The Clinical Microsystems Clerkship at University of California, San Francisco: Integrating Clinical Skills and Health Systems Improvement for Early Medical Students.

PROBLEM: Medical educators recognize that partnering actively with health system leaders closes significant health care experience, quality, and outcomes gaps. Medical schools have explored innovations training physicians to care for both individual patients and populations while improving systems of care. Yet, early medical student education fails to include systems improvement as foundational skills. When health systems science is taught, it is often separated from core clinical skills. APPROACH: The Clinical Microsystems Clerkship at the University of California, San Francisco School of Medicine, launched in 2016, integrates clinical skills training with health systems improvement from the start of medical school. Guided by communities of practice and workplace learning principles, it embeds first-year and second-year students in longitudinal clinical microsystems with physician coaches and interprofessional clinicians one day per week. Students learn medical history, physical examination, patient communication, interprofessional teamwork, and health systems improvement. Assessments include standardized patient examinations and improvement project reports. Program outcome measures include student satisfaction and attitudes, clinical skills performance, and evidence of systems improvement learning, including dissemination and scholarship. OUTCOMES: Students reported high satisfaction (first-year, 4.10; second-year, 4.29, on a scale of 1-5) and value (4.14) in their development as physicians. Clinical skills assessment accuracy was high (70%-96%). Guided by interprofessional clinicians across 15 departments, students completed 258 improvement projects in 3 health systems (academic, safety net, Veterans Affairs). Sample projects reduced disparities in hypertension, improved opiate safety, and decreased readmissions. Graduating students reported both clinical skills and health systems knowledge as important to physician success, patient experience, and clinical outcomes (4.73). Most graduates discussed their projects in residency applications (85%) and disseminated related papers and presentations (54%). NEXT STEPS: Integrating systems improvement, interprofessional teamwork, and clinical skills training can redefine early medical student education. Health system perspectives, long-term outcomes, and sustainability merit further exploration.

We Have No Choice but to Transform: The Future of Medical Education After the COVID-19 Pandemic.

Medical education exists to prepare the physician workforce that our nation needs, but the COVID-19 pandemic threatened to disrupt that mission. Likewise, the national increase in awareness of social justice gaps in our country pointed out significant gaps in health care, medicine, and our medical education ecosystem. Crises in all industries often present leaders with no choice but to transform-or to fail. In this perspective, the authors suggest that medical education is at such an inflection point and propose a transformational vision of the medical education ecosystem, followed by a 10-year, 10-point plan that focuses on building the workforce that will achieve that vision. Broad themes include adopting a national vision; enhancing medicine's role in social justice through broadened curricula and a focus on communities; establishing equity in learning and processes related to learning, including wellness in learners, as a baseline; and realizing the promise of competency-based, time-variable training. Ultimately, 2020 can be viewed as a strategic inflection point in medical education if those who lead and regulate it analyze and apply lessons learned from the pandemic and its associated syndemics.

Medical Education's Wicked Problem: Achieving Equity in Assessment for Medical Learners.

Despite a lack of intent to discriminate, physicians educated in U.S. medical schools and residency programs often take actions that systematically disadvantage minority patients. The approach to assessment of learner performance in medical education can similarly disadvantage minority learners. The adoption of holistic admissions strategies to increase the diversity of medical training programs has not been accompanied by increases in diversity in honor societies, selective residency programs, medical specialties, and medical school faculty. These observations prompt justified concerns about structural and interpersonal bias in assessment. This manuscript characterizes equity in assessment as a "wicked problem" with inherent conflicts, uncertainty, dynamic tensions, and susceptibility to contextual influences. The authors review the underlying individual and structural causes of inequity in assessment. Using an organizational model, they propose strategies to achieve equity in assessment and drive institutional and systemic improvement based on clearly articulated principles. This model addresses the culture, systems, and assessment tools necessary to achieve equitable results that reflect stated principles. Three components of equity in assessment that can be measured and evaluated to confirm success include intrinsic equity (selection and design of assessment tools), contextual equity (the learning environment in which assessment occurs), and instrumental equity (uses of assessment data for learner advancement and selection and program evaluation). A research agenda to address these challenges and controversies and demonstrate reduction in bias and discrimination in medical education is presented.

Designing Well-Being: Using Design Thinking to Engage Residents in Developing Well-Being Interventions.

PROBLEM: Improving well-being in residency requires solutions that focus on organizational factors and the individual needs of residents, yet there are few examples of successful strategies to address this challenge. Design thinking (DT), or human-centered design, is an approach to problem-solving that focuses on understanding emotions and human dynamics and may be ideally suited to tackling well-being as a complex problem. The authors taught residents to use DT techniques to identify, analyze, and address organizational well-being challenges. APPROACH: Internal medicine residents at the University of California, San Francisco completed an 8-month DT program in 2016-2017. The program consisted of four 2-hour workshops with small group project work between sessions. In each session, resident teams shared their progress and analyzed emerging themes to solve well-being problems. At the conclusion of the program, they summarized the final design principles and recommendations that emerged from their work and were interviewed about DT as a strategy for developing well-being interventions for residents. OUTCOMES: Eighteen residents worked in teams to design solutions to improve: community and connection, space for reflection, peer support, and availability of individualized wellness. The resulting recommendations led to new interventions to improve well-being through near-peer communities. Residents emphasized how DT enhanced their creative thinking and trust in the residency program. They reported that not having enough time to work on projects between sessions and losing momentum during their clinical rotations were their biggest challenges. NEXT STEPS: Residents found DT useful for completing needs assessments, piloting interventions, and outlining essential design principles to improve well-being in residency. DT's focus on human values may be particularly suited to developing well-being interventions to enhance institutional community and culture. One outcome-that DT promoted creativity and trust for participants-may have applications in other spheres of medical education.

Core Clerkship Grading: The Illusion of Objectivity.

Core clerkship grading creates multiple challenges that produce high stress for medical students, interfere with learning, and create inequitable learning environments. Students and faculty alike succumb to the illusion of objectivity-that quantitative ratings converted to grades convey accurate measures of the complexity of clinical performance.Clerkship grading is the first high-stakes assessment within medical school and occurs just as students are newly immersed full-time in an environment in which patient care supersedes their needs as learners. Students earning high marks situate themselves to earn entry into competitive residency programs and selective specialties. However, there is no commonly accepted standard for how to assign clerkship grades, and the process is vulnerable to imprecision and bias. Rewarding learners for the speed with which they adapt inherently favors students who bring advantages acquired before medical school and discounts the goal of all learners achieving competence.The authors propose that, rather than focusing on assigning core clerkship grades, assessment of student performance should incorporate expert judgment of learning progress. Competency-based medical education is predicated on the articulation of stepwise expectations for learners, with the support and time allocated for each learner to meet those expectations. Concurrently, students should ideally review their own performance data with coaches to self-assess areas of relative strength and areas for further growth. Eliminating grades in favor of competency-based assessment for learning holds promise to engage learners in developing essential patient care and teamwork skills and to foster their development of lifelong learning habits.

Competency-Based, Time-Variable Education in the Health Professions: Crossroads.

Health care systems around the world are transforming to align with the needs of 21st-century patients and populations. Transformation must also occur in the educational systems that prepare the health professionals who deliver care, advance discovery, and educate the next generation of physicians in these evolving systems. Competency-based, time-variable education, a comprehensive educational strategy guided by the roles and responsibilities that health professionals must assume to meet the needs of contemporary patients and communities, has the potential to catalyze optimization of educational and health care delivery systems. By designing educational and assessment programs that require learners to meet specific competencies before transitioning between the stages of formal education and into practice, this framework assures the public that every physician is capable of providing high-quality care. By engaging learners as partners in assessment, competency-based, time-variable education prepares graduates for careers as lifelong learners. While the medical education community has embraced the notion of competencies as a guiding framework for educational institutions, the structure and conduct of formal educational programs remain more aligned with a time-based, competency-variable paradigm.The authors outline the rationale behind this recommended shift to a competency-based, time-variable education system. They then introduce the other articles included in this supplement to Academic Medicine, which summarize the history of, theories behind, examples demonstrating, and challenges associated with competency-based, time-variable education in the health professions.

A qualitative approach to Bayes' theorem.

While decisions made according to Bayes' theorem are the academic normative standard, the theorem is rarely used explicitly in clinical practice. Yet the principles can be followed without intimidating mathematics. To do so, one can first categorise the prior-probability of the disease being tested for as very unlikely (less likely than 10%), unlikely (10-33%), uncertain (34-66%), likely (67-90%) or very likely (more likely than 90%). Usually, for disorders that are very unlikely or very likely, no further testing is needed. If the prior probability is unlikely, uncertain or likely, a test and a Bayesian-inspired update process incorporating the result can help. A positive result of a good test increases the probability of the disorder by one likelihood category (eg, from uncertain to likely) and a negative test decreases the probability by one category. If testing is needed to escape the extremes of likelihood (eg, a very unlikely but particularly dangerous condition or in the circumstance of population screening, or a very likely condition with a particularly noxious treatment), two tests may be needed to achieve. Negative results of tests with sensitivity ≥99% are sufficient to rule-out a diagnosis; positive results of tests with specificity ≥99% are sufficient to rule-in a diagnosis. This method overcomes some common heuristic errors: ignoring the base rate, probability adjustment errors and order effects. The simplicity of the method, while still adhering to the basic principles of Bayes' theorem, has the potential to increase its application in clinical practice.

A behavioral and systems view of professionalism.

Professionalism may not be sufficient to drive the profound and far-reaching changes needed in the US health care system, but without it, the health care enterprise is lost. Formal statements defining professionalism have been abstract and principle based, without a clear description of what professional behaviors look like in practice. This article proposes a behavioral and systems view of professionalism that provides a practical approach for physicians and the organizations in which they work. A more behaviorally oriented definition makes the pursuit of professionalism in daily practice more accessible and attainable. Professionalism needs to evolve from being conceptualized as an innate character trait or virtue to sophisticated competencies that can and must be taught and refined over a lifetime of practice. Furthermore, professional behaviors are profoundly influenced by the organizational and environmental context of contemporary medical practice, and these external forces need to be harnessed to support--not inhibit--professionalism in practice. This perspective on professionalism provides an opportunity to improve the delivery of health care through education and system-level reform.