Advancement, barriers and collaboration: the ABC's of addressing challenges and designing solutions between front-line physicians and business-oriented leaders.

BACKGROUND: The complexity of US healthcare has been increasing for many years, requiring clinicians and learners to understand care delivery systems in addition to clinical sciences. Thus, there has been a major push to educate faculty and trainees on healthcare functionality. This comes as hospitals expand into health systems requiring the help of more sophisticated expertise of departments such as operations excellence when problem-solving. As a medical student with a background in operations excellence, medical education leader and clinical administration leader all currently facilitating this transition, we wanted to reflect on the barriers we have experienced in clinical implementation of quality improvement projects and educating learners on the impact of operations excellence principles in their clinical education. METHODS: The ideas presented in this article were the result of a several collaborative discussion between the authors, on the key challenges to adopting operations excellence principles into health system science education. In an effort to add context to this reflection through the current body of research present, they supplemented a literature review on the topic which included 86 studies published between 2013 and 2021 regarding health systems science and healthcare leadership engagement in the USA. The themes that intersected between the literature review and the discussions were then expanded on in this paper. RESULTS: Through this process, we identified four challenges: (1) the difference in thinking styles, which we term, 'mental model differences'; (2) the strategic nature of process improvement projects and how that collides with physician priorities, or 'the chess game of stakeholder engagement'; (3) the language and precise methodology, or 'consistency of language and need for administrative resilience' and (4) the issue of teaching these concepts or bridging the learning gap.' CONCLUSION: In an increasingly complex healthcare landscape, physicians and trainee's need to bridge gaps between the mental models of administrative and clinical workflow.

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.

Breaking Down Silos Between Medical Education and Health Systems: Creating an Integrated Multilevel Data Model to Advance the Systems-Based Practice Competency.

ABSTRACT: The complexity of improving health in the United States and the rising call for outcomes-based physician training present unique challenges and opportunities for both graduate medical education (GME) and health systems. GME programs have been particularly challenged to implement systems-based practice (SBP) as a core physician competency and educational outcome. Disparate definitions and educational approaches to SBP, as well as limited understanding of the complex interactions between GME trainees, programs, and their health system settings, contribute to current suboptimal educational outcomes elated to SBP. To advance SBP competence at individual, program, and institutional levels, the authors present the rationale for an integrated multilevel systems approach to assess and evaluate SBP, propose a conceptual multilevel data model that integrates health system and educational SBP performance, and explore the opportunities and challenges of using multilevel data to promote an empirically driven approach to residency education. The development, study, and adoption of multilevel analytic approaches to GME are imperative to the successful operationalization of SBP and thereby imperative to GME's social accountability in meeting societal needs for improved health. The authors call for the continued collaboration of national leaders toward producing integrated and multilevel datasets that link health systems and their GME-sponsoring institutions to evolve SBP.

Systems-Based Practice: Expert Perspectives on the Origin and Evolution of an Ambiguous Competency.

PURPOSE: Systems-based practice (SBP) has been a core competency in graduate medical education in the United States since 1999, but it has been difficult to operationalize in residency programs due to its conceptual ambiguity. The authors explored the historical origin and subsequent development of the SBP competency from the perspective of individuals who were influential across critical phases of its implementation and ensuing development. The goal of this study was to elicit the history of SBP from the perspective of individuals who have expertise in it and to use those findings to inform the current SBP construct. METHOD: Between March and July 2021, 24 physicians, nurses, educators, and leaders in the field of SBP were individually interviewed about the origin and meaning of SBP as practiced in U.S. medical education using a semistructured guide. Individuals were selected based upon their influence on the origin or evolution of the SBP competency. Data were iteratively collected and analyzed using real-time analytic memos, regular adjudication sessions with the research team, and thematic analysis. Researchers identified themes from participants' perspectives and agreed upon the final results and quotations. RESULTS: Five themes were identified: SBP has many different definitions, SBP was intentionally designed to be vague, systems thinking was identified as the foundation of the SBP competency, the 6 core competencies established in the United States by the Accreditation Council for Graduate Medical Education were developed to be interdependent, and the SBP and practice-based learning and improvement competencies are uniquely related and synergistic. CONCLUSIONS: Interview data indicate that since its inception, SBP has been a nuanced and complex competency, resulting in a lack of mutually shared understanding among stakeholders. This deliberate historical examination of expert perspectives provides insight into specific areas for improving how SBP is taught and learned.

Promising Practices in US Sponsoring Institutions to Advance Diversity, Equity, and Inclusion in Graduate Medical Education.

Background Best practices to improve diversity, equity, and inclusion (DEI) in the biomedical workforce remain poorly understood. The Accreditation Council for Graduate Medical Education launched the Barbara Ross-Lee, DO, Diversity, Equity, and Inclusion award for sponsoring institutions to celebrate efforts to improve DEI in graduate medical education (GME). Objective To identify themes in practices used by award applicants to improve DEI efforts at their institutions, using a qualitative design. Methods This qualitative study employed an exploratory, inductive approach and constant comparative method to analyze award applications from 2 submission cycles (2020, 2021). Data analysis involved the use of a preliminary codebook of 29 program applications used in a previous study, which was modified and expanded, to perform a subsequent analysis of 12 sponsoring institution applications. Seven adjudication sessions were conducted to ensure coding consistency and resolve disagreements, resulting in the identification of final themes. Results Institutions' approaches to advancing DEI resulted from work within 5 themes and 10 subthemes. The themes encompassed organizational commitment (policies that reflect DEI mission), data infrastructure (tracking recruitment, retention, and inclusion efforts), community connection (service-learning opportunities), diverse team engagement (coproduction with residents), and systematic strategies for DEI support throughout the educational continuum. Consistent across themes was the importance of collaboration, avoiding silos, and the need for a comprehensive longitudinal approach to DEI to achieve a diverse GME workforce. Conclusions This qualitative study identified 5 themes that can inform and guide sponsoring institutions in promoting DEI.

Strategies and Best Practices to Improve Diversity, Equity, and Inclusion Among US Graduate Medical Education Programs.

Importance: Closing the diversity gap is critical to ensure equity in medical education and health care quality. Nevertheless, evidence-based strategies and best practices to improve diversity, equity, and inclusion (DEI) in the biomedical workforce remain poorly understood and underused. To improve the culture of DEI in graduate medical education (GME), in 2020 the Accreditation Council of Graduate Medical Education (ACGME) launched the Barbara Ross-Lee, DO, Diversity, Equity, and Inclusion Award to recognize exceptional DEI efforts in US residency programs. Objective: To identify strategies and best practices that exemplary US GME programs use to improve DEI. Design and Setting: This qualitative study performed an exploratory content analysis of award applications submitted to the ACGME over 2 cycles in 2020 and 2021, using the constant comparative method. The research team first acknowledged their own biases related to DEI, used caution to not overinterpret the data, and performed several cross-checks during data analysis to ensure confirmability of the results. A preliminary codebook was developed and used during regular adjudication sessions. Disagreements were discussed until agreements were reached. Main Outcomes and Measures: Foundational (ie, commonly cited, high-impact, and small-effort strategies considered achievable by all programs) and aspirational (ie, potential for high impact but requiring greater effort and investment) DEI strategies used by exemplary GME programs. Results: This qualitative study included 29 award applications submitted between August 17, 2020, and January 11, 2022. Strategies spanned the education continuum from premedical students through faculty. Foundational strategies included working with schools, community colleges, and 4-year college campuses; providing structured support for visiting students; mission-driven holistic review for admissions and selection; interviewer trainings on implicit bias mitigation and on how racism and discrimination impact admission processes and advancement; interview-day DEI strategies; inclusive selection and DEI committees; mission statements that include DEI; and retention efforts to improve faculty diversity. Aspirational strategies included development of longitudinal bidirectional collaborations (eg, articulation agreements, annual workshops, funded rotations and/or research) with organizations working with applicants who were historically excluded and underrepresented in medicine, blinding metrics in residency applications, longitudinal curricula on DEI and health equity, and faculty mentoring such as affinity groups, mentored research, and joint academic-community recruitments. Findings provide residency program leadership with a menu of options at various inflection points to foster DEI within their programs. Conclusions and Relevance: The findings of this qualitative study suggest that GME programs might adopt strategies of exemplary programs to improve DEI in residency, ensure compliance with accreditation standards, and improve health outcomes for all.

Implementation and Evaluation of an Interprofessional Health Systems Science Professional Development Program.

PROBLEM: Few interprofessional development programs focused on learning knowledge and skills in health systems science (HSS) have been described. The authors implemented a professional development program (the HSS Academy) for interprofessional clinicians and trainees. The authors describe the HSS Academy, report preliminary outcomes, and describe strategies for use in other programs. APPROACH: The HSS Academy (an 8-month active learning classroom and project-based curriculum) was implemented at Penn State College of Medicine in 2015. To create an interprofessional environment, participants were selected from various professions and phases of training. The curriculum was anchored in HSS competencies (e.g., high-value care, quality improvement, social determinants of health, health system strategy and delivery) and included 2 distinct threads focused on systems thinking competencies and academic skill development. It featured course speakers and faculty from diverse roles and disciplines both inside and outside the health system, application of HSS competencies in local system contexts, and networking with interprofessional colleagues. OUTCOMES: From 2015 to 2021, 121 of 128 participants, including physicians, medical students, and nurses, completed the HSS Academy (95% completion rate). Over 90 individuals, including faculty and system leaders, contributed to the HSS Academy as educators. Comparisons of pre-post evaluations demonstrated statistically significant self-perceived improvements in HSS knowledge and skills, systems thinking, and HSS teaching knowledge and skills. Projects (n = 110) most commonly focused on health care delivery, quality improvement, or patient safety. Teaching strategies to meet each objective, several barriers encountered, and strategies to address those barriers are described. NEXT STEPS: Next steps will be to address financial support for creating and sustaining the HSS Academy, ensure a mutually shared understanding of the HSS Academy's goals among all stakeholders, facilitate meaningful change from scholars' work, and provide networking and opportunities for scholars to continue work in HSS after completion of the HSS Academy.

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.

"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.

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.

The Effect of Bedside Rounds on Learning Outcomes in Medical Education: A Systematic Review.

PURPOSE: To determine if bedside rounds, compared with other forms of hospital ward rounds, improve learning outcomes in medical education. METHOD: For this systematic review, the authors searched Ovid MEDLINE, Embase, and Scopus from inception through February 20, 2020. Experimental studies were included if they (1) compared bedside rounds to any other form of rounds in a hospital-based setting, and (2) reported a quantitative comparison of a learning outcome (e.g., learner reaction, knowledge, skills, behavior, health care delivery) among physicians-in-training (medical students, residents, fellows). Extraction elements were summarized using descriptive statistics and a narrative synthesis of design, implementation, and outcomes. RESULTS: Twenty studies met inclusion criteria, including 7 randomized trials. All studies involved resident physicians, and 11 also involved medical students. The design and implementation of bedside rounds varied widely, with most studies (n = 13) involving cointerventions (e.g., staff education, real-time order entry).Of the 15 studies that reported learner satisfaction, 7 favored bedside rounds, 4 favored the control, and 4 were equivocal. Of the 4 studies reporting an outcome of learners' knowledge and skills, 2 favored bedside rounds and 2 were equivocal. Of the 8 studies that reported on learner behavior (e.g., bedside communication with patients), 5 favored bedside rounds, 1 favored the control, and 2 were equivocal. Finally, of the 14 studies that reported a health care delivery outcome (e.g., teamwork, rounding time), 8 favored bedside rounds and 6 were equivocal. Due to the high risk of bias and unexplained heterogeneity across studies, the overall strength of evidence was low. CONCLUSIONS: In hospital-based settings, learners' satisfaction with bedside rounds is mixed. However, bedside rounds appear to have a positive effect on learner behavior and health care delivery. Given their potential value, additional research is needed to identify barriers to and facilitators of educationally successful bedside rounds.

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.

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 opioid epidemic: Mobilizing an academic health center to improve outcomes.

Since 2000, opioid use disorder (OUD) has become an epidemic in the United States with more than 600,000 total deaths and a $51 billion annual cost. Patients with OUD require services from community-based organizations, local and state health departments, and health systems, all of which necessitate communication and collaboration among these groups to develop an effective strategy for diagnosis, treatment, and coordination of care. Academic health centers (AHCs) are poised to make significant contributions to the care of patients with OUD given in-house expertise across multiple medical specialties and the mission to care for patients in need. Despite the potential for AHCs to provide necessary services and address this public health crisis, progress has been slow. Many AHCs lack a clear roadmap for moving this agenda forward in their local regions. In response to rising deaths due to OUD, the authors' AHC undertook a significant redesign effort to facilitate the necessary processes and interdepartmental collaboration to provide patient-centered, comprehensive care for patients with OUD. In this article, using an organizational development framework (McKinsey 7S model), the authors describe their transformation process, and articulate strategies and potential barriers to implementing this framework. The goal of the article is to highlight the structural, procedural, and cultural changes that have occurred in one AHC so we can assist other AHCs in addressing the opioid epidemic.

Contributions of Health Professions Students to Health System Needs During the COVID-19 Pandemic: Potential Strategies and Process for U.S. Medical Schools.

The COVID-19 pandemic poses an unprecedented challenge to U.S. health systems, particularly academic health centers (AHCs) that lead in providing advanced clinical care and medical education. No phase of AHC efforts is untouched by the crisis, and medical schools, prioritizing learner welfare, are in the throes of adjusting to suspended clinical activities and virtual classrooms. While health professions students are currently limited in their contributions to direct clinical care, they remain the same smart, innovative, and motivated individuals who chose a career in health care and who are passionate about contributing to the needs of people in troubled times. The groundwork for operationalizing their commitment has already been established through the identification of value-added, participatory roles that support learning and professional development in health systems science (HSS) and clinical skills. This pandemic, with rapidly expanding workforce and patient care needs, has prompted a new look at how students can contribute. At the Penn State College of Medicine, staff and student leaders formed the COVID-19 Response Team to prioritize and align student work with health system needs. Starting in mid-March 2020, the authors used qualitative methods and content analysis of data collated from several sources to identify 4 categories for student contributions: the community, the health care delivery system, the workforce, and the medical school. The authors describe a nimble coproduction process that brings together all stakeholders to facilitate work. The learning agenda for these roles maps to HSS competencies, an evolving requirement for all students. The COVID-19 pandemic has provided a unique opportunity to harness the capability of students to improve health.Other AHCs may find this operational framework useful both during the COVID-19 pandemic and as a blueprint for responding to future challenges that disrupt systems of education and health care in the United States.

Health Systems Science in Medical Education: Unifying the Components to Catalyze Transformation.

Medical education exists in the service of patients and communities and must continually calibrate its focus to ensure the achievement of these goals. To close gaps in U.S. health outcomes, medical education is steadily evolving to better prepare providers with the knowledge and skills to lead patient- and systems-level improvements. Systems-related competencies, including high-value care, quality improvement, population health, informatics, and systems thinking, are needed to achieve this but are often curricular islands in medical education, dependent on local context, and have lacked a unifying framework. The third pillar of medical education-health systems science (HSS)-complements the basic and clinical sciences and integrates the full range of systems-related competencies. Despite the movement toward HSS, there remains uncertainty and significant inconsistency in the application of HSS concepts and nomenclature within health care and medical education. In this Article, the authors (1) explore the historical context of several key systems-related competency areas; (2) describe HSS and highlight a schema crosswalk between HSS and systems-related national competency recommendations, accreditation standards, national and local curricula, educator recommendations, and textbooks; and (3) articulate 6 rationales for the use and integration of a broad HSS framework within medical education. These rationales include: (1) ensuring core competencies are not marginalized, (2) accounting for related and integrated competencies in curricular design, (3) providing the foundation for comprehensive assessments and evaluations, (4) providing a clear learning pathway for the undergraduate-graduate-workforce continuum, (5) facilitating a shift toward a national standard, and (6) catalyzing a new professional identity as systems citizens. Continued movement toward a cohesive framework will better align the clinical and educational missions by cultivating the next generation of systems-minded health care professionals.