News and Commentary Ensuring Health Professions Students Understand the Systems of Care

It was in my very last month of fellowship—a full decade after I had begun medical school—that someone taught me about Medicare and Medicaid. This is somewhat embarrassing to admit now: I didn’t really understand the difference between the two. Fortunately, a billing specialist was reviewing my documentation, and she spotted my knowledge gap and helped me to close it.

While I take responsibility for not knowing this basic fact, I also note that I was “raised” in a medical education system that never prioritized or taught the “systems” issues that interweave every patient interaction and every clinical context. No one ever brought it up on rounds or in clinic, and I had fantastic mentors. My story is one of many, which raises the question: Are we educating future providers to be diagnosticians of disease and ALSO citizens of the healthcare system? Many think we’re still primarily focused on the former, and I agree.

Health Systems Science
For over 100 years, medical schools have focused education on the basic and clinical sciences. Since 2000, this format has been changing. Stimulated in part by increased awareness of medical errors and the need for improved care delivery systems, systems-related competencies have been increasingly integrated into curricula, which includes the systems-based practice competency, interprofessional collaboration, and the social determinants of health.

However, by 2012, these new competencies had not yet been fully integrated into medical school curricula, and perhaps more importantly, they lacked a more formal curricular framework. Building upon decades of work and following several national calls for change, many medical schools have re-envisioned a “third pillar” of medical education—Health Systems Science. Complementing the basic and clinical sciences, health systems science includes competencies related to healthcare policy, public and population health, interprofessional collaboration, clinical informatics, value-based care, health system improvement, and systems thinking. Perhaps for the first time, the health systems science pillar provides a comprehensive educational framework that is now being embraced by many medical schools, residency programs, and academic health systems.

We’re all in it together, for our patients
Some argue (and I am in this boat) that healthcare professionals have always needed these health systems science skills and the “systems mindset.” Certainly, the gaps in our healthcare system, including patient safety, access, quality and cost, are becoming increasingly apparent—and as they say, “the cavalry may not be coming.” Education is a critical component of this system, and we must do our part to lead and contribute to educational transformation. I believe it is our professional responsibility to do so. But this transformation is not only a medical school decision, as the larger system and culture must embrace this shift. We cannot only focus learning in health systems science on our students and residents, with the expectation that as they graduate these “new” providers will eventually populate and deliver on these new skills. Students and residents need to learn from and experience faculty mentors demonstrating how social determinants of health impact patient health, how the selection of a brand-name drug could cost too much for a patient, and how improving a system process is as much our responsibility as anyone else’s responsibility. Our clinical learning environments need to be ready now to teach learners of today and tomorrow.

As a Macy Faculty Scholar, that’s what I’m working on. Our faculty educators need to learn these health systems science skills and cultivate a systems-thinking mindset so they are then able to change and improve the system, and perhaps more importantly, so that they can role model these skills for learners in their formative years.

At the Penn State College of Medicine, we have designed and implemented a 9-month interprofessional Health Systems Science Academy for faculty educators, which includes nurses, physician’s assistants, respiratory technicians, and physicians (and some students and residents), to learn these new skills and work on projects related to improving care delivery or education in the participants’ local environment. The 60+ educators in this new program have come from every facet of the system itself (and beyond) and have learned together in project development and new and innovative classrooms. Many of these educators have not been called upon before to teach in the classroom. Yet here they are, significantly influencing a wave of innovation in medical education.

Our goal is that the Health Systems Science Academy will cultivate a new generation of systems citizens in healthcare—not just for medical students but for all healthcare professionals.

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