Health Systems Science Curricula in Undergraduate Medical Education: Identifying and Defining a Potential Curricular Framework

Development and Implementation of an Experiential Longitudinal Health Systems Science Thread Into an Existing Medical School Curriculum

PROBLEM

Medical school graduates enter a complex health care delivery system involving interprofessional teamwork and multifaceted value-based patient care decisions. However, current curricula on health systems science (HSS) are piecemeal, lecture based, and confined to preclinical training.

APPROACH

The VISTA program is a longitudinal, immersive learning curriculum integrated into the University of Chicago Pritzker School of Medicine curriculum between 2016 and 2018. Key components include a unit-based nursing interprofessional team experience, a discharge objective structured clinical examination (OSCE), a patient safety simulation, and the implementation of a Choosing Wisely SmartPhrase. Graduates before 2016-2017 and after 2018-2020 VISTA implementation completed a Likert-style survey assessing attitudes, knowledge, and behaviors on HSS topics. A free response question solicited improvement areas. The Association of American Medical Colleges (AAMC) Graduation Questionnaire (GQ) was also examined.

OUTCOMES

The overall VISTA survey response rate was 59%, with 126 fourth-year medical student respondents before VISTA and 120 after VISTA. Compared with pre-VISTA graduates, post-VISTA graduates reported a significantly higher rate of competence on the HSS questions, with the greatest increases seen in effective communication at discharge (n = 73/126 [57.9%] to 116/120 [96.7%], P < .001), knowledge on safety event reporting (n = 53/126 [42.1%] to 96/120 [79.8%], P < .001), and considering costs in making health care decisions (n = 76/126 [60.3%] to 117/120 [97.5%], P < .001). All were directly addressed through experiential learning interventions, and 2 were intended practice behaviors. VISTA graduate responses to free-text questions demonstrated a more nuanced understanding of HSS compared with pre-VISTA responses. The AAMC GQ data showed increased agreement with an item that mapped to HSS understanding.

NEXT STEPS

The VISTA program provides a model for institutions to enhance HSS education between curricular overhauls. Next steps include implementing value-added roles and additional immersive learning exercises.

Assessing the interplay of presentation and competency in online video examinations: a focus on health system science education

BACKGROUND

The integration of Health System Science (HSS) in medical education emphasizes mastery of competencies beyond mere knowledge acquisition. With the shift to online platforms during the COVID-19 pandemic, there is an increased emphasis on Technology Enhanced Assessment (TEA) methods, such as video assessments, to evaluate these competencies. This study investigates the efficacy of online video assessments in evaluating medical students' competency in HSS.

METHODS

A comprehensive assessment was conducted on first-year medical students (n = 10) enrolled in a newly developed curriculum integrating Health System Science (HSS) into the Bachelor of Medicine program in 2021. Students undertook three exams focusing on HSS competency. Their video responses were evaluated by a panel of seven expert assessors using a detailed rubric. Spearman rank correlation and the Interclass Correlation Coefficient (ICC) were utilized to determine correlations and reliability among assessor scores, while a mixed-effects model was employed to assess the relationship between foundational HSS competencies (C) and presentation skills (P).

RESULTS

Positive correlations were observed in inter-rater reliability, with ICC values suggesting a range of reliability from poor to moderate. A positive correlation between C and P scores was identified in the mixed-effects model. The study also highlighted variations in reliability and correlation, which might be attributed to differences in content, grading criteria, and the nature of individual exams.

CONCLUSION

Our findings indicate that effective presentation enhances the perceived competency of medical students, emphasizing the need for standardized assessment criteria and consistent assessor training in online environments. This study highlights the critical roles of comprehensive competency assessments and refined presentation skills in online medical education, ensuring accurate and reliable evaluations.

Centering equity in a longitudinal health systems science curricula

WHAT WAS THE EDUCATIONAL CHALLENGE?

Health inequity impedes care at every level of the health care system. Despite this, health equity is not the foundation for most health systems science (HSS) curricula.

WHAT WAS THE SOLUTION?

We reframed our HSS curricula to focus on health equity.

HOW WAS THE SOLUTION IMPLEMENTED?

We integrated equity concepts into all HSS content areas. First-year content emphasizes structural competency and is delivered through didactics, discussions, interprofessional education, panels, and service-learning requirements. Second-year content applies HSS principles in the clinical space through direct patient care and assignments. Third- and fourth-year content focuses on HSS advocacy and leadership.

WHAT LESSONS WERE LEARNED THAT ARE RELEVANT TO A WIDER GLOBAL AUDIENCE?

It is crucial to center health equity in medical curricula to improve patient outcomes. Proper faculty development, non-judgmental discussions, and integration with clinical and medical sciences are critical to successful implementation.

WHAT ARE THE NEXT STEPS?

We will address feedback, emphasize relevance to patients and populations, and refine outcome measures.

How a Team Effectiveness Approach to Health Systems Science Can Illuminate Undergraduate Medical Education Outcomes

ABSTRACT

Health care delivery requires physicians to operate in teams to successfully navigate complexity in caring for patients and communities. The importance of training physicians early in core concepts of working in teams (i.e., "teaming") has long been established. Over the past decade, however, little evidence of team effectiveness training for medical students has been available. The recent introduction of health systems science as a third pillar of medical education provides an opportunity to teach and prepare students to work in teams and achieve related core competencies across the medical education continuum and health care delivery settings. Although educators and health care system leaders have emphasized the teaching and learning of team-based care, conceptual models and evidence that inform effective teaming within all aspects of undergraduate medical education (including classroom, clinical, and community settings) are needed to advance the science regarding learning and working in teams. Anchoring teaming through the core foundational theory of team effectiveness and its operational components could catalyze the empirical study of medical student teams, uncover modifiable factors that lead to the evidence for improved student learning, and improve the link among competency-based assessments between undergraduate medical education and graduate medical education. In this article, authors articulate several implications for medical schools through 5 conceptual areas: admissions, the design and teaching of team effectiveness in health systems science curricula, the related competency-based assessments, and course and program evaluations. The authors then discuss the relevance of the measurable components and intended outcomes to team effectiveness in undergraduate medical education as critical to successfully prepare students for teaming in clerkships and eventually residency and clinical practice.

Integrating the social determinants of health into curriculum: AMEE Guide No. 162

The World Health Organization (WHO) defines the Social Determinants of Health (SDOH) as the non-medical factors influencing health outcomes. SDOH is associated with conditions in which people are born, grow, work, and live. Medical schools and licensing bodies are increasingly recognizing the need for doctors and healthcare professionals to be aware of their patient's social context and how it impacts their states of health and disease. However, there is considerable variation in the approaches of different institutions and countries to incorporating SDOH into their curricula. In order to allow clinicians to adopt a holistic approach to patient health, equipping them with extensive knowledge of SDOH would give learners the confidence, skills, knowledge, and attitudes needed to effectively engage with patients and their families. This approach aids health professionals with knowledge of the influence of the social context and cultural factors that affect patients' behaviors in relation to health. Incorporating the SDOH in medical and health professional school curricula would contribute towards adequately preparing future healthcare practitioners to provide effective, comprehensive, and equitable care, especially to marginalized and underserved populations. The Guide will take an evidence-based approach grounded in the available contemporary literature and case studies. The focus will be on integrating SDOH into undergraduate and postgraduate medical curricula to promote an understanding of the social factors that influence patients' and communities' health. Ultimately, this guide seeks to contribute to the reduction of inequalities in health.

A patient-centered evaluation of a novel medical student-based patient navigation program

OBJECTIVES

Understand the patient experience of a pilot medical student-based patient navigator (PN) program. (2) Assess areas of improvement for further development as a model for expansion.

METHODS

This was a cross-sectional study assessing patients' subjective experience of medical student navigators for rheumatological conditions. Current student navigators contacted enrolled patients by phone with both structured and free-response questions.

RESULTS

44 of 71 patients completed the questionnaire. 84% reported a satisfaction of ≥ 4 on a 5 point Likert scale. > 80% of patients felt that the program helped them better care for their health, feel more understood by their medical team, and feel cared for by their healthcare team. Medical student navigators were able to assist with most patient requests.

CONCLUSIONS

Patients enrolled in our medical student PN program expressed high levels of satisfaction and felt better able to access health resources with the help of a navigator.

PRACTICE IMPLICATIONS

Employing medical students as PNs may serve as a mutually beneficial intervention providing early clinical exposure to students while furthering patient access to care. Other institutions may benefit from similarly structured interventions.

The Need for Laboratory Medicine in the Undergraduate Medical Education Curriculum: A White Paper from the Association of Pathology Chairs

Considering laboratory results are used to make medical decisions, a fundamental understanding of laboratory medicine is paramount to enhance patient care, optimize health care cost containment, and prevent legal repercussions. With increasing laboratory testing complexity, this education is needed now more than ever. This article is a call to action to have medical schools adequately incorporate practical laboratory medicine content into their undergraduate medical education (UME) curricula. The authors discuss the definition of laboratory medicine, what it encompasses, who uses it and why it matters, and propose that a core laboratory medicine curriculum is a necessary part of UME.

Evaluating medical students' knowledge of patient-reported outcomes and the impact of curriculum intervention in consecutive cohorts

BACKGROUND

Patient-reported outcomes (PROs) collection and utilization improves patient-provider communication, symptom reporting, and patient satisfaction. Despite their significance, the science and utility of PROs are not part of required curriculum in medical education. The authors describe the results of a survey distributed to medical students evaluating their experience, knowledge, and perceptions of PROs, report on outcomes of the impact of formal PRO education on medical student knowledge, and describe strategies to foster the spread of PRO education into other programs.

METHODS

The authors developed and distributed a 20-question web-based survey distributed to medical students at two U.S. medical schools to evaluate students' experience, knowledge, and perceptions of PROs. To compare medical students' knowledge in their pre-clinical years (M1-M2) to those in their clinical years (M3-M4), the authors calculated odds ratios and determined significance determined using chi-squared tests. To determine the utility of formal education on medical students' knowledge of PROs, the authors invited 4th year medical students at a single institution to participate in a survey before and two weeks after receiving formal PRO education as part of the medical school curriculum, spanning three years.

RESULTS

137 (15%) medical students responded to the initial survey. Respondents' knowledge of PROs was low and did not differ when comparing pre-clinical to clinical years in school. Less than 10% had received education on PROs and only 16% felt prepared to use PROs in patient care. Respondents demonstrated positive attitudes towards PROs, with 84% expressing interest in learning about PROs. In the second phase education cohort of 231 (77% response rate) 4th -year medical students over three years, formal education improved correct response rates to PRO questions. After education, 90% (121/134) agreed PROs are an important component of high-quality care.

CONCLUSIONS

This study identifies a gap in knowledge about PROs among medical students irrespective of year in training. It also shows that structured education may help fill the PRO knowledge gap, potentially providing future clinicians with the skills to implement PROs into clinical practice, aligning with the broader shift towards patient-centric evidence-based healthcare practices.

Non-physician and physician preceptors in Landscapes of Practice: a mixed-methods study exploring learning for 1st-year medical students in clinical experiences

Medical education has traditionally relied on physician educators. With expanding Health Systems Science competencies, non-physician healthcare providers are required. To investigate preceptor-role types, communication frequency, and importance of preceptors in value-added patient navigator roles (PN) and clinical preceptorships (CP). Using a mixed-methods approach, medical students participating in PN and CP during the first year of medical school (n=191) identified individuals with whom they communicated and communication frequency (1=never, 7=frequently), and importance of preceptors to work/education (1=not important, 7=extremely important; open-ended responses). Quantitative data were analyzed via repeated measures using a mixed-effects model and McNemar's test; effect size was calculated via Cohen's d or Cohen's h; qualitative data was analyzed using thematic analysis. Comparing ratings for non-physicians to physician healthcare professionals in PN, communication frequency (5.54 vs 3.65; p<0.001, d=1.18), importance to work (5.77 vs 4.28, p<0.001, d=0.89) and education (5.02 vs 4.12, p<0.001; d=0.49) were higher for non-physician educators. Comparing ratings for non-physicians to physician healthcare professionals in CP, communication frequency (4.93 vs. 6.48, p<0.001, d=1.33), importance to work (5.12 vs 6.61 vs, p<0.001, d=1.29) and education (4.32 vs 6.55, p<0.001, d=1.89) were higher for physician educators. Qualitative analysis indicated that non-physician healthcare providers in PN focused on Health Systems Science concepts, including social determinants of health and healthcare delivery. In PN, students observed collaboration from the perspective of multiple providers. In CP, healthcare providers, mainly physicians, focused on physician-centric clinical skills and interprofessional collaboration from the physician's perspective. Educational benefits of non-physician healthcare professionals related to Health Systems Science in work-based clinical settings - or Landscapes of Practice - can help students understand systems-based concepts such as social determinants of health, healthcare delivery systems, and interprofessional collaboration. Differences in the educational value of non-physician healthcare educators perceived by students should be further explored.

Health Systems Science - A Primer for Radiologists

Health systems science (HSS) is an educational framework designed to promote improved care through enhanced citizenship and the training of systems-fluent individuals trained in the science of health care delivery.  HSS education in residency builds upon foundations established during medical school, emphasizing practical skills development, and fostering a growth mindset among trainees.  The HSS framework organizes elements of system-based practice for radiology trainees, promoting practice-readiness for providing safe, timely, effective, efficient, equitable and patient centered radiological care. This paper serves as a primer for radiologists to understand and apply the HSS framework. Additionally, we highlight radiology-specific curricular elements aligned with the HSS framework, and provide teaching resources both for classroom education and for resident self-study.

A Systematic Review on the Effectiveness of Systems-Based Practice Curricula in Health Professions Education

This systematic review aims to evaluate the effectiveness of systems-based practice (SBP) curricula from the perspective of health professions students and workers. A total of 8468 citations were sourced from six electronic databases and manual searches conducted independently by two researchers, of which 44 studies were eventually included. A meta-analysis using a random effects model and a meta-synthesis using the thematic synthesis approach were conducted. Most studies targeted medical students, residents, and resident physicians from various clinical specialties. Almost half of all studies focused on didactic or knowledge-based interventions to teach SBP. About a third of all studies measured non-self-evaluated knowledge change, clinical abilities, and clinical outcomes. Both meta-analysis and meta-synthesis results revealed positive outcomes of increased knowledge of SBP, increased recognition of SBP as a core competency in one's profession, and increased application of SBP knowledge in one's profession. Meta-synthesis results also revealed negative outcomes at the institutional and teacher/health professions level. This review highlights the importance of SBP education and supports the effectiveness of SBP curricula. There is a need to address the negative outcomes at the institutional and teacher/health professions level. Moreover, future studies could investigate the integration of self-assessment outcomes with comparison to some external standard.

Divergence and Convergence of the Public Health Leadership Competency Framework Against Others in Undergraduate Medical Education: A Scoping Review

Objective: The following scoping review is aimed at identifying leadership competency frameworks in Undergraduate Medical Education (UME) by analyzing the thematic scopes, target audiences, and methods involved. A further objective is to compare the frameworks against a standard framework. Methods: The authors extracted the thematic scope and methods of each framework based on the original author's formulations in each selected paper. The target audience was divided into three sections: UME, medical education, and beyond medical education. The frameworks were converged and diverged against the public health leadership competency framework. Results: Thirty-three frameworks covering thematic scopes such as refugees and migrants were identified. The most common methods to develop leadership frameworks were reviews and interviews. The courses targeted multiple disciplines including medicine and nurses. The identified competency frameworks have not converged among important domains of leadership such as systems thinking, political leadership, leading change, and emotional intelligence. Conclusion: There is a variety of frameworks that support leadership in UME. Nevertheless, they are not consistent in vital domains to face worldwide health challenges. Interdisciplinary and transdisciplinary leadership competency frameworks which address health challenges should be used in UME.

A Pilot Study Assessment of Medical Student Knowledge and System Citizenship Attitudes Pertaining to Health Systems Science

Background and Purpose

Health system science (HSS) has been described as the third pillar of medical education. We introduced a new health system science and interprofessional practice (HSSIP) curriculum, and measured students' HSS knowledge and attitudes concerning health system citizenship.

Methods

This pilot study involved first-year (M1) and fourth-year (M4) medical students in two cohorts across 2 years. Only M1 students in the second cohort participated in the new HSSIP curriculum. We compared student performance on a new National Board of Medical Examiners (NBME) HSS subject exam, and student attitudes toward system citizenship via a new attitudinal survey.

Results

Fifty-six eligible fourth-year students (68%) and 70 (76%) study eligible first-year students participated in the study. NBME HSS exam performance by M4 students was statistically significantly higher than M1 students for both cohorts, with moderate to large effect sizes. Exam performance for M1 students not experiencing the HSS curriculum was higher than for M1 students who received HSS curricular content. Attitudes toward HSS by M4 versus M1 students were statistically significantly different on several survey items with moderate effect sizes. Scale internal consistency for the HSS attitude survey was strong (0.83 or higher).

Discussion

There were differences among M4 and M1 medical students concerning knowledge of and attitudes toward HSS, with performance on the NBME subject exam similar to a national sample. Exam performance by M1 students was likely impacted by class size and other factors. Our results support the need for increased attention to HSS during medical education. Our health system citizenship survey has potential for further development and cross-institutional collaboration.

The Longitudinal and Vertical Integration of Health Systems Science in an Undergraduate Medical Education Program: A Means to Support "Curricular Elasticity"

Although health systems science (HSS) has become increasingly included as requisite curricular content in undergraduate medical education (UME), educators have many implementation options for integrating HSS content into medical school training. Learning from medical schools' authentic experiences and lessons learned for the successful and sustainable implementation of HSS would be valuable. We share our experience with the longitudinal and vertical integration of HSS at the Sidney Kimmel Medical College (SKMC) at Thomas Jefferson University in Philadelphia over the past six years. We posit that our approach to curricular design has afforded us the "curricular elasticity" needed to keep our educational program current and flexible in the rapidly changing healthcare and geopolitical landscape.

Extracurricular activities in medical education: an integrative literature review

BACKGROUND

The importance of extracurricular activities (EAs) has been emphasized in medical education. These activities could enhance medical students' emotional and physical health and afford them developmental opportunities. Despite the growing amount of research related to this theme, few studies review and synthesize the existing literature. This study aims to provide an understanding of the educational implications of EAs in medical colleges and constructs an integrated conceptual framework concerning their types and learning outcomes by literature review.

METHODS

An integrative literature review was conducted following Torraco's method, with the aim to generate a new framework for the given topic. The authors utilized Scopus and PubMed as databases, using search terms "extracurricular," "medical," and "students." Initially, titles and abstracts were screened to include relevant studies, and the researchers verified the eligibility of the articles by following the inclusion and exclusion criteria. Of the 263 articles identified, 64 empirical studies were selected for further review.

RESULTS

EAs in undergraduate medical education can be classified into direct extracurricular activities and indirect extracurricular activities, the latter of which is sorted into nine sub-categories. We identified seven main categories regarding the learning outcomes of EAs. In addition to general activities (e.g., pro-social activities, team sports), some distinctive activities such as research have been largely addressed in previous studies. The results of EAs were discussed in relation to academic growth, career development, and psychological experiences.

CONCLUSIONS

This review identified the types and learning outcomes of EAs in the context of medical education, thereby suggesting ways to improve the quality of EAs and maximize their educational effects.

Neurology Education in 2035: The Neurology Future Forecasting Series

In the past decade, there have been dramatic changes in all aspects of neurologic care, and along with this, neurology education has transformed. These changes have affected all aspects of education across the educational continuum, including learners, teachers, educators, content, delivery methods, assessments, and outcomes. Health systems science, health humanities, diversity, equity, and inclusion and health disparities are becoming core components of neurology curricula, and, in the future, will be integrated into every aspect of our educational mission. The ways in which material is taught and learned have been influenced by technologic innovations and a growing understanding of the science of learning. We forecast that this trend will continue, with learners choosing from an array of electronic resources to engage with fundamental topics, allowing front-line clinical teachers to spend more time supporting critical reasoning and teaching students how to learn. There has been a growing differentiation of educational roles (i.e., teachers, educators, and scholars). We forecast that these roles will become more distinct, each with an individualized pattern of support and expectations. Assessment has become more aligned with the work of the learners, and there are growing calls to focus more on the impact of educational programs on patient care. We forecast that there will be an increased emphasis on educational outcomes and public accountability for training programs. In this article, we reflect on the history of medical education in neurology and explore the current state to forecast the future of neurology education and discuss ways in which we can prepare.

Clinical informatics training in medical school education curricula: a scoping review

OBJECTIVES

This scoping review evaluates the existing literature on clinical informatics (CI) training in medical schools. It aims to determine the essential components of a CI curriculum in medical schools, identify methods to evaluate the effectiveness of a CI-focused education, and understand its delivery modes.

MATERIALS AND METHODS

This review was informed by the methodological guidance of the Joanna Briggs Institute. Three electronic databases including PubMed, Scopus, and Web of Science were searched for articles discussing CI between January 2010 and December 2021.

RESULTS

Fifty-nine out of 3055 articles were included in our final analysis. Components of CI education include its utilization in clinical practice, ethical implications, key CI-related concepts, and digital health. Evaluation of educational effectiveness entails external evaluation by organizations external to the teaching institute, and internal evaluation from within the teaching institute. Finally, modes of delivery include various pedagogical strategies and teaching CI using a multidisciplinary approach.

DISCUSSION

Given the broad discussion on the required competencies, we propose 4 recommendations in CI delivery. These include situating CI curriculum within specific contexts, developing evidence-based guidelines for a robust CI education, developing validated assessment techniques to evaluate curriculum effectiveness, and equipping educators with relevant CI training.

CONCLUSION

The literature reveals that CI training in the core curricula will complement if not enhance clinical skills, reiterating the need to equip students with relevant CI competencies. Furthermore, future research needs to comprehensively address current gaps in CI training in different contexts, evaluation methodologies, and delivery modes to facilitate structured training.

"They were an advocate for me": A Qualitative Study Exploring Medical Student Longitudinal Relationships and Patient Well-Being

BACKGROUND

Patient navigators, community health workers, and care management teams improve patient experience and health outcomes. Medical student involvement in these roles is limited. Evaluation of these programs focuses on the student experience with less attention to patient participants.

OBJECTIVES

We sought (1) to understand the experience of being a participant in a medical education program; (2) to explore the patient-medical student relationship; and (3) to describe the impact of this relationship on patient health and well-being.

DESIGN

This was a qualitative study that utilized in-depth semi-structured interviews.

PARTICIPANTS

Participants were selected based on enrollment in a preceptorship program at an urban academic medical center between 2017 and 2020. Participants worked with a medical student during an 18-month period in which the medical student was embedded in a primary care medical home, serving as a health systems navigator for 1-2 medically and socially complex patients.

APPROACH

Nine participants completed 1-h compensated phone interviews. This study was deemed IRB exempt.

KEY RESULTS

Three themes and eight subthemes were identified, including Navigators Were Key to Accessing the System, Interpersonal Partnerships Improved Health, and Fulfillment in Teaching of Lived Experience. Navigators eased the burden of chronic illness by being a point of contact in the health system, which improved participants' overall experience. Participants also described the relationship as therapeutic, citing improvement and stability in both mental and physical health. Lastly, participants found meaning in chronic illness by teaching their students empathy.

CONCLUSIONS

Longitudinal patient-medical student relationships may provide stability and health benefits. These partnerships have the possibility of adding value to patients' healthcare experiences. This study complements current literature highlighting the value of these relationships for pre-clinical medical students. As such, additional opportunities for and additional research regarding the value of longitudinal patient connection should be incorporated in undergraduate medical education.

"Finding My Piece in That Puzzle": A Qualitative Study Exploring How Medical Students at Four U.S. Schools Envision Their Future Professional Identity in Relation to Health Systems

PURPOSE

Health systems science (HSS) curricula equip future physicians to improve patient, population, and health systems outcomes (i.e., to become "systems citizens"), but the degree to which medical students internalize this conception of the physician role remains unclear. This study aimed to explore how students envision their future professional identity in relation to the system and identify experiences relevant to this aspect of identity formation.

METHOD

Between December 2018 and September 2019, authors interviewed 48 students at 4 U.S. medical schools with HSS curricula. Semistructured interviews were audiorecorded, transcribed, and analyzed iteratively using inductive thematic analysis. Interview questions explored how students understood the health system, systems-related activities they envisioned as future physicians, and experiences and considerations shaping their perspectives.

RESULTS

Most students anticipated enacting one or more systems-related roles as a future physician, categorized as "bottom-up" efforts enacted at a patient or community level (humanist, connector, steward) or "top-down" efforts enacted at a system or policy level (system improver, system scholar, policy advocate). Corresponding activities included attending to social determinants of health or serving medically underserved populations, connecting patients with team members to address systems-related barriers, stewarding health care resources, conducting quality improvement projects, researching/teaching systems topics, and advocating for policy change. Students attributed systems-related aspirations to experiences beyond HSS curricula (e.g., low-income background; work or volunteer experience; undergraduate studies; exposure to systems challenges affecting patients; supportive classmates, faculty, and institutional culture). Students also described future-oriented considerations promoting or undermining identification with systems-related roles (responsibility, affinity, ability, efficacy, priority, reality, consequences).

CONCLUSIONS

This study illuminates systems-related roles medical students at 4 schools with HSS curricula envisioned as part of their future physician identity and highlights past/present experiences and future-oriented considerations shaping identification with such roles. These findings inform practical strategies to support professional identity formation inclusive of systems engagement.

Mapping health, social and health system issues and applying a social accountability inventory to a problem based learning medical curriculum

Social accountability is a powerful concept. It is applied to medical education to encourage future doctors to take action to address health inequalities and overlooked health needs of disadvantaged populations. Problem-based learning (PBL) provides an ideal setting to teach medical students about these topics. The objective of this study is to explore how well the components of social accountability are covered in a pre-clinical PBL medical curriculum and to determine the usefulness of an adapted validated social accountability framework. We identified Irish health needs and social issues through a literature review. The retrieved documents were aligned to four values (relevance, equity, cost-effectiveness and quality) from a validated social accountability inventory, to generate a map of social accountability values present in the Irish health system and population. We then used the adapted validated social accountability inventory to evaluate the content of the PBL medical curriculum at an Irish medical school. We identified 45 documents, which upon analysis lead to the identification of health and social issues related to social accountability. 66 pre-clinical PBL cases included demographic, health and psychosocial issues similar to the local population. Analysing along the four social accountability values, the PBL cases demonstrated room for improvement in the equity and relevance domains. Topics for expansion are Traveller health, LGBTI health, alcohol use, climate change and more. Medical educators can use the paper as an example of how to apply this methodology to evaluate PBL cases. Adapting and applying a validated framework is a useful pedagogical exercise to understand established societal values related to social accountability to inform a medical curriculum. We identified opportunities to improve the PBL cases to depict emerging global and social issues.

Understanding Health Policy and Its Importance in Residency Education for Oral and Maxillofacial Surgery

Health policy shapes the delivery of surgical care and the reimbursement of oral and maxillofacial surgeons (OMSs). Understanding broad principles of health policy will better allow surgeons to develop policies that will ultimately affect surgical practice. The growing presence of corporate and private equity investments in OMS practice management as well as expanding interests in value-based reimbursement models has innumerable implications for OMSs and patients. A standardized health policy curriculum for educating OMS trainees in key health policy principles may encourage OMSs to actively participate in health care advocacy efforts and shape the policies that may affect their future scope of practice.

Transformative learning of medical trainees during the COVID-19 pandemic: A mixed methods study

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has had a transformative effect on individuals across the world, including those in healthcare. Transformative learning is an educational theory in which an individual's worldview is fundamentally altered through conscious reflection (Cognitive Rational), insights (Extrarational), or social reform (Social Critique). We utilized transformative learning theory to characterize the experiences of medical trainees during the pandemic.

METHODS

We used the Transformative Learning Survey in September and October 2020 to evaluate the processes and outcomes of transformative learning in health professions students and housestaff at an academic medical center during the pandemic. We analyzed survey scores for three process domains and four outcome subdomains. We inductively coded the survey's two open-ended questions and performed qualitative and mixed-methods analyses.

RESULTS

The most prominent TL outcome was Self-Awareness, Acting Differently was intermediate, and Openness and Worldview Shifts were lowest. Cognitive Rational and Social Critique processes were more prominent than Extrarational processes. Students were more likely than housestaff to undergo transformative learning through the Social Critique process (p = 0.025), in particular the sub-processes of Social Action (p = 0.023) and Ideology Critique (p = 0.010). Qualitative analysis via the aggregation of codes identified four responses to the pandemic: negative change, positive change, existential change, or no change. Negative changes (67.7%) were most common, with students reporting more of these changes than housestaff (74.8% vs 53.6%; p < 0.01). Only 8.4% of reported changes could be defined as transformative.

CONCLUSIONS

Through the theoretical lens of transformative learning, our study provides insight into the lives of learners during the pandemic. Our finding that medical students were more likely to use Social Critique processes has multiple parallels in the literature. If leaders in academic medicine desire to create enlightened change agents through transformative learning, such education must continue throughout graduate medical education and beyond.

Informatics in Undergraduate Medical Education: Analysis of Competency Frameworks and Practices Across North America

BACKGROUND

With the advent of competency-based medical education, as well as Canadian efforts to include clinical informatics within undergraduate medical education, competency frameworks in the United States have not emphasized the skills associated with clinical informatics pertinent to the broader practice of medicine.

OBJECTIVE

By examining the competency frameworks with which undergraduate medical education in clinical informatics has been developed in Canada and the United States, we hypothesized that there is a gap: the lack of a unified competency set and frame for clinical informatics education across North America.

METHODS

We performed directional competency mapping between Canadian and American graduate clinical informatics competencies and general graduate medical education competencies. Directional competency mapping was performed between Canadian roles and American common program requirements using keyword matching at the subcompetency and enabling competency levels. In addition, for general graduate medical education competencies, the Physician Competency Reference Set developed for the Liaison Committee on Medical Education was used as a direct means of computing the ontological overlap between competency frameworks.

RESULTS

Upon mapping Canadian roles to American competencies via both undergraduate and graduate medical education competency frameworks, the difference in focus between the 2 countries can be thematically described as a difference between the concepts of clinical and management reasoning.

CONCLUSIONS

We suggest that the development or deployment of informatics competencies in undergraduate medical education should focus on 3 items: the teaching of diagnostic reasoning, such that the information tasks that comprise both clinical and management reasoning can be discussed; precision medical education, where informatics can provide for more fine-grained evaluation; and assessment methods to support traditional pedagogical efforts (both at the bedside and beyond). Assessment using cases or structured assessments (eg, Objective Structured Clinical Examinations) would help students draw parallels between clinical informatics and fundamental clinical subjects and would better emphasize the cognitive techniques taught through informatics.

Bridging medical education goals and health system outcomes: An instrumental case study of pre-clerkship students' improvement projects

INTRODUCTION

Many medical schools engage students in health system improvement (HSI) efforts. Evaluation of these efforts often focuses on students' learning outcomes and rarely considers the impact on health systems, despite the significant commitment health systems make to these efforts. Our study identified and evaluated system-level outcomes of pre-clerkship medical students' engagement in HSI efforts.

METHODS

We used an instrumental case study approach to examine the effects of pre-clerkship medical students' engagement in HSI projects as part of a 15-month experiential curriculum. We extracted data from 53 project summaries and posters completed during the 2017-18 academic year and follow-up survey data collected in May 2019 from physician coaches and health system professionals who mentored students, contributed to these projects, and worked in the clinical microsystems where the projects occurred.

RESULTS

We identified three categories and ten indicators of health system outcomes relevant to medical student engagement in HSI. Using these indicators, our evaluation found multiple benefits to the microsystems in which projects occurred. These included achievement of project aims, perceived immediate and sustained project impact on the health system, and development and implementation of projects with aims that aligned with national and health system priorities.

CONCLUSION

Evaluation of HSI curricula needs to include effects on health systems so that program design can optimize the experience for all involved. Our study offers a framework others can use to evaluate system-level effects of project-based HSI curricula and shows several ways in which students' engagement can add value to health systems.

Implementation of simulation-based health systems science modules for resident physicians

BACKGROUND

Health system science (HSS) encompasses both core and cross-cutting domains that emphasize the complex interplay of care delivery, finances, teamwork, and clinical practice that impact care quality and safety in health care. Although HSS skills are required during residency training for physicians, current HSS didactics have less emphasis on hands-on practice and experiential learning. Medical simulation can allow for experiential participation and reflection in a controlled environment. Our goal was to develop and pilot three simulation scenarios as part of an educational module for resident physicians that incorporated core and cross-cutting HSS domains.  METHODS: Each scenario included a brief didactic, an interactive simulation in small-group breakout rooms, and a structured debriefing. The case scenario topics consisted of educational leadership, quality and safety, and implementation science. Learners from four residency programs (psychiatry, emergency medicine, orthopedics, ophthalmology) participated January - March 2021.

RESULTS

A total of 95 resident physicians received our curricular module, and nearly all (95%) participants who completed a post-session survey reported perceived learning gains. Emotional reactions to the session were positive especially regarding the interactive role-play format. Recommendations for improvement included participation from non-physician professions and tailoring of scenarios for specific disciplines/role. Knowledge transfer included use of multiple stakeholder perspectives and effective negotiation by considering power/social structures.

CONCLUSIONS

The simulation-based scenarios can be feasibly applied for learner groups across different residency training programs. Simulations were conducted in a virtual learning environment, but future work can include in-person and actor-based simulations to further enhance emotional reactions and the reality of the case scenarios.

Medical school curriculum in the digital age: perspectives of clinical educators and teachers

BACKGROUND

There is a need to reexamine Singapore's medical school curricula in light of the increasing digitalization of healthcare. Notwithstanding Singapore's digital competitiveness, there is a perceived gap in preparing its medical students for the digital age. Furthermore, limited research has evaluated the extent to which skills in using digital technologies should be taught to medical students in Asian medical schools to prepare them for future clinical practice- a gap that is filled by this study. Using Singapore as a case study, it explores the views of some local clinical educators and teachers towards the need to impart skills in digital technologies to medical students. It also offers recommendations on ways to balance the clinicians' concerns about these technologies with the digital competencies needed for clinical practice.

METHODS

Findings were drawn from individual interviews with 33 clinical educators and teachers from Singapore's public and private healthcare sectors. They were recruited using purposive sampling. Data were interpreted using qualitative thematic analysis.

RESULTS

Participants included vice deans of education from all three local medical schools and senior consultants from a wide variety of disciplines. Overall, they acknowledged two benefits of equipping students with skills in digital technologies including promoting the culture of innovation and improving work efficiency. However, they also highlighted four main concerns of imparting these skills: (i) erosion of basic clinical skills, (ii) neglect of a generalist approach to healthcare characterized by holistic management of patients, inter-professional collaboration, and commitment to breadth of practice within each specialty, (iii) rapid pace of technological advances, and (iv) de-personalisation by technology.

CONCLUSIONS

The findings show that medical students in Singapore would benefit from a curriculum that teaches them to use digital technologies alongside core clinical skills.

Preparing Faculty to Incorporate Health Systems Science into the Clinical Learning Environment: Factors Associated with Sustained Outcomes

This study assesses participants' perceptions of long-term impacts of the Teachers of Quality Academy, a medical school faculty development program designed to prepare faculty to both practice and teach health system science. A previously published 1-year evaluation of the first cohort of 27 participants showed improved perceived skills, with positive career and health system impacts. In this 5-year evaluation, a mixed-methods design included a questionnaire followed by semistructured interviews to assess perceived long-term impacts on participants. Quantitative and qualitative analyses were completed. Questionnaire response rate was 88% (N = 22), and 14 interviews were analyzed. Results demonstrated that participants had incorporated quality improvement concepts into their clinical work and teaching, better understood interprofessionalism, and observed continued improvements in care delivery. They felt the longitudinal training, delivered in a shared setting, created a learning community with lasting positive effects in institutional culture, supported long-term professional development, and had broader institutional impact. Advancements in clinical care, medical education, and professional and academic advancements were noted.

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

Medical education is increasingly recognizing the importance of the systems-based practice (SBP) competency in the emerging 21st-century U.S. health care landscape. In the wake of data documenting insufficiencies in care delivery, notably in patient safety and health care disparities, the Accreditation Council for Graduate Medical Education created the SBP competency to address gaps in health outcomes and facilitate the education of trainees to better meet the needs of patients. Despite the introduction of SBP over 20 years ago, efforts to realize its potential have been incomplete and fragmented. Several challenges exist, including difficulty in operationalizing and evaluating SBP in current clinical learning environments. This inconsistent evolution of SBP has compromised the professional development of physicians who are increasingly expected to advance systems of care and actively contribute to improving patient outcomes, patient and care team experience, and costs of care. The authors prioritize 5 areas of focus necessary to further evolve SBP: comprehensive systems-based learning content, a professional development continuum, teaching and assessment methods, clinical learning environments in which SBP is learned and practiced, and professional identity as systems citizens. Accelerating the evolution of SBP in these 5 focus areas will require health system leaders and educators to embrace complexity with a systems thinking mindset, use coproduction between sponsoring health systems and education programs, create new roles to drive alignment of system and educational goals, and use design thinking to propel improvement efforts. The evolution of SBP is essential to cultivate the next generation of collaboratively effective, systems-minded professionals and improve patient outcomes.

Early Medical Students' Experiences as System Navigators: Results of a Qualitative Study

PURPOSE

To explore how early meaningful experiential learning in community settings impacted medical students' application of systems thinking, their perceptions of systems navigation, and their professional identity as health system change agents.

METHODS

Following an immersive Health Systems Science course, first-year medical students partnered with veterans or newly arrived refugee families and served as health system patient navigators embedded within primary care teams for a year. Across two cohorts, fifty-six students participated in the elective. Three voluntary focus groups were conducted each year for a total of six groups with 50 patient navigator students. Inductive content analysis of focus group transcripts was conducted.

RESULTS

Qualitative analysis produced three major themes: program impact on students, student impact on patients, and student perceptions of the role of healthcare providers. Students reported a rich understanding of social determinants of health. By improving patient awareness of health and well-being, building capacity to understand medical issues, and increasing medication adherence through teaching, students recognized their impact on patient care. The importance of interprofessional collaboration with social workers also emerged and helped shape students' understanding of how they as physicians are part of a coordinated team working toward better patient care.

CONCLUSION

The Case Western Reserve University WR2 curriculum teaches students how to address complex determinants of health and how to consider their role in dynamic health systems. This study highlights rich themes that emerged from students as they recognized the context that creates health for both individuals and communities. It underscores the role of such experiences in reinforcing systems thinking and development of change agency, both contributing to their professional identity formation as physicians.

"We Want Good Education for All of Us" - A Participatory Quality Improvement Approach

Introduction

In ever changing conditions, medical faculties must face the challenge of preparing their medical students as best as possible for the demands of their future work. This requires involving all stakeholders, especially medical students in the constant redefinition of medical curricula. Using the idea of "Communities of Practice" as conceptual framework, this study looks at semester spokespeople as an example for participatory quality management.

Methods

We conducted focus-group interviews with semester spokespeople at a German Medical Faculty. Data was recorded, transcribed, and analysed using MAXQDA. The interviews were analysed using meaning condensation method.

Results

Eleven out of 48 semester spokespeople took part. We found seven topics that fell within three main categories: (1) role of the semester spokesperson, (2) role of the fixed meeting, and (3) contact and commitment. Communities of Practice principles could be aligned to topics and categories.

Discussion

The idea of semester spokespeople based on the concept of Communities of Practice are useful in the quality management processes of a medical school and lead to greater involvement of medical students, identifying their needs. The reciprocal commitment among all stakeholders fosters mutual understanding and collaboration. Future studies could investigate the underlying motivational factors of dedicated students and how to transfer these characteristics to a larger cohort.

Student-faculty co-creation of experiential learning in health systems science

INTRODUCTION

Health Systems Science (HSS) teaches students critical skills to navigate complex health systems, yet medical schools often find it difficult to integrate into their curriculum due to limited time and student disinterest. Co-developing content with students and teaching through appropriate experiential learning can improve student engagement in HSS coursework.

METHODS

Medical students and faculty co-developed a patient outreach initiative during the early phases of the COVID-19 pandemic and integrated that experience into a new experiential HSS elective beginning May 2020. Students called patients identified as high-risk for adverse health outcomes and followed a script to connect patients to healthcare and social services. Subsequently, this initiative was integrated into the required third-year primary care clerkship.

RESULTS

A total of 255 students participated in HSS experiential learning through the elective and clerkship from May 2020 through July 2021. Students reached 3,212 patients, encountering a breadth of medical, social, and health systems issues; navigated the EMR; engaged interdisciplinary professionals; and proposed opportunities for health systems improvement.

DISCUSSION AND CONCLUSION

This educational intervention demonstrated the opportunity to partner with student-led initiatives, coproducing meaningful educational experiences for the learners within the confines of a busy medical curriculum.

Identification of Health Systems Science in a Problem-Based Learning Clinical Reasoning Exercise

The creation of developmentally appropriate and meaningfully complex clinical reasoning exercises in the pre-clerkship curriculum is a common challenge for many medical schools. We provide an overview of one component of the pre-clerkship clinical reasoning curriculum at Case Western Reserve University School of Medicine, and present evidence that inclusion of Health Systems Science in this exercise facilitates integrated thinking in a Problem-Based Learning curriculum.

Triple Challenge: How Medical Students May Solve 3 Long-Standing Problems Bedeviling Health Systems and Medical Education

Medical education and the health system must address challenges that, despite significant effort, seem unsolvable. Health systems science (HSS)-the fundamental understanding of how care is delivered, how health professionals work together to deliver that care, and how the health system can improve patient care and health care delivery-is increasingly being recognized as a potential source of solutions to these challenges. In this article, the authors review the 43 abstracts submitted to the American Medical Association Accelerating Change in Medical Education 2018 Health Systems Science Student Impact Competition that aligned with the goals of HSS. Their qualitative review identified 3 long-standing problems in medicine and medical education that were frequently addressed by the submissions: improving care for those with mental illness (5 submissions), improving diversity in medicine (4 submissions), and improving teamwork and interprofessional education (4 submissions). The authors extracted lessons learned from these abstracts. Many of the projects detailed in this article continue to make an impact at multiple levels. While not all projects were scientifically rigorous enough to be published on their own and the quality of the data presented in the abstracts varied widely, many provide innovative ideas for potentially solving long-standing problems that may have been overlooked or not considered sufficiently. These projects and their subsequent analysis demonstrate that not only do medical students make significant impacts on the health system, patients, and other health professionals when equipped with HSS skills, working in health care teams, and advised by mentors, but they also may be able to address some of medicine's and medical education's long-standing challenges. The fresh perspective and high energy of medical students are valuable and should be nurtured and encouraged.

The triple helix of clinical, research, and education missions in academic health centers: A qualitative study of diverse stakeholder perspectives

INTRODUCTION

Academic health centers are poised to improve health through their clinical, education, and research missions. However, these missions often operate in silos. The authors explored stakeholder perspectives at diverse institutions to understand challenges and identify alignment strategies.

METHODS

Authors used an exploratory qualitative design and thematic analysis approach with data obtained from electronic surveys sent to participants at five U.S. academic health centers (2017-18), with four different types of medical school/health system partnerships. Participants included educators, researchers, system leaders, administrators, clinical providers, resident/fellow physicians, and students. Investigators coded data using constant comparative analysis, met regularly to reconcile uncertainties, and collapsed/combined categories.

RESULTS

Of 175 participants invited, 113 completed the survey (65%). Three results categories were identified. First, five higher-order themes emerged related to aligning missions, including (a) shared vision and strategies, (b) alignment of strategy with community needs, (c) tension of economic drivers, (d) coproduction of knowledge, and (e) unifying set of concepts spanning all missions. Second, strategies for each mission were identified, including education (new competencies, instructional methods, recruitment), research (shifting agenda, developing partnerships, operations), and clinical operations (delivery models, focus on patient factors/needs, value-based care, well-being). Lastly, strategies for integrating each dyadic mission pair, including research-education, clinical operations education, and research-clinical operations, were identified.

CONCLUSIONS

Academic health centers are at a crossroads in regard to identity and alignment across the tripartite missions. The study's results provide pragmatic strategies to advance the tripartite missions and lead necessary change for improved patient health.

Exploring pooled analysis of pretested items to monitor the performance of medical students exposed to different curriculum designs

Several methods have been proposed for analyzing differences between test scores, such as using mean scores, cumulative deviation, and mixed-effect models. Here, we explore the pooled analysis of retested Progress Test items to monitor the performance of first-year medical students who were exposed to a new curriculum design. This was a cross-sectional study of students in their first year of a medical program who participated in the annual interinstitutional Progress Tests from 2013 to 2019. We analyzed the performance of first-year students in the 2019 test and compared it with that of first-year students taking the test from 2013 to 2018 and encountering the same items. For each item, we calculated odds ratios with 95% confidence intervals; we also performed meta-analyses with fixed effects for each content area in the pooled analysis and presented the odds ratio (OR) with a 95% confidence interval (CI). In all, we used 63 items, which were divided into basic sciences, internal medicine, pediatrics, surgery, obstetrics and gynecology, and public health. Significant differences were found between groups in basic sciences (OR = 1.172 [CI95% 1.005 CI 1.366], p = 0.043) and public health (OR = 1.54 [CI95% CI 1.25-1.897], p < 0.001), which may reflect the characteristics of the new curriculum. Thus, pooled analysis of pretested items may provide indicators of different performance. This method may complement analysis of score differences on benchmark assessments.

Assessment of Medical Laboratory Undergraduates Training in Different School Year Systems

OBJECTIVE

To assess the effect of the change from the 5-year system of coursework to a 4-year system on the achievements of medical laboratory undergraduates.

METHODS

We analyzed and then compared the topics of training and the test scores among all subject individuals in the 5-year vs the 4-year undergraduate program.

RESULTS

Five-year-program undergraduates and 4-year-program undergraduates were required to complete 50 courses. The average weekly education time in the 4-year program (27.05 lesson-hours/week) was greater than that in the 5-year program (22.99 lesson-hours/week). The proportion of clinical practice in the hospital setting in the 4-year program (26.8%) was higher than that in the 5-year program (24.5%). The average, excellent, and good scores among 4-year-program undergraduates in general education courses, professional basic courses, professional courses, all courses, and common courses were lower than those scores among the 5-year-program undergraduates.

CONCLUSIONS

The 5-year undergraduate program should be adapted to help boost the achievements and practical skills among its students, in helping them adapt quickly to the new, 4-year training plan (which presented a serious challenge in our cohort).

Developing a Transitions of Care Elective for Medical Students during the COVID-19 Pandemic and Beyond

OBJECTIVES

Health care in the United States is costly, fragmented, and often ineffective. Transitions of care (TOC), particularly from the inpatient to the outpatient setting, is an especially complicated time and one that is potentially fraught with errors that contribute to negative outcomes. The coronavirus 2019 pandemic exacerbated many of these challenges. In particular, vulnerable patient populations have experienced more barriers to successful care transitions. Effective care transitions should include interprofessional teamwork, robust patient education, and seamless communication among the various healthcare team members. Increasingly, medical schools are working toward graduating systems-ready physicians who demonstrate competency in the health system sciences and are able to operate effectively within the healthcare system, including being able to navigate complex transitions of care issues. Undergraduate medical education, however, continues to provide experiential learning in the traditional silos of inpatient versus outpatient medicine, so that learners do not have the opportunity to directly participate in transitions of care. Although transitions of care is a pivotal part of patient care, it is rarely taught at the undergraduate level, and when it is, it is typically relegated to the classroom setting.

METHODS

We used the disruption of the coronavirus 2019 pandemic to develop a TOC elective. The aim was to fulfill an acute educational need and to develop competencies around care transitions for students while concurrently providing support for patient care and teamwork. The elective was offered to second-, third- and fourth-year medical students. Our educational innovation was initiated within our safety-net hospital where we care for a high percentage of uninsured patients, with a high language discordance. In addition, our city has multiple care systems without a single or connected electronic health record system, further complicating patient care transitions. The work of the TOC elective crossed inpatient and outpatient silos, with close collaboration with our local federally qualified health centers. This remotely conducted elective includes three main pillars: participation in team activities, including virtual participation in interdisciplinary rounds and care coordination; discharge planning; and communication, including goals of care and end of life communication.

RESULTS

Medical students successfully integrated into team structures to directly counsel families, facilitate goals of care conversations, and engage a multidisciplinary team for discharge planning. Students found this experience valuable in their reflections. In addition, there was a value-added component from a patient care and teamwork perspective.

CONCLUSIONS

Participation of students in TOC is a valuable educational experience and contributes a value-added component to patient care and interprofessional teamwork. Moreover, an appreciation of the failures of the current system is pivotal as learners start to reimagine, explore, and design improved patient-centered systems in the future.

Value-Added Roles of Medical Students During the COVID-19 Pandemic: Assessment of Medical Students' Perceptions and Willingness in Sri Lanka

Purpose

Since the coronavirus disease 2019 (COVID-19) pandemic is an opportune time to introduce the value-added roles of medical students, this study assessed medical students’ perceptions and willingness to assist in COVID-19 health sector preparedness and response via value-added roles in Sri Lanka.

Methods

A cross-sectional online survey was conducted among all medical students studying in six batches of the Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, in June 2020. A Google form in English with 10 statements about individual perceptions of medical students’ roles and their willingness to assist in the COVID-19 health sector response via value-added roles was used to collect data. The responses were recorded on a five-point Likert scale. The chi-squared test for independence was used to explore the associations between the academic year and the responses to each statement.

Results

Out of 856 (response rate 79.6%) study participants, the majority were females (n=601, 70.2%). The majority (n=804, 93.9%) reported that they have a responsibility to contribute to the country’s COVID-19 health sector response. There was a statistically significant association between medical students’ perceived level of clinical knowledge, having the clinical skills to assist in the COVID-19 health sector response and academic year (p<0.001). The commonly identified value-added roles were developing (n=770, 89.9%) and disseminating (n=744, 86.9%) health education messages, and field contact tracing activities (n=653, 76.3%). Other value-added roles were assisting the curative health sector in COVID-19 patient management (n=380, 44.4%) and other non-COVID-19 patient management (n=463, 54.1%).

Conclusion

Medical students are mostly willing to engage in preventive health sector value-added roles and, to a lesser extent, in curative health sector value-added roles during the COVID-19 outbreak. However, medical educators need to clearly define the value-added roles and provide adequate training and supervision for medical students across academic years to enable them to combine learning with making meaningful contributions to the health-care system during the COVID-19 pandemic.

Realizing the vision of the Lancet Commission on Education of Health Professionals for the 21st Century: Transforming medical education through the Accelerating Change in Medical Education Consortium

In the last two decades, prompted by the anticipated arrival of the 21st Century and on the centenary of the publication of the Flexner Report, many in medical education called for change to address the expanding chasm between the requirements of the health care system and the educational systems producing the health care workforce. Calls were uniform. Curricular content was missing. There was a mismatch in where people trained and where they were needed to practice, legacy approaches to pedagogical methods that needed to be challenged, an imbalance in diversity of trainees, and a lack of research on educational outcomes, resulting in a workforce that was described as ill-equipped to provide health care in the current and future environment. The Lancet Commission on Education of Health Professionals for the 21st Century published a widely acclaimed report in 2010 that called for a complete and authoritative re-examination of health professional education. This paper describes the innovations of the American Medical Association Accelerating Change in Medical Education Consortium schools as they relate to the recommendations of the Lancet Commission. We outline the successes, challenges, and lessons learned in working to deeply reform medical education.

Health systems science education: The new post-Flexner professionalism for the 21st century

The foundations of medical education have drawn from the Flexner Report to prepare students for practice for over a century. These recommendations relied, however, upon a limited set of competencies and a relatively narrow view of the physician's role. There have been increasing calls and recommendations to expand those competencies and the professional identity of the physician to better meet the current and future needs of patients, health systems, and society. We propose a framework for the twenty-first century physician that includes an expectation of new competency in health systems science (HSS), creating 'system citizens' who are effective stewards of the health care system. Experiential educational strategies, in addition to knowledge-centered learning, are critically important for students to develop their professional identity as system citizens working alongside interprofessional colleagues. Challenges to HSS adoption range from competing priorities for learners, to the need for faculty development, to the necessity for buy-in by medical schools and their associated health care systems. Ultimately, success will depend on our ability to articulate, encourage, support, and evaluate system citizenship and its impact on health care and health care systems.

The Accelerating Change in Medical Education Consortium: Key Drivers of Transformative Change

The American Medical Association's (AMA's) Accelerating Change in Medical Education (ACE) initiative, launched in 2013 to foster advancements in undergraduate medical education, has led to the development and scaling of innovations influencing the full continuum of medical training. Initial grants of $1 million were awarded to 11 U.S. medical schools, with 21 schools joining the consortium in 2016 at a lower funding level. Almost one-fifth of all U.S. MD- and DO-granting medical schools are represented in the 32-member consortium. In the first 5 years, the consortium medical schools have delivered innovative educational experiences to approximately 19,000 medical students, who will provide a potential 33 million patient care visits annually. The core initiative objectives focus on competency-based approaches to medical education and individualized pathways for students, training in health systems science, and enhancing the learning environment. At the close of the initial 5-year grant period, AMA leadership sought to catalogue outputs and understand how the structure of the consortium may have influenced its outcomes. Themes from qualitative analysis of stakeholder interviews as well as other sources of evidence aligned with the 4 elements of the transformational leadership model (inspirational motivation, intellectual stimulation, individualized consideration, and idealized influence) and can be used to inform future innovation interventions. For example, the ACE initiative has been successful in stimulating change at the consortium schools and propagating those innovations broadly, with outputs involving medical students, faculty, medical schools, affiliated health systems, and the broader educational landscape. In summary, the ACE initiative has fostered a far-reaching community of innovation that will continue to drive change across the continuum of medical education.

Assessing the Transition of Training in Health Systems Science From Undergraduate to Graduate Medical Education

BACKGROUND

The American Medical Association Accelerating Change in Medical Education (AMA-ACE) consortium proposes that medical schools include a new 3-pillar model incorporating health systems science (HSS) and basic and clinical sciences. One of the goals of AMA-ACE was to support HSS curricular innovation to improve residency preparation.

OBJECTIVE

This study evaluates the effectiveness of HSS curricula by using a large dataset to link medical school graduates to internship Milestones through collaboration with the Accreditation Council for Graduate Medical Education (ACGME).

METHODS

ACGME subcompetencies related to the schools' HSS curricula were identified for internal medicine, emergency medicine, family medicine, obstetrics and gynecology (OB/GYN), pediatrics, and surgery. Analysis compared Milestone ratings of ACE school graduates to non-ACE graduates at 6 and 12 months using generalized estimating equation models.

RESULTS

At 6 months both groups demonstrated similar HSS-related levels of Milestone performance on the selected ACGME competencies. At 1 year, ACE graduates in OB/GYN scored minimally higher on 2 systems-based practice (SBP) subcompetencies compared to non-ACE school graduates: SBP01 (1.96 vs 1.82, 95% CI 0.03-0.24) and SBP02 (1.87 vs 1.79, 95% CI 0.01-0.16). In internal medicine, ACE graduates scored minimally higher on 3 HSS-related subcompetencies: SBP01 (2.19 vs 2.05, 95% CI 0.04-0.26), PBLI01 (2.13 vs 2.01; 95% CI 0.01-0.24), and PBLI04 (2.05 vs 1.93; 95% CI 0.03-0.21). For the other specialties examined, there were no significant differences between groups.

CONCLUSIONS

Graduates from schools with training in HSS had similar Milestone ratings for most subcompetencies and very small differences in Milestone ratings for only 5 subcompetencies across 6 specialties at 1 year, compared to graduates from non-ACE schools. These differences are likely not educationally meaningful.

Introduction to Health Systems Science: Experiential Learning Through Patient Interviews in the Emergency Department

Increased complexity in health care delivery is now a problem of national proportions. Traditional medical education fails to sufficiently prepare students for the realities of practicing medicine in the 21st century. To address this critical problem, health systems science (HSS), which focuses on the broader system of care, has emerged as the "third pillar" of undergraduate medical education complementing the basic and clinical sciences. The authors identified a need to increase the amount and quality of HSS education in a way that would engage students and provide a platform to learn how patients interact with the health care system. UNITED (Understanding Needs in the Emergency Department) was thus designed and implemented to introduce preclinical medical students to HSS through patient interactions in the emergency department (ED). EDs serve as America's health care "safety net" and there is no lack of opportunity to learn how the current system of care does and does not work for patients. Qualitative analysis of students' written reflections revealed the following themes of the UNITED experience: 1) medical students question their understanding of the health care system after listening to patients' stories, 2) focused patient interviews about the health care system provides a unique perspective of the patient experience not found elsewhere in the preclinical curriculum, and 3) discussing the realities of being a patient in the U.S. health care system is an emotional experience for students. Based on these data, the authors concluded that asking preclinical students to interview patients about their experience in the health care system leads to emotional activation and a subsequent stated desire to improve care delivery.

Learning New Skills in Innovation, Leadership, and Discovery During a 9-Month Scholarly Concentration: Results from the First Cohort at a New Medical School

Dell Medical School (DMS) has weaved health systems science (HSS) throughout its curriculum. During the third year, students complete a master's degree program or an immersive distinction in research or design during a 9-month Innovation, Leadership, and Discovery (ILD) block. Faculty assessments revealed all students met expectations, but dual-degree students were rated higher than distinction students in leading future innovative teams competencies. Student self-assessments revealed statistically significant improvements in HSS competencies during the block with little difference by ILD choice (dual degree or distinction). We will continue to examine the long-term impact of these experiences and skills in career trajectories.

Design and outcomes of a nurse practitioner preceptor development program

ABSTRACT

Nurse practitioners (NPs) are educated to provide high-quality patient- and family-centered care to underserved, culturally diverse, medically complex populations. Nurse practitioner faculty plan curricular activities that challenge NP students to critically assess individuals and populations with the goal of preparing NP students to be "practice-ready" upon graduation. Nurse practitioner clinical training occurs in practice settings with NP preceptors, with specific areas of clinical expertise. However, there is a lack of NP clinical preceptors educationally prepared to clinically teach and evaluate NP students. This article presents the design, implementation, evaluation, and outcomes from a 3-year grant funded by the United States Human Resources and Administration Services that featured a web-based Primary Care Nurse Practitioner Preceptor Development Program. Ninety percent of NPs who precepted NP students completed all web-based learning modules. Preceptors with educational preparation via online modules to guide NP student learning in clinical settings are a critical resource for faculty to prepare NP students to be practice-ready upon graduation. This web-based learning platform for online NP preceptor education may be a successful approach for expanding and improving the NP preceptor pool nationwide.