IAMSE Spring 2020 WAS Session 5 Highlights

[The following notes were generated by Rebecca Rowe, PhD.]

IAMSE Webinar Series, Spring 2020

Speakers: Jed Gonzalo, MD MSc, Penn State College of Medicine and Stephanie Starr, MD, Mayo Clinic Alix School of Medicine
Title: “Health Systems Science is the Broccoli of US Medical Education: Tackling the Key Challenges of Implementation”
Series: Evolution and Revolution in Medical Education: Health Systems Sciences


  • Describe the phases of implementation of HSS in US medical schools
  • Identify the “TOP 7” – selected key challenges to HSS education
  • Explore three vignettes related to HSS education in US medical schools, with articulation of potential solutions or “take-aways”
  • Commit to one action to address challenges at your school

The Phases of Change: Where is your Medical School?

  • Exploration Phase – Just beginning to think about HSS
  • Decision and Planning Phase – Have decided to incorporate HSS and are now in the planning phase.
  • Implementation Phase – We launched! Now What?
  • Maintenance and Continuous Improvement Phase – Have been doing this for a while but are still experiences challenges that exist along the continuum.

The “TOP” 7 Challenge Areas for HSS Education (There are many more but these are the top challenges across some of the phases.

Issue 1: The Nomenclature and Language

  • The evidence around any one of the 12 different areas of HSS have been around for decades, for example Patient Safety has been around for decades, Quality Improvement has been around for decades as well.
  • With this said, the last 7 years have seen all of these areas coalescing into 1 strategic and comprehensive framework.
  • The definition that we typically assign to HSS includes “The methods, the processes and the principals involved with improving outcomes, the quality and cost of care of patients of populations within a larger context of systems of care.”
  • The nomenclature issues involves some schools stating they may integrate the Social determinants of health or quality care, but these are only two components of HSS. In order to fully integrate HSS in to medical education all 12 components must be integrated.
  • This led to a study (Gonzalo, et. al. HSS in Med Ed: Unifying the Components to Catalyze Transformation. Acad Med, 2020) that mapped the 12 different areas of HSS with the different resources, expectancies, competencies, curriculum recommendations that exists and milestones that are used in medical education, that would show and demonstrate the areas of overlap and where there may be gaps across the different components of HSS.
  • HSS is not equivalent to some of the finite pieces but is more comprehensive framework balancing all 3 pillars of medical education.

Issue 2: Curriculum Timing, Sequence, Integration

  • Includes the total footprint of incorporating HSS
  • Lack of consensus of HSS competencies (pieces in AAMC core EPAs, LCME, DC)
  • Curriculomegaly – where can we find more space to add content?
  • Drip vs bolus method— Drip method where add in several HSS topics into the preexisting system blocks with the basic and clinical sciences. Bolus method have several stand-alone intensive 2 week courses
  • Development sequence – what is the right order of business for folks to learn these topics?
  • Integrating well with the basic and clinical sciences. Want the students to experience a seamless three science strands across all four years. To be able to do this is a challenge!

Issue 3: Student Perceptions

Adding HSS into existing curricular is not an easy thing to do, especially in the area of student perceptions and student engagement.  In a study that was done prior to implementing HSS into the curriculum to determine the pedagogical challenges, which are the issues that need to be identified before starting the work of adding HSS to make sure you are able to overcome these issues in order to have everyone engaged in your educational program.

Current medical student priorities (includes two pillars of medical science, basic and clinical science) vs alternative medical students priorities that includes the HSS along with basic and clinical sciences.

Current Medical Student                                           Alternative Medical Student

Best Residency Program                                             Best Doctor Possible

Grades and Board Exams        ←AT ODDS→            Patient-Centered Skills

Basic and Clinical Science Courses                            Balance of Basic, Clinical and HSS

  • Look at student perceptions of the two-pillar model to medical education to the three pillar approach to medical education. And these two areas are at ODDS.
  • In another study (Gonzalo, JD, et. al. Unpacking Medical Students’ Mixed Engagement in HSS. Teach Learn Med, 2019), where a qualitative analysis was done from all of their students’ comments at the end of sessions and courses. These are the themes that emerged:

Issue 4: Faculty Role Modeling and Skills

Comes from the study (Gonzalo, et.al. Concerns and Recommendations for Integrating HSS into Medical Student Education, Acad Med, 2017) that looked at faculty comments and issues shown below:

Importance of Learning HSS

  1. “If medical education isn’t broke, don’t fix it.”
  2. “HSS is too complex and best learned in residency or practice.”
  3. “Early students do not have skills to contribute to health care, and the value added roles already exist.” The roles of medical education is not for the future. The roles of medical education is now and can make a difference today!
  4. “Health Systems Science is not yet a true science.”  All of the components of HSS have been around for a while. What is new is bringing them all together in a comprehensive framework. Basic and Clinical Sciences are not enough.

Practical Concerns

  1. “There is limited space in an already packed curriculum.” Most of HSS may be already present in our curriculum. It just needs to be relabeled.
  2. “Few faculty have the knowledge and skills to teach HSS.”
  3. “Accreditation agencies and licensing boards do not support medical education transformation.”
  4. “Evolving health systems are not ready to partner with schools with HSS curricula.”
  • May be that some of our pre-clinical and clinical faculty are already teaching components of HSS but the topics are not labeled as such.
  • May need to develop new educator roles for HSS as documented in the paper by Gonzalo, et. al. New Educator Roles for HSS: Implications for US Medical School Faculty: Acad Med, 2019, where three new or reimagined types of educator roles in HSS were discussed. These are:
  1. Classroom or Zoom Instructors
  2. Clinical Supervisors or Educators
  3. Curriculum leader/evaluator
  4. Mentor/advisor (projects, scholarship, career path)

In Summary:

  • “New” educators are here.
  • Need to advance skills based on education science with attention to learning environments (classroom, online or clinical learning environments).
  • Need to acknowledge and reward these roles and work on faculty development.

Issue 5: Assessment of Learners

How do you assess? This is not always an easy thing to do. Start by looking at Miller’s pyramid.

  • Learner triangle has four components at the base are cognition and at the top or apex is behavior.
  • Base of the triangle is KNOWS: Fact Gathering
  • Next level is KNOWS HOW: Interpretation/Application
  • These two areas make up ~ 80% of where medical students are.
  • Third level is SHOWS: Demonstration of Learning
  • Top level or apex is DOES: Performance Integrated into Practice
  • Top two levels is where 20% of medical students are.
  • The bottom two levels make up the Cognition portion of the triangle and the top two levels make up the Behavior portion of the triangle.
  • The percentages are the opinion of Dr. Gonzalo.

Where does HSS appear on the USMLE Board Examinations?

  1. Behavioral Health
    • Patient Adherence
  1. Epidemiology/Population Health
    • Epidemiology/population health
  1. Social Sciences
    • Communication/cultural competence
    • Death/dying and palliative care
  1. Systems-Based Practice
    • Complexity/systems thinking
    • Quality improvement
    • Patient safety
    • Health care policy and economics

Content Analysis of HSS Content on NBME USMLE Examinations: (Please note most of this data is anecdotal and should not be quoted!)

  • Before 2020 ~7%
  • After 2020 estimated that Step 1 and Step 2 would include more HSS ~10-15%
  • It is possible that Step 3 could contain as much as 20%.
  • What this is showing is HSS is appearing on the Board Exams more frequently.

Issue 6: Clinical Learning Environment

“The learning environment refers to the social interactions, organizational culture and structures, and physical and virtual spaces that surround and shape the learners’ experiences, perceptions, and learning.” (Macy Foundation Conference on the Clinical Learning Environment (Gruppen, Irby, Durning, Maggio, van Schaik)

  • Closer gradient of HSS concept knowledge, skills between faculty and learners. Therefore, the students are teaching the faculty, as well as, faculty teaching students
  • Practice and education silos
  • Practice pressures
  • Faculty development
  • Insufficient UME structures, processes to ensure reliable ongoing horizontal and vertical integration of HSS

Issue 7: Program Evaluation

This is looking beyond level of the individual learner, but from also the programmatic standpoint.

  • Level 1 Reaction: Satisfaction Engagement Relevance (Surveys and Course Evaluations)
  • Level 2 Learning: Knowledge, Skills, Attitude Confidence Commitment (NBME HSS Exam Grad. Questionnaire)
  • Level 3 Behavior: Application Drivers (Course Assessment, Clinical Assessment, AMA-GME Milestones)
  • Level 4 Results: Outcomes Indicators (Patient Outcomes Big Data)

Completed the TOP 7 areas of challenges of the different phases of where institutions might be!

At the end of the Webinar, the speakers took us through a few vignettes from institutions at various stages of bringing HSS into their curriculum that reached out to them for consultation. The title of the vignettes and the specific phase of change are:

Vignette 1: “We’re Thinking about HSS!” – Exploration Phase
Vignette 2: “Our Student Satisfaction Scores are So Low!” – Implementation Phase
Vignette 3: “How Do We Integrate with Our Health System?” – Implementation Phase

Please refer to the archive to listen to the discussion of these vignettes about these implementation challenges.

Lastly, HSS is not just an education framework. It is actually a framework that unifies all health care.