Tools for tomorrow's health care system: a systems-informed mental model, moral imagination, and physicians' professionalism

"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.

How group coaching contributes to organisational understanding among newly graduated doctors

BACKGROUND

Practising medicine at an expert level requires skills beyond medical expert knowledge. Research shows that newly appointed consultants feel less prepared to deal with leadership issues compared to issues regarding medical expertice. Newly graduated (NG) doctors and residents in particular struggle with leadership and organisational issues. The purpose of this study was to explore the impact of group coaching on NG doctors' approach to organisational and leadership challenges in daily practice during the transition period from medical school to clinical work.

METHODS

Newly graduated doctors participated in a group coaching course comprising three full-day sessions and five two-hour sessions. The purpose was to support NG doctors' professional development regarding organisational issues in the first years after graduation. The coaches were health professionals with certified coaching training. Data from the intervention were collected from open-ended questionnaires and observational notes. A thematic analysis was performed.

RESULTS

Forty-five NG doctors participated in a total of six courses sharing experiences and problems reflected in their professional lives. The following themes emerged: Revelation of the hidden curriculum, importance of professional relations, inter-professional communication, conflict management and emerging leadership skills. Participants' communication skills improved due to an increased awareness of other peoples' perspectives and preferences. They realized the importance of good relations, saw how they could become active contributors in their departments and began to practice leadership skills through e.g. involvement of the team, delegation of work and negotiation of own obligations.

CONCLUSION

Newly graduated doctors seemed to develop a growing awareness of organisational issues and a deeper understanding of the complexity of health care organisations through participation in a group coaching course. The study indicates that participation in a group coaching course probably contributes to improve practice among NG doctors. Further studies are needed to consolidate the findings and explore possible organisational effects.

Systems of career influences: a conceptual model for evaluating the professional development of women in academic medicine

BACKGROUND

Surprisingly little research is available to explain the well-documented organizational and societal influences on persistent inequities in advancement of women faculty.

METHODS

The Systems of Career Influences Model is a framework for exploring factors influencing women's progression to advanced academic rank, executive positions, and informal leadership roles in academic medicine. The model situates faculty as agents within a complex adaptive system consisting of a trajectory of career advancement with opportunities for formal professional development programming; a dynamic system of influences of organizational policies, practices, and culture; and a dynamic system of individual choices and decisions. These systems of influence may promote or inhibit career advancement. Within this system, women weigh competing influences to make career advancement decisions, and leaders of academic health centers prioritize limited resources to support the school's mission.

RESULTS AND CONCLUSIONS

The Systems of Career Influences Model proved useful to identify key research questions. We used the model to probe how research in academic career development might be applied to content and methods of formal professional development programs. We generated a series of questions and hypotheses about how professional development programs might influence professional development of health science faculty members. Using the model as a guide, we developed a study using a quantitative and qualitative design. These analyses should provide insight into what works in recruiting and supporting productive men and women faculty in academic medical centers.

Systems-based practice in graduate medical education: systems thinking as the missing foundational construct

BACKGROUND

Since 2001, residencies have struggled with teaching and assessing systems-based practice (SBP). One major obstacle may be that the competency alone is not sufficient to support assessment. We believe the foundational construct underlying SBP is systems thinking, absent from the current Accreditation Council for Graduate Medical Education competency language.

SUMMARY

Systems thinking is defined as the ability to analyze systems as a whole. The purpose of this article is to describe psychometric issues that constrain assessment of SBP and elucidate the role of systems thinking in teaching and assessing SBP.

CONCLUSION

Residency programs should incorporate systems thinking models into their curricula. Trainees should be taught to understand systems at an abstract level, in order to analyze their own healthcare systems, and participate in quality and patient safety activities. We suggest that a developmental trajectory for systems thinking be developed, similar to the model described by Dreyfus and Dreyfus.

Saving and Ignoring Lives: Physicians’ Obligations to Address Root Social Influences on Health—Moral Justifications and Educational Implications

The predominant influences on health are social or upstream factors. Poverty, inadequate education, insecure and toxic environments, and inferior opportunities for jobs and positions are inequitable disadvantages that adversely affect health across the globe. Many causal pathways are yet to be understood. However, elimination of these social inequalities is a moral imperative of the first order. Some physicians by word and deed argue that medical doctors should oppose the “structural violence” of social inequalities that greatly shorten lives and wreak so much suffering.

Comparative efficacy of group and individual feedback in gross anatomy for promoting medical student professionalism

Professionalism is a core competency of medical training that requires students to develop the skills of providing and receiving feedback. Our study evaluated the effectiveness of delivering feedback in a group setting compared with an individual setting. The first-year class of Mayo medical students (n = 49) enrolled in gross anatomy (in dissection teams), completed weekly anonymous evaluations of themselves and their teammates regarding seven aspects of professionalism (altruism, compassion, respect, honesty/integrity, responsibility, commitment to excellence, and self-reflection). Professionalism scores from these surveys were calculated using a six-point Likert scale. Students were also asked to comment on strengths and possible areas for improvement on each peer. At the midpoint of the course, peer comments and professionalism scores were shared with students in debriefing sessions either individually or with their team. Analysis of preintervention and postintervention professionalism scores indicated that the students receiving feedback in a one-on-one setting (student and instructor) were more likely to demonstrate higher scores on subsequent evaluations as compared with those students receiving feedback in a group setting (all team members and one instructor). Our findings suggest that providing feedback to first-year medical students on an individual basis is the best way to improve professional attitudes and behaviors.

Remediation of the deficiencies of physicians across the continuum from medical school to practice: a thematic review of the literature

Despite widespread endorsement of competency-based assessment of medical trainees and practicing physicians, methods for identifying those who are not competent and strategies for remediation of their deficits are not standardized. This literature review describes the published studies of deficit remediation at the undergraduate, graduate, and continuing medical education levels. Thirteen studies primarily describe small, single-institution efforts to remediate deficient knowledge or clinical skills of trainees or below-standard-practice performance of practicing physicians. Working from these studies and research from the learning sciences, the authors propose a model that includes multiple assessment tools for identifying deficiencies, individualized instruction, deliberate practice followed by feedback and reflection, and reassessment. The findings of the study reveal a paucity of evidence to guide best practices of remediation in medical education at all levels. There is an urgent need for multiinstitutional, outcomes-based research on strategies for remediation of less than fully competent trainees and physicians with the use of long-term follow-up to determine the impact on future performance.

Physician practice change I: a critical review and description of an Integrated Systems Model

The long lag time between medical discovery and when Americans benefit from that discovery has a huge cost in terms of morbidity and mortality. Medicine needs more effective methods for moving discovery to practice. In this article, the authors first offer a critical review of the models of structure and change process gleaned from the physician change literature. Next, they describe the Integrated Systems Model (ISM) that they derive from this review. The ISM has four major components: superstructure, change motivators, change process, and functional interactions. The ISM considers the physician practice to operate as a complex adaptive system requiring diversion of resources from reserves to make a change. In the ISM, resource return is a function of improved quality of care and reimbursement for services. Changes decreasing the resources of the system (parasitic) will be harder to make than those that increase resources (symbiotic) because of resistance to resource loss. The authors extend the ISM to the individual level and describe the need to consider whether individuals within the practice have sufficient reserves to fulfill their part in making the change. Any given change is generally competing with other changes for adoption. Finally, the authors consider the strengths and weaknesses of their model, concluding that by keeping patient welfare, quality care, and finances in the forefront, the ISM provides a more complete picture of forces affecting medical practice change.

Physician practice change II: implications of the Integrated Systems Model (ISM) for the future of continuing medical education

In a companion paper, the authors provide the development and description of the Integrated Systems Model (ISM). In this article, they describe 14 general implications of the ISM for continuing medical education (CME). They discuss how applying the ISM would change CME by describing (1) how CME and the larger health care environment would be restructured if they were based on the ISM and (2) how the ISM would impact CME under the current environment of health care in the United States. They close by describing how the ISM can be used as CME moves to address the long lag between discovery and practice and begins to decrease its dependence on pharmaceutical companies. The ISM helps not only explain why the current health care system in the United States (or anywhere) produces what it produces, but also predict what that system would produce if it changed. At present, the ISM is a conceptual model, but with more research into measures of its various elements, it could become a more quantitatively predictive model. In its present form, however, the ISM can serve Marinopoulos's call for a "sound conceptual model of what influences the effectiveness of CME" and address Grimshaw's concern that current research lacks "a theoretical base to support the choice and development of interventions as well as the interpretation of study results." The statistician George Box said, "All models are wrong, some models are useful." The authors believe that the ISM is useful and that maybe it will prove Box wrong.

Increasing bioethics education in preclinical medical curricula: what ethical dilemmas do clinical clerks experience?

PURPOSE

The increase in bioethics education in preclinical curricula enables medical students to recognize ethical issues and determine right action. The authors sought to explore the ethical dilemmas medical students experience during clinical clerkships.

METHOD

Following an e-mail invitation, 100 of 104 graduating medical students allowed their final ethics assignment, a written description of an ethical dilemma experienced during clinical clerkship, to be analyzed. After all identifiers were removed, the narratives underwent qualitative analysis and were then reanalyzed using Jameton's determinants of moral action.

RESULTS

Four themes emerged: the clinical service rotation, target, source, and nature of the ethical dilemma. For many clinical clerks, the ethical dilemma arose because they recognized an ethical issue but neither brought it to their supervisors nor resolved it themselves for fear of incurring disfavor. The source of the ethical dilemma was most frequently the student's supervisor (46%), which may explain why, although all narratives demonstrated the Jameton criteria of "moral sensitivity" and 76% demonstrated "moral judgment," only 24% indicated "moral motivation" and only 4% suggested "moral courage." Patients were the most frequent target (76%), followed by students (14%). Students reported informed consent (18%) and inadequate care (17%) as the most common types of dilemmas under the nature theme.

CONCLUSIONS

Clinical clerks' experiences of ethical dilemmas might be mitigated if residency education and professional development mirrored the increase in preclinical ethics education, if ethics training included encouraging students to discuss ethical issues as they arise, and if educators developed innovative models of student evaluation.