Using Kern's 6-Step Approach to Integrate Health Systems Science Curricula Into Medical Education

Lessons learned from implementing health systems science and community service course for fourth-year medical students

BACKGROUND

With the call to integrate health systems science (HSS) in medical education curriculum comes the need for more practical guidance from implementation experiences. In June 2020, the University of Texas Medical Branch John Sealy School of Medicine implemented a required course entitled "Health Systems Science and Community Service (HSS)" for fourth-year medical students. This quality improvement study describes the course and the lessons learned in the first four iterations.

METHODS

The course was formatted as a 10-month-long, asynchronous course that ran concurrently with post-clerkship rotations. Throughout the four iterations, we used close- and open-ended questions to systematically collect students' feedback twice annually. Descriptive analysis of quantitative data was performed, and general themes were drawn from qualitative items from the evaluations. In addition, the National Board of Medical Examiner (NBME) HSS Subject Examination was administered in the course during the third and fourth iterations; student performance was analyzed. The course contents were iteratively revised each year to incorporate more HSS and community service components.

RESULTS

The course cohorts 1 through 4 from each iteration had 234, 221, 220, and 217 students, respectively. The response rates for the end-of-year course evaluations were 91% for cohorts 1, 2, and 3, and 94% for cohort 4. Most students reported that the amount of material they were required to cover was reasonable across all four iterations. While most respondents from cohorts 1, 2, and 4 found the number of community service hours reasonable, the majority of respondents in cohort 3 indicated it was excessive. The common themes from students' responses across cohorts included that some of the course content should have been taught in earlier years of their medical training, that community service activities are valuable but should have been optional, and that students appreciated the flexibility of the course. Student performance on the NBME exam was comparable to national performance. We summarized the iterative changes for each cohort based on feedback.

CONCLUSIONS

We described the implementation of a post-clerkship course on health systems science integrating with community service and service-learning. A major lesson learned was the need to take an iterative approach in building components like service-learning and addressing challenges, including student buy-in.

Effects of strategies to tackle racism experienced by healthcare professionals: a systematic review

OBJECTIVES

The objective of this study is to evaluate the effect of equality, diversity and inclusion (EDI) training interventions on race inequalities experienced by healthcare professionals.

DESIGN

Systematic review.

DATA SOURCES

Cochrane, MEDLINE and Embase databases were searched from database inception to February 2024.

ELIGIBILITY CRITERIA

Randomised trials, observational studies and mixed-methods studies published in English were included. Studies that reported the effects of EDI training interventions targeting healthcare professionals were included.

DATE EXTRACTION AND SYNTHESIS

A narrative synthesis approach was used to evaluate the impact of EDI interventions on healthcare professionals.

RESULTS

17 studies were included. EDI interventions were delivered using several methods including didactic, group discussion, game-based learning or a combination of methods. Out of nine studies, eight (88.9%) interventions resulted in an improvement in knowledge and awareness. Five studies reviewed the effect on cultural competence and four (80.0%) improved cultural competence. Out of eight studies, six (75.0%) resulted in willingness to change and skills gained to promote behavioural change. Most of the improvements seen were with theory-based, multimethod curriculum in comparison to a non-theory-based didactic approach. However, there was insufficient evidence to suggest that these interventions impact the racism that healthcare professionals from an ethnic/racial minoritised group experience.

CONCLUSIONS

EDI interventions may improve healthcare workers' knowledge and awareness of racial inequalities and cultural competence. Although a willingness to change may occur and behavioural change is promoted, there is insufficient evidence from this review to suggest that this reduces the experience of racism.

Empowering Continuing Medical Education (CME) in India: leveraging Kern's instructional design model

INTRODUCTION

Continuing Medical Education (CME) is vital for healthcare professionals to remain current with advancements and maintain their competence. In India, CME remains in its early stages, lacking a systematic approach. There is a pressing need for a comprehensive framework that addresses needs assessment, program development, accreditation, and credit allocation. Specifically, there is a gap in delivering targeted CME that meets the needs of different medical professionals at appropriate times. The aim of this study is to employ Kern's six steps of curriculum design to plan and evaluate a faculty development program focused on Entrustable Professional Activities (EPAs) for MD (Doctor of Medicine) Biochemistry professionals.

METHODS

This study utilized Kern's six-step approach to design a training program on Entrustable Professional Activities (EPAs) tailored for MD Biochemistry professionals. Approval was obtained from the Institutional Human Ethics Committee. Following problem identification, a targeted needs assessment was conducted through expert consultations. The goal of the program was established, focusing on the development and delivery of an interactive online CME program. The program was developed, implemented and evaluated using surveys and feedback questionnaires.

RESULTS

A comprehensive literature review revealed a notable gap in EPA-related works for MD Biochemistry program. Expert consultations highlighted significant training needs and barriers, such as limited resources and professional commitments. Consequently, the program's primary objective was to raise awareness and sensitize participants to EPA development. A 4-h online CME was designed, featuring expert-led sessions and collaborative group activities. The program attracted 152 participants and utilized interactive elements, such as polls and chats, to foster engagement. Group activities allowed participants to apply concepts in EPA validation. Pre- and post-program surveys demonstrated significant improvements in participants' knowledge and confidence. Feedback highlighted the practical relevance of the content and the interactive, hands-on nature of the sessions.

CONCLUSION

Kern's six-step approach provided a structured and effective framework for developing the CME program, addressing identified needs and barriers, and enhancing faculty development in MD Biochemistry. This study underscores the importance of a systematic approach in CME to improve program effectiveness.

TRIAL REGISTRATION

Not applicable.

Academic Health System Framework for Health Services Transformation: A Perspective View from West Java, Indonesia

Although the field of medicine has made significant progress in recent decades, low and middle-income countries continue to face significant difficulties in addressing the unprecedented obstacles to improving health. Medical schools should play a critical role in driving health services reform and take on a new leadership role in strengthening the health system. This paper discusses a conceptual framework and outlines the Academic Health Systems (AHS) agenda in Indonesia. A comprehensive analysis was conducted on the existing literature and frameworks regarding AHS, applying the system thinking method, which engages stakeholders actively. The findings and interpretations from interviews, focus groups, and collaborative workshops were consolidated and a set of proposed frameworks, fundamental principles, and a route for enhancing the health system in Indonesia were put forward. Our recommendations include transformative learning, community engagement, and translational research as pillar principles of AHS program. These recommendations have the potential to be modified and implemented in other low- and middle-income countries.

COVID As a Catalyst: A Qualitative Study Of Professional Identity Formation among U.S. Medical Students During COVID-19

PHENOMENON

Students become physicians not only by mastering medical knowledge, but also through a process of Professional Identity Formation (PIF). In this study, we used the conceptual framework of Jarvis-Selinger et al. to explore the impact of COVID, as a major public health crisis, on the PIF of preclinical medical students in our country.

APPROACH

At two U.S. medical schools, we interviewed 28 medical students twice as they moved from first to second year during the 2020-2021 COVID pandemic and explored the impact of COVID-19 on PIF. We coded the transcribed interviews and identified themes using constructivist thematic analysis.

FINDINGS

We identified three themes: 1) mental health and wellness impacts; 2) inhabiting identity as a health professional during COVID; and 3) questioning the role of physicians in society. Routines and support systems were disrupted, undermining wellness and confidence in professional choices. Students noted the need to be public health role models, and COVID prompted feelings of pride, while also causing them to question expectations of self-sacrifice amid a new politicization of medicine. Students felt that physicians must be increasingly engaged in public health and political communication.

INSIGHTS

Our findings inform medical educators seeking to build a scaffolding to support PIF during a public health crisis, and highlight the importance of current events and politics on PIF. Our recommendations include the need for student support, longitudinal mentorship, curricular space to discuss the impact of sociopolitical factors on PIF, and revisiting foundational concepts such as professionalism to take into account the social and political context. Our findings add to understanding of PIF during the COVID pandemic, but are also relevant to teaching and learning during future public health crises.

Kern's six-step approach allows for meaningful implementation of an orthognathic surgery training course

OBJECTIVES

This study investigated the effectiveness of simulation training in improving the confidence and competency of oral and maxillofacial surgery (OMS) residents in performing orthognathic surgery (OGS).

METHODS

Kern's six-step approach was applied when designing the simulation training for OMS residents. The difficulties encountered by the residents when learning OGS were considered when designing the training program. A training course consisting of didactic sessions, hands-on training on three-dimensional training models, and an assessment tool was implemented for OMS residents. Improvement in the confidence and competence of OMS residents in performing OGS, fidelity of the three-dimensional models, and satisfaction with the course was evaluated.

RESULTS

All OMS residents (10/10) completed the course. The perceived difficulty in learning OGS was mainly related to the manipulation of the jawbones. While there were improvements in the median confidence and competence scores (3/5 to 4/5), only the differences in competence were found to be statistically significant (p < 0.01, Wilcoxon signed-rank test). Improvements in confidence and competence did not correlate. The mean fidelity scores of both the maxillary and mandibular models were adequate at 3.2 out of 5. Overall, satisfaction with the course was high (5/5).

CONCLUSIONS

The six-step approach provides a guided process for educators to formulate a training course directed toward the perceived needs of students. Targeted training can significantly enhance the students' competence. Greater efforts should also be put in place to allow simultaneous developments in the students' confidence along with their competence.

Identifying Physician Public Health Competencies to Address Healthcare Needs in Underserved, Border, and Outer Island Areas of Indonesia: A Rapid Assessment

Phenomenon: Most medical schools in Indonesia have developed innovations to integrate public health content into the curricula. However, ensuring that all schools meet appropriate standards regarding the quality of subjects, content relevancy, and course delivery takes time and effort. Approach: This study employed a rapid assessment procedure to identify the current knowledge and competencies required to practice medicine effectively in underserved, border, and outer island areas of Indonesia. Ninety-three participants from six remote districts were involved in 12 focus group discussions. Qualitative data were analyzed using content analysis using the social determinants of health as a guiding framework. Findings: Under decentralized health system governance, the local socio-geographical context is critical to understanding the current public health landscape. Medical education with respect to public health must emphasize physicians' ability to advocate and encourage the coordination of healthcare services in responding to disasters, as well as community-based surveillance and other relevant data for synergistic disease control. As part of a healthcare facility management team, prospective doctors should be able to apply systems thinking and provide critical input to improve service delivery at local health facilities. Also, recognizing underlying factors is essential to realizing effective interprofessional collaboration practices and aligning them with leadership skills. Insights: This study outlines recommendations for medical schools and relevant colleges in formulating compulsory block or integrated public health curricula. It also provides a public health learning topic that may aid medical schools in training their students to be competent for practice in underserved, border, and outer island areas. Medical schools should offer initiatives for students to acquire the necessary public health competencies merited by the population's health needs.

Education Scholarship Assessment Reconsidered: Expansion of Glassick's Criteria to Incorporate Health Equity

ABSTRACT

Recent events have ignited widespread attention to structural racism and implicit bias throughout the U.S. health care system and medical institutions, resulting in a call for antiracism approaches to advance health equity. Medical education leaders are well positioned to advance health equity, not only through their training of fellows, residents, and medical students, but also in their approach to scholarship. Education scholarship drives innovation and critical evaluation of current practices; it impacts and intersects with multiple factors that have the potential to reduce health inequities. Thus, it is critical to prioritize the assessment of education scholarship through a health equity lens. Medical education scholarly dissemination has markedly expanded over the past 2 to 3 decades, yet medical educators have continued to embrace Boyer's and Glassick and colleagues' definitions of scholarship. The authors propose an approach to medical education scholarship assessment that expands each of Glassick's 6 existing criteria to address health inequities and adds health equity as a seventh criterion. With this, medical educators, researchers, reviewers, and others can consider how education scholarship affects diverse populations and settings, direct educational products and scholarship to address health inequities, and raise the importance of advancing health equity in medical education scholarship. By expanding and standardizing the assessment of scholarship to incorporate health equity, the medical education community can foster a cultural shift that brings health equity to the forefront of education scholarship.

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.

Creating transformational learning experiences for 21st century healthcare students through preclinical skills training at a South African university

BACKGROUND

Creating an inclusive interprofessional teaching and learning community can enhance student engagement and ultimately develop essential graduate attributes (GA) (also known as generic, transferable, core, soft, work-ready or nontechnical skills). The early practical development of GA within a diverse space is essential in health profession education, as students experience the transition to clinical training as challenging.

AIM

This paper describes the conceptualization and implementation of an inclusive interprofessional curriculum focused on GA development in the preclinical years.

METHODS

A phased multimethod research design was applied. Phase 1 focused on the conceptualization of a preclinical GA development curriculum through a consensus-seeking process among all staff in the School of Health and Rehabilitation Sciences (N = 36). Subsequently, in Phase 2, quantitative and qualitative data were gathered from participating first-year students (N = 135) as an early curricular implementation review. Descriptive statistical analyses for quantitative and thematic analyses for qualitative data were performed.

RESULTS

During Phase 1, five themes were identified (Ethics, Professionalism, General principles for interventions, Organizations and institutions, Management) informing preclinical curriculum development. Forty-one first-year students (30%) participated in Phase 2. The majority of participants (87%) indicated that they had a positive learning experience during Phase 2. Students expressed that engagement was encouraged (83%) within a space of mutual respect (83%), with interprofessional groups assisting in building "a trusting environment and a supportive one". Students indicated they "liked that it [module] wasn't just about one topic", as it concretized that "there is more to being a healthcare professional that just treating people".

CONCLUSION

GA development provides an invaluable opportunity for interprofessional engagement. Creating a diverse and inclusive curricular space through multimodal and interprofessional training, GA training was transformed to be more practical and future-focused, creating a positive learning experience. Future research should focus on the longer-term impact of this practical, preclinical GA development during the transition of these students into the clinical training space.

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.

Consensus Statement No. 434: Simulation in Obstetrics and Gynaecology

OBJECTIVE

To provide a comprehensive and current overview of the evidence for the value of simulation for education, team training, patient safety, and quality improvement in obstetrics and gynaecology, to familiarize readers with principles to consider in developing a simulation program, and to provide tools and references for simulation advocates.

TARGET POPULATION

Providers working to improve health care for Canadian women and their families; patients and their families.

OUTCOMES

Simulation has been validated in the literature as contributing to positive outcomes in achieving learning objectives, maintaining individual and team competence, and enhancing patient safety. Simulation is a well-developed modality with established principles to maximize its utility and create a safe environment for simulation participants. Simulation is most effective when it involves interprofessional collaboration, institutional support, and regular repetition.

BENEFITS, HARMS, AND COSTS

This modality improves teamwork skills, patient outcomes, and health care spending. Upholding prescribed principles of psychological safety when implementing a simulation program minimizes harm to participants. However, simulation can be an expensive tool requiring human resources, equipment, and time.

EVIDENCE

Articles published between 2003 and 2022 were retrieved through searches of Medline and PubMed using the keywords "simulation" and "simulator." The search was limited to articles published in English and French. The articles were reviewed for their quality, relevance, and value by the SOGC Simulation Working Group. Expert opinion from relevant seminal books was also considered.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

All health care professionals working to improve Canadian women's health, and relevant stakeholders, including granting agencies, physician/nursing/midwifery colleges, accreditation bodies, academic centres, hospitals, and training programs.

RECOMMENDATIONS

"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.

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.

Ignorance Isn't Bliss: We Must Close the Machine Learning Knowledge Gap in Pediatric Critical Care

Pediatric intensivists are bombarded with more patient data than ever before. Integration and interpretation of data from patient monitors and the electronic health record (EHR) can be cognitively expensive in a manner that results in delayed or suboptimal medical decision making and patient harm. Machine learning (ML) can be used to facilitate insights from healthcare data and has been successfully applied to pediatric critical care data with that intent. However, many pediatric critical care medicine (PCCM) trainees and clinicians lack an understanding of foundational ML principles. This presents a major problem for the field. We outline the reasons why in this perspective and provide a roadmap for competency-based ML education for PCCM trainees and other stakeholders.

The power of interdependence: Linking health systems, communities, and health professions educational programs to better meet the needs of patients and populations

Promoting optimal health outcomes for diverse patients and populations requires the acknowledgement and strengthening of interdependent relationships between health professions education programs, health systems, and the communities they serve. Educational programs must recognize their role as integral components of a larger system. Educators must strive to break down silos and synergize efforts to foster a health care workforce positioned for collaborative, equitable, community-oriented practice. Sharing interprofessional and interinstitutional strategies can foster wide propagation of educational innovation while accommodating local contexts. This paper outlines how member schools of the American Medical Association Accelerating Change in Medical Education Consortium leveraged interdependence to accomplish transformative innovations catalyzed by systems thinking and a community of innovation.