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.

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.

The Exceptional Teacher Initiative: Finding a Silver Lining in Addressing Medical Student Mistreatment.

PROBLEM: The Penn State College of Medicine (PSCOM) faced escalating reports of learner mistreatment in 2013-2017. As systems were implemented to gather and respond to student reports, faculty members expressed concern that these were creating a culture that focused on negative behaviors to the exclusion of acknowledging outstanding teaching that was also occurring. APPROACH: The Exceptional Teacher Initiative was introduced in August 2017 to attempt to shift the institutional conversation around learner mistreatment by balancing reports of mistreatment with reports highlighting examples of excellent teaching considered in-line with organizational values. The primary goals of the program were to make it easy for students to submit narratives describing outstanding teaching experiences and to capture the nuances of what the teacher did that were notable to the student. Students were invited to write about teachers who challenged and changed them. Narratives were sent to the named teachers and their educational and clinical leaders. OUTCOMES: Over the first 12 months of the Exceptional Teacher Initiative, learners submitted 553 narratives naming 253 different individuals across 37 departments. Faculty members and students expressed appreciation for this effort to highlight the positive. A monthly Exceptional Moments in Teaching feature was introduced in 2018, in which a named educator is featured prominently across the PSCOM. NEXT STEPS: Future plans include examining the impact of being named an exceptional teacher, ways exceptional teachers create respectful teaching interactions, and common threads within student narratives that illuminate specific techniques, behaviors, and attitudes that create exceptional teaching experiences.

Curricular Transformation in Health Systems Science: The Need for Global Change.

In this Invited Commentary, the authors propose a counterperspective to the article by Borkan and colleagues, who advocate for a circumscribed, piloted, choice-focused approach to introducing curricular redesign options in undergraduate medical education, particularly in the area of health systems science. In making this case, Borkan and colleagues cluster several kinds of innovative curricular changes that the authors of this commentary believe are best separated by the scope of change and associated educational strategy: (1) innovations customized to student interest and motivation, which are best served by focused programmatic interventions; (2) innovations such as longitudinal integrated clerkships that represent creative and needed educational strategies but may be difficult to expand because of complex barriers; and (3) innovations that are truly transformational, with critical connections far beyond the boundaries of the medical school curriculum, which must be addressed in a comprehensive approach-despite the challenges, frustrations, and difficulties. The authors situate health systems science squarely into the third category, and address three important questions addressing the nature and demands of this change. In making these arguments, the authors draw from experiences at the Penn State College of Medicine and collaborations with other U.S. medical schools related to large-scale curricular transformation and challenges that impact this change. The authors contend that medical education needs to navigate this major change for all students in a way that not only succeeds for learners but, more important, addresses the needs of patients seeking care in rapidly evolving systems of care.

Educating for the 21st-Century Health Care System: An Interdependent Framework of Basic, Clinical, and Systems Sciences.

In the face of a fragmented and poorly performing health care delivery system, medical education in the United States is poised for disruption. Despite broad-based recommendations to better align physician training with societal needs, adaptive change has been slow. Traditionally, medical education has focused on the basic and clinical sciences, largely removed from the newer systems sciences such as population health, policy, financing, health care delivery, and teamwork. In this article, authors examine the current state of medical education with respect to systems sciences and propose a new framework for educating physicians in adapting to and practicing in systems-based environments. Specifically, the authors propose an educational shift from a two-pillar framework to a three-pillar framework where basic, clinical, and systems sciences are interdependent. In this new three-pillar framework, students not only learn the interconnectivity in the basic, clinical, and systems sciences but also uncover relevance and meaning in their education through authentic, value-added, and patient-centered roles as navigators within the health care system. Authors describe the Systems Navigation Curriculum, currently implemented for all students at the Penn State College of Medicine, as an example of this three-pillar educational model. Simple adjustments, such as including occasional systems topics in medical curriculum, will not foster graduates prepared to practice in the 21st-century health care system. Adequate preparation requires an explicit focus on the systems sciences as a vital and equal component of physician education.

Value-Added Clinical Systems Learning Roles for Medical Students That Transform Education and Health: A Guide for Building Partnerships Between Medical Schools and Health Systems.

To ensure physician readiness for practice and leadership in changing health systems, an emerging three-pillar framework for undergraduate medical education integrates the biomedical and clinical sciences with health systems science, which includes population health, health care policy, and interprofessional teamwork. However, the partnerships between medical schools and health systems that are commonplace today use health systems as a substrate for learning. Educators need to transform the relationship between medical schools and health systems. One opportunity is the design of authentic workplace roles for medical students to add relevance to medical education and patient care. Based on the experiences at two U.S. medical schools, the authors describe principles and strategies for meaningful medical school-health system partnerships to engage students in value-added clinical systems learning roles. In 2013, the schools began large-scale efforts to develop novel required longitudinal, authentic health systems science curricula in classrooms and workplaces for all first-year students. In designing the new medical school-health system partnerships, the authors combined two models in an intersecting manner-Kotter's change management and Kern's curriculum development steps. Mapped to this framework, they recommend strategies for building mutually beneficial medical school-health system partnerships, including developing a shared vision and strategy and identifying learning goals and objectives; empowering broad-based action and overcoming barriers in implementation; and generating short-term wins in implementation. Applying this framework can lead to value-added clinical systems learning roles for students, meaningful medical school-health system partnerships, and a generation of future physicians prepared to lead health systems change.

Evolutionary Science as a Method to Facilitate Higher Level Thinking and Reasoning in Medical Training.

Evolutionary science is indispensable for understanding biological processes. Effective medical treatment must be anchored in sound biology. However, currently the insights available from evolutionary science are not adequately incorporated in either pre-medical or medical school curricula. To illuminate how evolution may be helpful in these areas, examples in which the insights of evolutionary science are already improving medical treatment and ways in which evolutionary reasoning can be practiced in the context of medicine are provided. In order to facilitate the learning of evolutionary principles, concepts derived from evolutionary science that medical students and professionals should understand are outlined. These concepts are designed to be authoritative and at the same time easily accessible for anyone with the general biological knowledge of a first-year medical student. Thus we conclude that medical practice informed by evolutionary principles will be more effective and lead to better patient outcomes.Furthermore, it is argued that evolutionary medicine complements general medical training because it provides an additional means by which medical students can practice the critical thinking skills that will be important in their future practice. We argue that core concepts from evolutionary science have the potential to improve critical thinking and facilitate more effective learning in medical training.

The status of evolutionary medicine education in North American medical schools.

BACKGROUND: Medical and public health scientists are using evolution to devise new strategies to solve major health problems. But based on a 2003 survey, medical curricula may not adequately prepare physicians to evaluate and extend these advances. This study assessed the change in coverage of evolution in North American medical schools since 2003 and identified opportunities for enriching medical education. METHODS: In 2013, curriculum deans for all North American medical schools were invited to rate curricular coverage and perceived importance of 12 core principles, the extent of anticipated controversy from adding evolution, and the usefulness of 13 teaching resources. Differences between schools were assessed by Pearson's chi-square test, Student's t-test, and Spearman's correlation. Open-ended questions sought insight into perceived barriers and benefits. RESULTS: Despite repeated follow-up, 60 schools (39%) responded to the survey. There was no evidence of sample bias. The three evolutionary principles rated most important were antibiotic resistance, environmental mismatch, and somatic selection in cancer. While importance and coverage of principles were correlated (r = 0.76, P < 0.01), coverage (at least moderate) lagged behind importance (at least moderate) by an average of 21% (SD = 6%). Compared to 2003, a range of evolutionary principles were covered by 4 to 74% more schools. Nearly half (48%) of responders anticipated igniting controversy at their medical school if they added evolution to their curriculum. The teaching resources ranked most useful were model test questions and answers, case studies, and model curricula for existing courses/rotations. Limited resources (faculty expertise) were cited as the major barrier to adding more evolution, but benefits included a deeper understanding and improved patient care. CONCLUSION: North American medical schools have increased the evolution content in their curricula over the past decade. However, coverage is not commensurate with importance. At a few medical schools, anticipated controversy impedes teaching more evolution. Efforts to improve evolution education in medical schools should be directed toward boosting faculty expertise and crafting resources that can be easily integrated into existing curricula.

Expressing clinical reasoning and uncertainties during a Thai internal medicine ambulatory care rotation: does the SNAPPS technique generalize?

BACKGROUND: SNAPPS is a learner-centered approach to case presentations that was shown, in American studies, to facilitate the expression of clinical reasoning and uncertainties in the outpatient setting. AIM: To evaluate the SNAPPS technique in an Asian setting. METHODS: We conducted a quasi-experimental trial comparing the SNAPPS technique to the usual-and-customary method of case presentations for fifth-year medical students in an ambulatory internal medicine clerkship rotation at Khon Kaen University, Thailand. We created four experimental groups to test main and maturation effects. We measured 12 outcomes at the end of the rotations: total, summary, and discussion presentation times, number of basic clinical findings, summary thoroughness, number of diagnoses in the differential, number of justified diagnoses, number of basic attributes supporting the differential, number of student-initiated questions or discussions about uncertainties, diagnosis, management, and reading selections. RESULTS: SNAPPS users (90 case presentations), compared with the usual group (93 presentations), had more diagnoses in their differentials (1.81 vs. 1.42), more basic attributes to support the differential (2.39 vs. 1.22), more expression of uncertainties (6.67% vs. 1.08%), and more student-initiated reading selections (6.67% vs. 0%). Presentation times did not differ between groups (12 vs. 11.2 min). There were no maturation effects detected. CONCLUSIONS: The use of the SNAPPS technique among Thai medical students during their internal medicine ambulatory care clerkship rotation did facilitate the expression of their clinical reasoning and uncertainties. More intense student-preceptor training is needed to better foster the expression of uncertainties.

SNAPPS-Plus: an educational prescription for students to facilitate formulating and answering clinical questions.

PURPOSE: To analyze the content and quality of PICO-formatted questions (Patient-Intervention-Comparison-Outcome), and subsequent answers, from students' educational prescriptions added to the final SNAPPS Select step (SNAPPS-Plus). METHOD: Internal medicine clerkship students at the University of Minnesota Medical Center were instructed to use educational prescriptions to complement their bedside SNAPPS case presentations from 2006 to 2010. Educational prescriptions were collected from all eligible students and coded for topic of uncertainty, PICO conformity score, presence of answer, and quality of answer. Spearman rank-order correlation coefficient was used to compare ordinal variables, Kruskal-Wallis test to compare distribution of PICO scores between groups, and McNemar exact test to test for association between higher PICO scores and presence of an answer. RESULTS: A total of 191 education prescriptions were coded from 191 eligible students, of which 190 (99%) included a question and 176 (93%, 176/190) an answer. Therapy questions constituted 59% (112/190) of the student-generated questions; 19% (37/190) were related to making a diagnosis. Three-fifths of the questions (61%, 116/190) were scored either 7 or 8 on the 8-point PICO conformity scale. The quality of answers varied, with 37% (71/190) meeting all criteria for high quality. There was a positive correlation between the PICO conformity score and the quality of the answers (Spearman rank-order correlation coefficient = 0.726; P < .001). CONCLUSIONS: The SNAPPS-Plus technique was easily integrated into the inpatient clerkship structure and guaranteed that virtually every case presentation following this model had a well-formulated question and answer.

Student uncertainties drive teaching during case presentations: more so with SNAPPS.

PURPOSE: To compare the nature of uncertainties expressed by medical students using the six-step SNAPPS technique for case presentations (Summarize history and findings; N>arrow the differential; Analyze the differential; Probe preceptors about uncertainties; Plan management; Select case-related issues for self-study) versus those expressed by students doing customary presentations and to elucidate how preceptors respond. METHOD: The authors performed a secondary analysis in 2009 of data from a 2004-2005 randomized study, comparing SNAPPS users' case presentations with other students' presentations. Authors coded transcriptions of audiotaped presentations to family medicine preceptors for type of student uncertainties, nature of preceptor responses, alignment of preceptor responses with uncertainty types, and expansion of preceptors' responses beyond addressing uncertainties. RESULTS: The analysis included 19 SNAPPS and 41 comparison presentations. SNAPPS students expressed uncertainties in all case presentations, nearly twice as many as the comparison group (χ1df = 12.89, P = .0001). Most SNAPPS users' uncertainties (24/44 [55%]) focused on diagnostic reasoning compared with 9/38 (24%) for comparison students' (χ1df = 8.08, P = .004). Uncertainties about clinical findings and medications/management did not differ significantly between groups. Preceptors responded with teaching aligned with the uncertainties and expanded 24/66 (36%) of their comments. CONCLUSION: Students can drive the content of the teaching they receive based on uncertainties they express to preceptors during case presentations. Preceptors are ready to teach at "the drop of a question" and align their teaching with the content of students' questions; these learning moments-in context and just-in-time-can be created by students.

Using SNAPPS to facilitate the expression of clinical reasoning and uncertainties: a randomized comparison group trial.

PURPOSE: When medical students present cases to preceptors, they focus mainly on factual information and reveal little about their diagnostic reasoning or uncertainties. Do third-year students using the six-step, learner-centered SNAPPS technique (Summarize history and findings, Narrow the differential; Analyze the differential; Probe preceptor about uncertainties; Plan management; Select case-related issues for self-study) for case presentations to family medicine ambulatory care preceptors express clinical reasoning and learning issues more than students not trained in the technique? METHOD: The authors conducted a posttest-only, comparison groups, randomized trial in 2004-2005 with 64 students in three groups: SNAPPS training, feedback training (controlling for training time), and usual-and-customary instruction. SNAPPS training combined brief faculty development with more extensive learner development followed by practice during a four-week family medicine rotation. During the last week, students audiotaped case presentations, which the authors coded for 10 dependent variables organized into six outcome categories that measure expression of clinical diagnostic reasoning and learning issues. RESULTS: The authors coded 66 SNAPPS, 67 comparison, and 82 usual-and-customary case presentations. Students in the SNAPPS group outperformed students in comparison and usual-and-customary groups for each outcome category. SNAPPS presentations were no longer than usual presentations but were one minute longer than those of the comparison group. CONCLUSIONS: SNAPPS greatly facilitates and enhances expression of diagnostic reasoning and uncertainties during case presentations to ambulatory care preceptors. Students can conduct case presentations using a technique that makes each step explicit and gives learners, rather than preceptors, the responsibility for expressing their clinical reasoning and uncertainties.

Population medicine in a curricular revision at Case Western Reserve.

Inclusion of population medicine in a medical school curriculum has received growing attention. Recently, the Association of American Medical Colleges has highlighted this issue through support of the Regional Medicine and Public Health Education Centers initiative. The Case Western Reserve University School of Medicine joined this consortium while implementing a new curriculum in which population medicine would be an underlying theme woven with the classic science elements of disease. The organization for the first two years of the new curriculum, which was implemented in 2006, is a six-block structure during which the basic sciences are learned with key concepts of population medicine woven throughout. The focus for this article is Block One, in which population medicine is the major emphasis of the introduction to medicine. The first week, students learn social determinants, impact on communities, and social aspects of diabetes mellitus, even before addressing a patient's clinical presentation. Emphasis on student-centered learning is undertaken as part of the new curriculum, using a series of weekly, case-based, small-group sessions. This type of group learning is used throughout Block One as students encounter key components of population medicine. A thesis requirement was also introduced as a mechanism to emphasize research with opportunities for research in population medicine as well as other medical sciences. A variety of mechanisms are described to measure the outcomes of Block One.

SNAPPS: a learner-centered model for outpatient education.

The unique character of medical education in the outpatient setting has created challenges in teaching and learning that cannot be solved by the adaptation of traditional inpatient approaches. Previous work and the authors' own observational study describe a relatively passive learner focused on reporting history and physical examination data to the preceptor. Based on the work of Bordage in cognitive learning, and that of Osterman and Kottkamp on reflective practice for educators, the authors have developed a collaborative model for case presentations in the outpatient setting that links learner initiation and preceptor facilitation in an active learning conversation. This learner-centered model for case presentations to the preceptor follows a mnemonic called SNAPPS consisting of six steps: (1) Summarize briefly the history and findings; (2) Narrow the differential to two or three relevant possibilities; (3) Analyze the differential by comparing and contrasting the possibilities; (4) Probe the preceptor by asking questions about uncertainties, difficulties, or alternative approaches; (5) Plan management for the patient's medical issues; and (6) Select a case-related issue for self-directed learning. The authors conducted a pilot study of SNAPPS, introducing the model to both third-year medical students and their preceptors. Feedback was enthusiastic and underscored the importance of the paired approach. SNAPPS represents a paradigm shift in ambulatory education that engages the learner and creates a collaborative learning conversation in the context of patient care.