necessary for meaningful change. 55 Design thinking involves iterative cycles of identifying complex challenges through understanding end-user perspectives, developing opportunities for intervention, and generating pilots to test and reevaluate. We view design thinking as a well-defined approach to continuous QI that is specifically structured to address complex challenges. As such, it can be flexibly applied across diverse institutions, particularly with SBP. The process of design thinking not only advances the professional development of our trainees but also integrates and highlights the needs of diverse stakeholders, including patients and system leaders. Change is hard. Residency programs must adopt new ways of going about the work of change to have a meaningful impact on the professional development of learners, health of our communities, and systems of care.

Concluding Observations

Medical education in the United States is taking significant steps to better align education with the needs of patients, communities, and health systems. Developed over 20 years ago, the SBP competency opened the necessary space for a new learning agenda to help close this educational gap. There is now a critical need for education and health systems to come together to evolve SBP and work toward shared goals, and this need has been brought into high relief by the current pandemic. Addressing priority areas—comprehensive systems-based learning content, the professional development continuum, teaching and assessment methods for SBP, CLEs in which SBP is learned and practiced, and professional identity as systems citizens—are essential to achieve desired outcomes. Strategies to align education and health systems include embracing complexity, coproducing processes and outcomes, creating new roles to facilitate alignment, and using design thinking. The coproduced work of education and health systems can accelerate the change needed to fully realize the potential of SBP, cultivate systems citizens, and improve patient outcomes.

Box 1

Accreditation Council for Graduate Medical Education Definition of Systems-Based Practice 1 and Expectations for Resident Physicians

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to:

  • Work effectively in various health care delivery settings and systems relevant to their clinical specialty.
  • Coordinate patient care within the health care system relevant to their clinical specialty.
  • Incorporate considerations of cost awareness and risk–benefit analysis in patient- and/or population-based care as appropriate.
  • Advocate for quality patient care and optimal patient care systems.
  • Work in interprofessional teams to enhance patient safety and improve patient care quality.
  • Participate in identifying system errors and implementing potential systems solutions.

Acknowledgments:

The authors would like to acknowledge the clinicians, educators, system leaders, students, and other collaborators who have invested their time to contribute to the educational mission at our institutions.

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