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

IAMSE Webinar Series, Spring 2020

Speakers: Anna Change, MD, Director, Clinical Microsystems Clerkship, University of San Francisco School of Medicine; Adrienne Green, MD, Chief Medical Officer and Vice President for Patient Safety and Accreditation, University of San Francisco Health System and Edgar Pierluissi, MD, Director, Health Systems Improvement, University of San Francisco School of Medicine.
Title: “Health Systems Sciences: The Pre-Clinical Years in Medical Education”
Series: Evolution and Revolution in Medical Education: Health Systems Sciences

Objectives for the Session:
1. Identify the importance of health systems science in medical student education
2. Describe one sample strategy for integrating health system science with basic and clinical sciences in pre-clinical undergraduate medical education
3. List benefits of value-added student roles from the perspective of health system

During the session the following sections will be addressed:
1. What is health systems science and why is it important to medical education? Presented by Dr. Edgar Pierluissi.
2. How do we teach HSS in the pre-clerkship years? Presented by Dr. Anna Chang
3. Why do academic health centers want HSS education? Presented by Dr. Adrienne Green

Dr. Pierluissi started by reminding us the definition of HSS.
HSS is defined as “the study of how health care is delivered. It seeks to improve the quality of health care for patients and populations”. American Medical Association

1. Why is HSS important to Medical Education?
• Quality
• Patient Complexity
• Cost

Quality (JAMA, 2018; 319 (10); 1024-1039)
• There are many areas where American medicine doesn’t deliver care that we know can be achieved, although there are some areas of excellence.
• When comparing to the other wealthy countries, the USA ranked highly in Clinical Outcomes (1st), but did not do as well in other domains such as Access (6th), Perception of care (10th) and Disparities in Health Care (11th).
• There are significant gaps in health care quality across the US such as either overuse of diagnostic imaging or underuse of cancer screening.
• Basically, the quality of care in the US is not what is should be.
• The inclusion of HSS in medical education is a response to this problem.

Patient Complexity
• As patients age, the number of patients with complex medical and psychosocial factors is increasing.
• Patients that present with 4 or more co-morbidities increases with age.
• This population of patients disproportionately account for poor health outcomes and health care costs. ( J Amer Board of Fam Med 2018)
• In summary, “as the number of patients with multimorbid, complex, and medical and psychosocial factors increase, health outcomes will depend more on teams and systems of care than the individual physician.”

Cost
• The US spends more, by far, on health care than other wealthy countries.
• The cost of health care has consequences.
• Data shows that at least 25% of Americans, or a family member, delayed care for a serious health medical condition owing to the cost of care. (The Washington Post 2019)
• One-third of people that filed for bankruptcy confirmed the cost of health care was a contributing factor.
• Adhering to evidence, aligning care with patient’s values, increasing collaboration and care has the potential to reduce waste.
• Much of the cost of health care is due to waste.
• The aim of HSS in medical education is to reduce waste and to increase the value of care.

This concludes this section on the Drivers for HSS in Medical Student Education. By incorporating HSS in medical education, future physicians will be better equipped to participate in and lead systems change that addresses these issues, not alone, but part of a larger solution.

2. How do we teach HSS in pre-clerkship years? Presented by Anna Chang
Concerns for integrating HSS: (Gonzalo et al. Academic Medicine 2018 and 2019)
• Pre-clerkship medical students…is it too early?
o Feel it is not too early as students bring in a fresh perspective and motivation to make the world a better place.
• The medical student curriculum is already packed. Where do we put this?
o Through a process of re-envisioning, integration, and thoughtful change management are strategies that make this important transformation feasible.
• Clinical Faculty never learned this. Who will teach it?
o Through the strategy of co-learning and expansion of the definition of “educator” has helped to address this gap.
• Health systems are still working to improve. How can they partner to teach students?
o Invited the students to join the faculty to improve this together!

In addition to lectures and small classroom learning, there are a number of ways medicals in the US, Canada and the UK, have engaged medical students in experiential learning of HSS.
HS Experiential Learning Models
• Students can act as Patient navigators for individual patients
• Students can serve as Medical scribes for individual clinicians
• Engages students in Patient population health managers for groups of patients
• Medical Students serve as Quality improvement team members for health systems

The remaining of this section will explain how UCSF School of Medicine uses Medical Students as Quality improvement team members for health systems.

UCSF School of Medicine and PharmD program starts the New Bridges Curriculum in 2016.
The rest of this section will focus on foundation 1, which is the phase that encompasses the first and second years of medical school.

For UCSF School of Medicine, HSS is taught in multiple places with the focus being in the Clinical Microsystems Clerkship, which is a longitudinal element that combines direct patient care with health systems improvements. This is where experiential learning focus on quality improvement occurs.

Therefore, the goals of Clinical Microsystems Clerkship is to help early learners to learn:
• Health Systems Improvement
• Interprofessional Collaboration
• Direct Patient Care

Components critical to this curriculum:
• Faculty development
• Lectures and small groups
• Projects applying learn

3. Do academic health centers want HSS education presented by Dr. Adrienne Green.

Dr. Green shared with the audience why academic medical centers like UCSF want to collaborate with educational leaders to develop these types of programs.

Dr. Green presented Why HSS? From a Chief Medical Officer Perspective.
• Formal experiential training is far more effective than learning by doing on the job and I wish I’d had this kind of training in medical school.
• Students enter medical school eager to contribute to positive change, and for exposure to improvement strategies and policy implications.
• Early introduction and engagement in local health care value (quality/cost) work is key.
• Systems based practice is a core competency for students, residents, fellows, and practicing physicians, so there is a need to build these skills for the long term, regardless of their site or their type of practice.

• For UCSF, alignment of student quality improvement projects with UCSF Health True North priorities and Lean strategies is the key.
• Health systems and educational leaders collaborate and iterate each year.
• Training for physicians coaches and students includes:
o Health systems priorities to guide project selection and design
o Lean improvement methodology (same as health system)
• Students integrate into existing improvement teams and ongoing work.
• Students are seen as unique contributors to teams and expand the improvement workforce.

What is meant by Lean tool?
• Dr. Green discussed an example called “A3 Thinking” as a way of problem-solving and documenting their project work than contains the following parts:
o Problem
o Current state
o Target
o Gap analysis
o Experiments
o Action plan
o reflection
• This forces then to fully work through the problem they are trying to solve, at the current state in that particular area to determine the root cause of the problem, before developing their intervention and action plans.

The last part of Dr. Green’s session took us through one of the UCSF student presentations illustrating the work they are doing.

Take-home points by:
Dr. Pierluissi: Because of the gaps in our health care systems, today’s medical educators need to add HSS early in undergraduate medical education.

Dr. Chang: There are models to integrate HSS into the classroom and experiential learning in the first two years of medical school for early students.

Dr. Green: Academic health system leaders perceive an alignment and value in having early medical students engaged in health systems improvement.

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

IAMSE Webinar Series, Spring 2020

Speakers: Ami DeWaters, MD, Assistant Professor Internal Medicine, Assistant Director Health Systems Sciences, Penn State College of Medicine and Jed Gonzala, MD, MS, Associate Dean for Health Systems Sciences Education, Penn State College of Medicine
Title: “The Third Pillar of Medical Education: Health Systems Science”
Series: Evolution and Revolution in Medical Education: Health Systems Sciences

Objectives for the session:

1. Describe and define Health System Science (HSS).
2. Highlight the historical context of HSS and how the field has emerged over the past century
3. Identify the need for conducive clinical learning environments to enhance HSS education.
4. Appraise the evolving medical professionalism in healthcare towards systems citizens.
5. Describe a brief overview of sessions 2 – 5 and how they integrate with one another.

While each of the 5 sessions is designed to be a stand-alone session, they are integrated and build sequentially and developmentally across the 5 sessions.

The main goal of the sessions is to shine a light on this third pillar of medical education so that you can find areas in your internal program for improvement to make your program even better.

The first two pillars of medical education, Basic Science and Clinical Science have been around for well over a century.

HSS is defined as “the principles, methods, and practice of improving quality outcomes, and cost of healthcare delivery for patients and populations within systems of medical care.”

HSS is presented as a three-pillar model as an interdependent and integrated framework as a third pillared that is integrated with the other two pillars of medical education.

In order for Basic Science and Clinical Science to be manifested and learned to improve patient outcomes, they need to be integrated with HSS and vice versa.  Where all three pillars are working together in order to improve patient care.

The following milestones were organized to show that HSS has been around for a while and is not a fad, but is here to stay. The following tells the story of how HSS has gotten to where it is today.

HSS Historical Milestones:

1. 1913 Flexner Report: Over a century ago, identified the 2 + 2 model of medical education including basic and clinical sciences that established these two pillars of medical education that are still used today.
2. 1920 Ernest Amory Codman: Was physician at the Harvard Medical School and he and others began to look at outcomes of surgical patients that were outside of whether or not they made it out of the operating room. They were looking at patient outcomes 30 and 60 days after their surgical procedures. They came up with the end results cards system that began to document the quality outcomes well beyond the procedure itself. Their work led to the quality standards across units and the joint commissions came from this work. Lead to the idea that “structure drive outcomes in healthcare delivery and medical education.”
3. 1963 Interprofessional Education in Europe: First time IPE appeared in the literature. Really took traction recently through the work of George Tebow and the Macy Foundation. There is increasing evidence that diverse and interprofessional care teams improve patient’s outcomes.
4. 1967 First Department of Humanities: The first such department was at Penn State College of Medicine and since this time there have been other departments, centers, etc. that have opened up in other medical schools that really focused on the health humanities as a key pillar of medical education.
5. 1980 George Engle’s Biopsychosocial Model: Engle’s work established that patient’s outcomes are not only contingent on the biomedical diagnosis and therapeutic plan, but the psycho, social and systemic contexts matter just as much. It is an integrated whole for the patient and his work and the addition of many others really established the patient-centered framing for care delivery.
6. 1983 Libby Zion Case: Centers around a young female that dies 12- 14 hours after being admitted into a NY hospital. Her case really shined a light on the safety structures that we have in place in the hospitals and the structures that were in place that manifested for bad patient outcomes and put the spotlight on patient safety and examining structures.
7. 1994 Harvard Medical Practice study identified that up to 4% of hospitalized patients and adverse events and one in five of these events resulted in death. Patients experienced poor health outcomes in the context of care delivery itself and really shined a light on unsafe care and quality outcomes.
8. 1999 Systems-Based Practice Competency: provided a key moment in GME in that it opened up a space for systems-based learning. If this space had not opened up, it is doubtful that HSS would have emerged.
9. 2001 IOM Reports: articulated a lot of the data that came out the prior decade with regards to quality, safety, structure, systems education.
10. 2007 AAMC Social Determinants of Health: AAMC put out a recommendation that medical schools should increase the focus of the social determinants of health and behavioral health.
11. 2009 College of Population Health: The first college of population of health in a US health center was at Thomas Jefferson University further established population health as a key pillar.
12. 2012 Waste/Value: The increasing data through the work of Don Berwick and others identified the key categories of waste, identified the high care value equation.
13. 2015 HSS coined: mainly through the work of the AMA consortium.
14. 2018 HSS text books and Board Exams:
15. 2019 HSS and SBP:

The key takeaway from the historical milestones of HSS is that HSS framework is built on evidence and is as focused on patients and is a patient-centered as you can possibly be.

The HSS Framework, that the AMA has produced and it is a series of circles or rims that is clearly centered on the patient. The first circle is the 6 core domains that surround the patient. The 6 core domains are:

• Health system improvement
• Value in health care
• Population, public, and social determinants of health
• Clinical informatics and health technology
• Health care policy and economics
• Health care structure and process.

The next rim includes cross-cutting domains, such as:

• Teaming
• Change agency management and advocacy
• Ethics and legal
• Leadership

The third and final rim is systems thinking, which we think is a critical, cohesive concept or domain area for the HSS framework. It’s a set of tools, it’s a mindset, it’s an attitude, that is required to cohesively see all the parts of the system, the interconnectedness of them all.

The HSS framework contains 12 core domains and sub-domains, in parenthesis (see below) are outlined in a schema crosswalk of all HSS domains and these domains were mapped with the GME competencies, the Clear Report, Systems based practiced, and textbooks to see if HSS was contained in the other items.

• Patient experience and context (patient experience, behaviors)
• Healthcare delivery (structure, process)
• Policy and economics (policy, economics)
• Clinical informatics and health technology (informatics, decision support, technology)
• Population and public health (social determinants, public health, population health improvement)
• High-value care (quality, cost, evaluation)
• Health system improvement (quality improvement, data and measurement, innovation and scholarship)
• Systems thinking
• Change management
• Ethics and law
• Leadership
• Teamwork

There are a lot of holes between HSS and these other measures. We view HSS as a comprehensive, integrated third pillar of medical education and when you do a schema crosswalk you can see where the heavy overlap is, such as:

• Process or transition of care
• Social determinants
• Quality or Patient safety
• Quality improvement
• Teamwork or IPE

This overlap is where most US medical schools and residencies then to focus their time.

Why does this comprehensive HSS framework matter? Here are six tenants that were articulated in the paper :

1. Ensures core competencies are not marginalized.
2. Accounts for related competencies in curricular design
3. Establishes a foundation for comprehensive pedagogies
4. Provides a clear learning pathway for UME ® GME ® workforce
5. Facilitates a shift towards a national standard
6. Catalyzes the new healthcare professionalism of systems citizens.

Key Implications for US Medical Education (probably more than 50, but is limited to these four)

1. Value-added roles for Medical Students
2. The expanding educator bench of US Medical Schools
3. The Clinical Learning Environment
4. The New Professionalism: Systems Citizens

Value-Added Roles for Medical Students

• Are Medical Students an asset or “liability”?
• Value-added roles for Medical students are defined as experiential roles for students in practice environments that can positively impact patient and population health outcomes, cost of care, or other processes within the health system, while also enhancing student competencies in Clinical or Health Systems Science.
• Results table of how student learners can add value:
  • Direct patient care
    • History taking
    • Evidence-based medicine
    • Patient education
    • Patient advocates
    • Value chief
  • Care extenders
    • Clinical process extenders
    • Patient navigator
    • Safety analysts
    • QI team extenders
    • Population health managers
  • Research and systems projects
    • “systems” projects
  • Penn State has built a student patient navigator program where they are embedded into the clinical community not as physicians but as medical students and can do many of the patient navigator tasks. Mentored by non-clinicians, such as nurses, social workers, etc.
  • What are students actually learning in this patient navigator program?
    • Patient’s perspective on health care and his/her health
    • Patient’s social determinants that are impacting his/her health
    • Communicating with patients
    • Interprofessional collaboration and teamwork
    • Healthcare delivery and the system
    • Systems thinking
    • Clinical medicine
  • Penn State College of Medicine Medical Student EPA for Patient Navigation. Student is entrusted to:
    • Interact professionally with patients, staff, and clinicians in both informal and clinically-based settings.
    • Effectively manage communications with patients and members of the interprofessional care team.
    • Comprehensively assess and diagnosed the root cause of a patient’s healthcare situation.
    • Identify and facilitate linkage of health system and community resources for patients in need.
    • Participate in and contribute to the ongoing work of an interprofessional care team within a clinical setting.
    • Document patient encounters in the electronic health record in a timely and accurate manner.
    • Apply the habits of a system thinker when they work to address patients’ healthcare situation.
    • Build a therapeutic relationship with a patient.

The Expanding Educator Bench for Medical Schools

• Harden and Crosby wrote a fantastic article in Medical Teacher in 2000 outlining how we need to expand our definition of teacher. Outlined six different roles of a teacher:
  • Facilitator
  • Role model
  • Information provider
  • Resource developer
  • Planner
  • Assessor
• Each one of these roles has a different balance of educational expertise versus clinical expertise.
• When looking at a program to help implement HSS, one of the things that cannot be ignored is there are plenty of people who are experts in this outside of the physician community and we need to expand our thoughts outside of just physicians.
• New roles include Director of Nursing Ambulatory Care, QI Chief, for example.
• Implication 1: These “new” educators are already in our community.
• Implication 2: We can help develop the skills of these educators.
• Implication 3: We can meaningfully acknowledge and “incentivize” these educators.

The Clinical Learning Environment

• Shift away from individual and teams and move towards the actual clinical environment
• The environment (primary service) is determining clinical care based on factors such as teamwork, policy, and structures and process.
• Can’t ignore the learning environment when we are thinking about HSS.
• A study by Asch, et al. published in Jama 2009 shows where residents train in an OB/GYN Residency Program clearly correlated to their patient outcomes when they became attendings.
• What learners gather from their environment when they are training is what they will do in practice years later.
• So, the environment itself is hugely influential in deciding how people choose to practice.

The New Professionalism: Systems Citizenship

• “Is medical education designed to be transformative (e.g., a physician as a refined alloy produced from the ore of a medical student) or additive (she is the same person but with highly enhanced skills in science, technology and humanities)?”
• Clearly, there is no right answer but is probably a blend of both, but cannot clearly just be the later.
• Hafferty and colleagues developed these waves of Professionalism:
  • Wave 1: Discovery
  • Wave 2: Definition
  • Wave 3: Measurement
  • Wave 4: Institutionalization
  • New Wave: System Citizenship
• The professionalism tenant needs to also look at the relationship between the physician and the system itself.
• Physicians should be citizens of the health care system or healthcare country and with this comes rights and responsibilities.
• It is not an option but an obligation that we should be addressing the social determinants of health.
• Health system improvement should be part of the identity of what physicians do.
• We feel HSS is starting to shift the professional identity.

What’s to come in the upcoming Webinars:

• Session 2: HSS in the preclinical years of UME
• Session 3: HSS in the clinical years of UME
• Session 4: HSS and GME and faculty
• Session 5: Challenges for HSS: The broccoli of US Medical Education