Addition to Health Systems Science Education: Development and Implementation
Written by Victoria Stagg Elliott, MA; Jeffrey Borkan, MD, Ph.D.; Maya Hammoud, MD, MBA
Health systems science (HSS), a foundational framework for the study and understanding of how care is delivered, how health professionals work together to deliver that care, and how the health system can improve patient care and health care delivery[i], is increasingly incorporated into the education and training of physicians,[ii] but physicians don’t work alone. The full potential of the increased understanding of HSS by physicians—improved population health and a better patient experience along with other aspects of the Quintuple Aim— cannot happen without other healthcare professionals incorporating HSS into their education, training, and practice.
HSS emerged as a third science and pillar of medical education, to be integrated alongside basic and clinical sciences, about a decade ago with the formation of the American Medical Association (AMA) Accelerating Change in Medical Education Consortium[iii] (since renamed ChangeMedEd). In 2013, the AMA awarded 11 medical schools $1 million in five-year grants to explore innovation in medical education.[iv] The need for medical students to learn HSS emerged early in the consortium’s work, and faculty at member schools of the consortium developed an HSS framework. This is an amalgamation and integration of learning areas that were previously either ignored or scattered throughout the medical school curriculum such as leadership, health policy, informatics, and population health. Faculty of member schools of the consortium (which was expanded to 32 schools in 2015) then wrote the first edition of the Health Systems Science textbook. This was published by Elsevier in 2016.[v] Elsevier published a second edition in 2020, and this book along with the Health Systems Science Review and the most recently published Health Systems Science Education: Development and Implementation have increased the incorporation of HSS into medical education. New medical schools are launching curricula that already include it.[vi],[vii] Fortunately, the education of other healthcare professionals is increasing including health systems science as well.[viii]
For example, the AMA’s Health Systems Science Scholars Program has long included many healthcare professionals in addition to physicians.[ix] Medical schools often include non-physicians in HSS educational experiences.[x],[xi],[xii] HSS is also increasingly included in the curricula for physician assistants, nurses,[xiii], and other health care professionals.[xiv]
Our hope is that medical schools and institutions that train other health professionals will implement HSS education in even greater numbers and to an even greater degree. Our latest textbook, Health Systems Science Education: Development and Implementation, explores exactly how to do that in the pre-clerkship curricula as well as in the clinical learning environment and in graduate medical education. A chapter is dedicated to interprofessional education and collaborative practice. Teaming is one of health systems science’s foundational domains, and interprofessional education is integral to strengthening physicians’ knowledge of the special skill sets of other health professionals and approaches in order to leverage the entire team’s capacity to advance optimal care.
Interprofessional care and collaboration are critical to good patient outcomes, and for HSS to achieve its full potential, all healthcare professionals need to be trained as systems citizens adept at incorporating HSS into everyday practice. This means that future physicians will sometimes train and work alongside other healthcare professionals while always understanding the importance of teaming and interprofessional practice. It will also mean that physician assistants, nurse practitioners, nurses, and other health care professionals will need their own training in HSS so that physicians and other health care professionals will work alongside each other even better than ever before. All can become system citizens who are effective stewards of the health care system.
[i] Skochelak SE, Hammond MM, Lomis KD, et al., eds. Health Systems Science. 2nd ed. St. Louis: Elsevier; 2020.
[ii] Gonzalo JD, Ogrinc G. Health systems science: the “broccoli” of undergraduate medical education. Acad Med. 2019;94(10): 1425-1432.
[iii] Borkan JM, Hammoud MM, Nelson E, et al. Health systems science education: the new post-Flexner professionalism for the 21st century. Med Teach. 2021;43(suppl 2):S25-S31.
[iv] Skochelak SE, Lomis KD, Andrews JS, Hammoud MM, Mejicano GC, Byerley J. Realizing the vision of the Lancet Commission on Education of Health Professionals for the 21st Century: Transforming medical education through the Accelerating Change in Medical Education Consortium. Med Teach. 2021; 43:sup2, S1-S6
[v] American Medical Association. Just in time for the holidays: AMA’s health systems science textbook. Published December 15, 2016. https://www.ama-assn.org/press-center/press-releases/just-time-holidays-ama-s-health-systems-science-textbook. Accessed July 11, 2023.
[vi] Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science. https://medschool.kp.org/about/offices-and-departments/department-of-health-systems-science. Accessed July 11, 2023.
[vii] Alice L. Walton School of Medicine. Alice L. Walton School of Medicine Announces Leadership Hires. Published May 4, 2023. https://www.alwmedschool.org/news/alice-l-walton-school-of-medicine-announces-leadership-hires. Accessed July 11, 2023.
[viii] Will KK, Mutyala J, Essary AC. Health systems science: A call to action. JAAPA. 36(6):p 45-46, June 2023.
[ix] American Medical Association. Health Systems Science Scholars. Updated November 22, 2022. https://www.ama-assn.org/education/accelerating-change-medical-education/health-systems-science-scholars. Accessed July 11, 2023.
[x] DeSimone AK, Siegel DT. Integrating Health Systems Science Education into Five Graduate Programs. Institute for Healthcare Improvement Open School, Emory University. https://www.ihi.org/education/IHIOpenSchool/resources/Documents/27ForumPosters/27Forum%20Ariadne%20DeSimone.pdf. Accessed July 11, 2023.
[xi] Musick DW, Vari RC, Kraemer MS, Trinkle DB, Vari PM, Smith JC, Learman LA. Building Health Systems Science Education from the Core Domain of Interprofessional Education at Virginia Tech Carilion School of Medicine. Med Sci Educ. 2021 Feb; 31(1): 215–222.
[xii] Gonzalo JD, Hamilton M, DeWaters AL, Munyon R, Miller E, Wolf H, Wolpaw DR, Thompson BM. Implementation and Evaluation of an Interprofessional Health Systems Science Professional Development Program. Acad Med. 2023 Jun 1;98(6):703-708.
[xiii] Johns Hopkins School of Nursing. Health Systems Sciences Interprofessional Scholars Program. https://nursing.jhu.edu/excellence/interprofessional/initiative.html. Accessed July 11, 2023.
[xiv] Olson APJ, Danielson J, Stanley J, Graber ML. Improving Education – A Key to Better Diagnostic Outcomes. Rockville, MD: Agency for Healthcare Research and Quality; March 2022. AHRQ Publication No. 22-0026-1-EF. https://www.ahrq.gov/sites/default/files/publications2/files/dxsafety-issuebrief-education.pdf. Accessed July 11, 2023.
Interview with Rosalyn Maben-Feaster, MD, MPH; Jeffrey Borkan, MD, MBA; Ami Dewaters, MD, MSc; and Stephanie Starr, MD
Why did you feel it was important to write a book on Health Systems Science Education: Development and Implementation, 1st Edition? What does your book add to the field?
Dr. Maben-Feaster: The AMA’s health systems science (HSS) textbooks (Health Systems Science and Health Systems Science Review) have done a great job of defining HSS and its domains as well as making the case for why it is so important for medical education and health care reform. However, given the broad nature of the content, it can be challenging to consider how you might implement this practically. This book is designed to build on the HSS textbooks and provide practical advice and examples to help educators incorporate HSS into their curricula.
Dr. Borkan: Health systems science is critical to successful functioning in the health care system and all students and trainees should be engaged in its domains. This book fills a gap by providing the “how to develop and implement” at your institution or program.
Dr. DeWaters: A lot of educators are recognizing the importance of including health systems science (HSS) in the training of health care professionals. However, adding a new field of education like HSS is a heavy lift at any institution. It was important to write this book so that we could help guide fellow educators on how best to implement this critical work in their local environments.
Dr. Starr: We have had many medical educators/faculty asking us to share our approach to and experience regarding HSS education. Before this book, there was no single resource which pulled together the components and considerations faculty must reflect upon and plan for to build and/or modify a successful HSS program. While we will continue to learn over time how to improve our shared work, this is a singular reference for all faculty to start with and for us collectively to build upon.
What is the most exciting aspect of your book Health Systems Science Education: Development and Implementation, 1st Edition? What chapter or topic covered in this book are you most excited about?
Dr. Maben-Feaster: I am really excited that we were able to include health systems science competencies that were developed by the AMA Health Systems Science Competency Taskforce in chapter 2. There has been a great need for this in the field, and this will serve as a great foundation for anyone looking to implement HSS into their curricula.
Dr. Borkan: I like it all—but am inspired by the first chapters that provide the framework—we have come so far in a short time in developing it.
Dr. DeWaters: I’m personally very excited about the information in the book that relates to the graduate medical education (GME) space. There has been so much incredible work related to HSS that has happened at the medical school level. As national focus shifts toward improving the UME-GME transition, the HSS work that has been occurring at the GME level is becoming even more relevant. I’m so glad that we can present what HSS innovations are already happening in residency programs as it can serve as a foundation for upcoming HSS UME-GME transition work.
Dr. Starr: It’s hard to choose one chapter – I’ll highlight two that I am most excited about and I think will have significant impact.
Who will find the greatest value from Health Systems Science Education: Development and Implementation, 1st Edition and why?
Dr. Maben-Feaster: Educators in the UME and GME space will find the greatest value from this book because it provides practical considerations for designing, implementing, and evaluating curriculum for those who are doing it in their day-to-day work.
Dr. Borkan: Educators at all stages of medical training—medical schools, residencies, fellowships, CME. Also, I would like to see it expand to pre-medical studies and other health professions.
Dr. DeWaters: I think there are many interested parties who could benefit from this book. Certainly, we hope our medical educators find this book practical and useful as they look to implement HSS in their own programs/schools. However, I think leaders and learners alike may find this book very useful as it clearly outlines the rationale behind HSS as an education pillar and the benefits from implementing HSS in medical education institutions and health systems.
Dr. Starr: Indirectly, patients and learners. Directly, any medical educator or team of medical educators seeking to build or modify existing HSS programs with the goal of helping physician trainees learn to integrate HSS into their knowledge and skills in the basic and clinical sciences toward improving the health of individuals.
What new ideas, practices, or procedures do you hope your readers take away from Health Systems Science Education: Development and Implementation, 1st Edition?
Dr. Maben-Feaster: I hope that readers will take away that HSS education development and implementation is about more than just creating the content but also about integrating change management/leadership principles to help reshape the professional identify of current and future clinicians.
Dr. DeWaters: There are some critical descriptions in this book about the importance of utilizing change management skills and curriculum development skills to successfully build HSS educational work. While those may not be new practices or ideas, I do think that their application to this content is new and cannot be overemphasized in terms of their importance.
How would you like to see this book used?
Dr. Maben-Feaster: I hope that this book will serve as a reference to help those who are just starting out on their HSS educational journey but also as an inspiration to those who have been working hard in this space already and seeking fresh ideas.
Dr. DeWaters: Ideally, educators would be able to use this book as a pragmatic roadmap for building their own health systems science curricula at their local institutions. Hopefully laying out common challenges and tips and tricks for successful implementation of health systems science helps other educators do this work with ease!
Dr. Starr: I’d like to see this book be used by educators in schools and GME programs to help them maximize their time and effort to have the greatest impact on learners and patients. I also hope those who use the book build on our shared HSS experience to date, prompting discussion and innovation so we can improve our shared efforts toward successful HSS education as part of physician training.
Is there anything else about Health Systems Science Education: Development and Implementation, 1st Edition you’d like to say?
Dr. Maben-Feaster: I am really proud of the diversity of experience that was represented via the authors throughout the book and hope this will help other HSS educators in their future endeavors.
Dr. Borkan: All other health professions need HSS—I hope that other fields and disciplines take it to heart.
Dr. DeWaters: Putting in place any new curricula is a lot of work, but the importance of HSS makes it worth it!
About the editors and authors:
Rosalyn Maben-Feaster, MD, MPH is an associate professor of obstetrics and gynecology at the University of Michigan Medical School where she serves as the health systems science curricular thread director and the associate director of the Women’s Health Division. She has also served as a faculty for the American Medical Association’s Health Systems Science Scholars Program since 2021. She completed undergraduate school, medical school, school of public health, and her obstetrics and gynecology residency at the University of Michigan.
Jeffrey Borkan, MD, Ph.D. is a family physician educator, researcher, clinician, and advocate whose career has bridged two fields (family medicine and medical anthropology), both in the US and abroad. He is a professor and assistant dean for primary care-population health at the Warren Alpert Medical School of Brown University in Rhode Island.
Ami Dewaters, MD, MSc, is the interim director of health systems science at the Penn State College of Medicine. She is an associate professor of medicine and works clinically as a general internist. She is also leading the Penn State College of Medicine strategic plan focused on improving the implementation of health systems science in the clinical learning environment. She completed her medical degree at the Medical College of Georgia and earned her master’s degree at UT Southwestern Medical Center. Her research focus is primarily on curriculum development within medical education.
At the time this book was written, Stephanie Starr, MD, was director of science of health care delivery education at Mayo Clinic Alix School of Medicine and vice-chair for quality and safety, community pediatric and adolescent medicine at Mayo Clinic in Rochester, Minnesota. She completed her education at Saint Louis University School of Medicine and training in the National Capital Area Uniformed Services Pediatric Residency Program before serving overseas in the U.S. Navy. At Mayo Clinic she served in many education leadership roles, including vice-chair for education (Department of Pediatric and Adolescent Medicine) and assistant medical director, Quality Academy. Her scholarship has primarily focused on health systems science, quality improvement, and pediatric education. She is currently a community pediatrician teaching the University of Washington WWAMI students in Bozeman, Montana.
Purchase your copy of Health Systems Science Education: Development and Implementation, 1st Edition here!
By: Carol D. Berkowitz, MD
ISBN: 9780323813792
Pub Date: July 28, 2021
Reviewed By: Joseph Hageman, MD (University of Chicago Pritzker School of Medicine)
Description
This is volume 68 of “Advances in Pediatrics,” which includes an excellent series of current review articles of relevant topics for pediatric providers.
Purpose
The overall purpose is to update pediatric providers about current topics in pediatrics in addition to all of the clinical information about COVID-19 disease. The topics range from health systems science, to overdiagnosis, antibiotic stewardship, chronic illnesses, tumors, and recreational drug use.
The objectives are worthy and the book meets the objectives.
Audience
The audience for this ongoing series includes pediatric providers at all levels.
The articles are about the needs of children and pediatric providers and do not include COVID-19 disease topics as they had already been chosen for post-pandemic as per the author. The articles in the book definitely meet the needs of the intended audience and the author, coauthors, and contributors are credible authorities.
Features
The content is novel, diverse, thoughtful, and well written. The book begins with health systems science, overdiagnosis, treatment, and antibiotic stewardship, then discusses balancing autonomy and patient protection. It continues with the effects of adverse childhood experiences, which is excellent. The articles then present discussions of chronic and medically complex illnesses, tumors, esophageal atresia, post-operative management, and aspects of vitamin D, and finish with recreational drug use and ingestions.
Assessment
This volume is an outstanding collection of clinically relevant reviews for pediatric providers at all levels. The focus is post-pandemic and there is still much to discuss in the care of pediatric patients in addition to COVID-19 disease. The authors and contributors do an excellent job. As the editor of a continuing educational pediatric journal, I highly recommend this volume.
©Doody’s Review Service, 2022, Joseph Hageman, MD (University of Chicago Pritzker School of Medicine)
Doody’s Score: 96 – 4 Stars!
Interview with Maya M. Hammoud, MD, MBA and Gregory W. Schneider, MD
Why did you feel that it was important to write Value-Added Roles for Medical Students?
Dr. Hammoud: Medical students are very motivated and capable of being integral parts of the health care team. Sharing ways to create value-added roles for medical students provides educators with ideas on how to integrate students in their health systems so they can learn while contributing to patients’ care.
Dr. Schneider: In a way, I feel like we have come full circle. Medical education is striving to recapture ways in which students can play vital roles within the health care team. We may no longer have students drawing blood on our patients, wheeling patients to the radiology suite, or running a quick urinalysis, but they can play other crucial roles. This book helps us envision these new roles for our students that benefit local health care systems and the students’ educational experiences, while retaining that former spirit of helping students feel essential.
How would you define a value-added role and what do you think is the biggest misconception about value-added roles for medical students?
Dr. Hammoud: Value-added roles allow students to contribute to patient care in a meaningful way while learning. Experiential learning that is well structured and assessed can stimulate intellectual curiosity and develop professional identity by promoting leadership and teamwork. The biggest misconception about value-added roles is the perception that students are being used for free labor that is not valuable to their academic development.
Dr. Schneider: The central features of value-added roles involve students taking on legitimate tasks within a local health care context that add value to that system and provide students experience with health systems science and clinical skills. I also like emphasizing the corollary benefit of an enriched educational experience for students that can be a factor in students seeing themselves as future physicians. The biggest misconception, from my perspective, is thinking of these roles as merely add-ons or some kind of volunteer experience. True value-added roles are genuine, although they may not appear so at first glance.
What new ideas, practices, or procedures do you hope your readers take away from Value-Added Roles for Medical Students ?
Dr. Hammoud: The book provides a range of topics and approaches depending on what the reader or educator is looking to learn or implement. My favorite part is reading all the examples because they provide very practical approaches to apply value-added roles in effective ways.
Dr. Schneider: I suppose it depends on different kinds of readers. For those who are drawn to the theoretical, there are a number of chapters that really provide well-grounded conceptual frameworks for thinking through the whole process of these types of programs from inception to assessment and evaluation. For those who like examples, the whole middle section is filled with great models that might generate ideas. Being involved with the editing, I loved hearing people’s stories of their successes and failures, what kept them going, and what approaches to managing change helped them the most.
What is the biggest challenge when implementing value-added roles for medical students?
Dr. Hammoud: The biggest challenge when implementing value-added roles is getting the buy in from all stakeholders to develop and implement a well-structured program. Sometimes, significant resources might be required upfront to implement the program. You need to have the ability to demonstrate the value while visioning.
Dr. Schneider: At least in my experience, ensuring enough resources, as a program evolves, emerges as a daunting challenge. Those resources are multidimensional, from having well-trained and committed preceptors and staff to curricular support, and they require ongoing nurturing. Administrators may change and may not see the value or may see the program in a different way. Working with different interested parties to learn from their changing perspectives can make a big difference.
What about value-added roles for medical students makes them so important for the modern health care system and modern medical education?
Dr. Hammoud: Value-added roles provide the experiential learning for students to develop into effective system thinkers. The ability to interact with the system from different perspectives and exposing the students to the breadth of health systems science domains will simply help them develop into better doctors!
Dr. Schneider: In a health care system (or systems or non-system) as complicated as ours, it is vital for our students to appreciate the whole range of what we now call health systems science: delivery models, social determinants of health, population health, health informatics, quality improvement, etc. As we also appreciate the importance of active and experiential learning, it makes so much sense to engage our students in real ways in the health systems that make up our local environments. When students experience having an impact, whether on patients that they helped navigate through a labyrinthine care network or on a clinic’s performance on a health metric, it sticks with them and broadens their sense of what a physician can do.
What do you hope happens after people read Value-Added Roles for Medical Students?
Dr. Hammoud: I hope that readers get inspired to communicate with others about the importance of value-added roles and/or decide to implement more value-added roles at their institutions if they are in the position to do so.
Dr. Schneider: On the most basic level, I hope that educators come away inspired: You can do this! Every educational environment is different, but there are enough examples and strategies in this short book to plant seeds in a wide variety of contexts. My hope is that readers start having discussions at their institutions about ways to start a new program or tweak one that is already underway. Even working on this book, I took away several ideas that we have implemented in our own value-added program. We are always learning, and trying out new educational endeavors keeps us challenged.
Is there anything else about the book you’d like readers to know?
Dr. Hammoud: The book is very rich and has a lot of practical information on implementing value-added roles for medical students. I hope readers get inspired by all the examples and commit to implementing value-added roles at their institutions.
Dr. Schneider: This book really serves as a testament to the diverse and creative ways that educators are involved in making a difference for students and for the broader US health care system. I truly enjoyed working with so many people from different institutions and hearing their stories. If I were encountering the book for the first time, I would probably skim the examples first, just to get inspired and then go from there.
Dr. Maya Hammoud is the J. Robert Willson Research Professor of Obstetrics and Gynecology and Professor of Learning Health Sciences at the University of Michigan Medical School. She is the Chief of Women’s Health Division and Associate Chair for Education. Dr. Hammoud holds many leadership roles nationally, including senior adviser for Medical Education Innovations at the American Medical Association (AMA) with a focus on health systems science and coaching. She has over 70 peer-reviewed publications and has published three books. Dr. Hammoud completed her MD and MBA degrees and residency training at the University of Michigan.
Dr. Gregory Schneider teaches medical students at all levels, concentrating on clinical skills, ethics, and the social factors involved in health. His career has focused on higher and medical education with over 20 years of teaching. Dr. Schneider spent a decade teaching undergraduate liberal arts, earning tenure at a liberal arts college, and more than 10 years teaching at the medical school level. He has practiced primary care in academic health, student health care, and community health center settings. These experiences have all contributed to his appreciation of the importance of the doctor-patient relationship, empathy, and working as part of a diverse caregiving team.
The Master Adaptive Learner, 1st Edition
By William Cutrer, Martin Pusic, Larry D Gruppen, PhD, Maya M. Hammoud, MD, MBA and Sally A. Santen, MD, PhD
ISBN: 9780323711111
Pub Date: October 14th, 2019
Reviewed By: Jennifer Rockfeld, MD (University of Texas Southwestern Medical Center)
Description
This book describes the master adaptive learner model in great detail. The authors developed this concept and describe the theory underlying it, how to teach and assess it in individual learners, and its broader applications to leadership and health systems science. The website is a digital version of the book.
Purpose
The purpose is to describe the master adaptive learner framework that “details a metacognitive approach to self-regulated learning within health professions education.” It integrates several existing educational theories and makes them applicable. I have eagerly awaited this book since reading the primary literature on this model. The book meets its objectives to be used as a reference.
Audience
The audience is medical educators. The authors do not target a specific type of practitioner, just those who teach in the health professions. The book is more accessible to those who participate in curriculum development and assessment, but it can be understood by anyone who teaches. The authors are the most credible authorities on this subject as they developed this model and have published on it.
Features
The first three chapters introduce the concept of the master adaptive learner and the educational theory behind it. The book then delves into the personality characteristics, cognitive processes, and self-assessment needed to achieve this goal. The authors then focus more on teaching and assessing learners in these skills. Each chapter describes a different setting or use of this model and has learning objectives, cases, take-home points, and questions for further thought. Graphs and charts illustrate important points or processes. This is an extremely thorough review of this concept and its application. I primarily used the print book and cannot comment on the value of the online format.
Assessment
As this is the first book on this topic, there are no comparable books. It is well written, easy to follow, and thought provoking. It provides enough information to build content around and clearly establishes where there is room for more research. I highly recommend this book to anyone who is in medical education and aims to develop their learners into medical professionals who engage in self-regulated learning and develop adaptive expertise.
© Doody’s Review Service, 2021, Jennifer Rockfeld, MD (University of Texas Southwestern Medical Center) Review Score: 100-5 Stars!
Health Systems Science, 2nd edition, Elsevier
Writers: Victoria Stagg Elliott, MA; Jeffrey Borkan, MD, PhD; Jed Gonzalo, MD, MSc; Maya Hammoud, MD, MBA; Luan Lawson, MD, MAEd; and Stephanie Starr, MD
Health systems science has emerged as the third pillar of medical education along with the basic and clinical sciences. Elsevier released the 2nd edition of the Health Systems Science textbook at the end of May 2020, which includes a science fiction story (Chapter 17) describing an imaginary pandemic. This chapter, entitled Looking Ahead: the Dynamic Nature of Health Systems Science, Future Trends, and the Role of Learners as Change Agents, was written prior to the emergence of COVID-19 and explored the future of health systems science. The science fiction story depicts a team of medical students using their knowledge of health systems science to assist with the containment of an outbreak of a fictional vaccine-preventable infectious disease at an undetermined future time and place.
The COVID-19 pandemic has underscored the need for all medical students, health professions trainees, physicians, and other health professionals to achieve competency in health systems science alongside the basic and clinical sciences. Health systems science is defined as the understanding of how care is delivered, how health care professionals work together to deliver that care, and how the health system can improve patient care and health care delivery. It provides a holistic framework for previously underappreciated and underrepresented concepts such as leadership, teamwork, patient safety, structural and social determinants of health, population health, systems thinking, and others that are emerging as critical to addressing this pandemic. An understanding of these concepts, how they are connected to each other, and how they are tightly linked to the basic and clinical sciences allows every health professional, clinical team, and health system to utilize the basic and clinical sciences to more effectively care for patients and the populations they serve.
The pandemic and some of the early failures in the response were partly due to insufficient attention to and ownership of health systems science and its lessons. For example, basic and clinical sciences helped physicians, other health professionals, and scientists around the world understand what is currently known about SARS-CoV2 transmission and how to best deploy personal protective equipment (PPE) to minimize infections among clinical teams caring for COVID-19 patients. COVID-19 has spread throughout the U.S. in part as a result of inadequate systems thinking (implications of an interconnected and vulnerable supply chain) and failure of the health system and society to prioritize and address the structural and social determinants of health (such as housing and poverty) as the per capita rates of infection among vulnerable populations rise.
Gratefully, there have been many successes in addressing the COVID-19 pandemic. Many of these successes illustrate the importance of understanding and applying health systems science concepts.
Population and Public Health
Never has there been a more critical need to integrate and unify traditional health care and public health. The nation will not be able to adequately respond to this pandemic and decrease the risk for similar pandemics in the future without embracing the need for population health.1,2 For example, a physician may need to reach out to high-risk patients to discuss additional preventive steps they should consider. Virtual visits may be needed to address non-COVID-19 health issues for patients at high risk of mortality or severe morbidity. Physicians and other health care professionals treating patients infected with COVID-19 must identify ways to prevent spread to others and work with public health entities working to contain this pandemic.
Leadership
In mid-March when the response to this pandemic was accelerating in the U.S., the Association of American Medical Colleges issued guidance strongly suggesting that medical students not be involved in direct patient contact activities.3 This did not stop medical students from using their leadership skills to create opportunities to make a meaningful impact. Medical students formed the COVID-19 Student Service Corps in order to increase the capacity of health professional students to engage in service-learning to address the needs of health systems and communities. This effort started at Columbia Medical School and spread nationally.4 Medical students at Harvard Medical School formed the National Student Response Network linking medical and other health profession students to opportunities to deliver personal protective equipment, trace contacts, and deliver food to the elderly.5 Medical students organized themselves and others to deliver food to vulnerable populations, staff public health call centers, assist with COVID-19 related research, help with patient intake, create morale-boosting goodie bags for health care personnel, and take care of the children of physicians and other health care professionals. There are too many examples to cite and list.
Patient safety
In the early days of the pandemic there were efforts to keep COVID-19 patients separate from other patients in health care facilities in order to reduce spread and maintain patient safety. These efforts continue, although it has become clear that every patient in a health care facility is a potential COVID-19 patient, whether or not they have tested positive. Patient safety strategies must be used to help reduce iatrogenic infections and maintain health system capacity.6 Many patients are being screened by phone before scheduled outpatient visits, and those with potential COVID-19 symptoms are seen at a separate location and/or during specific hours to minimize exposure to asymptomatic patients, families, and staff.
Teamwork
COVID-19 is straining the health system, providing a new urgency for health care professionals to work well in teams. This outbreak will not be stopped by a single hero, but by thousands of heroic teams working well together.7,8 Teams are being formed across disciplines and medical specialties to care for COVID-19 patients, especially those in special circumstances such as pregnancy.9 Teams are being formed across facilities that have not traditionally worked closely together such as those in primary, community, acute, and long-term care settings. The concept of “essential workers” has underscored the importance of others outside of health care on the COVID-19 team, from supermarket clerks to cell-phone tower maintenance staff. Good teamwork can also mean that some clinicians may have to provide care outside their usual practice, forcing rapid learning and adaptation to additional systems.10,11
Clinical informatics
The vast majority of the U.S. health system has access to some form of an EHR12, and these computer systems have become vital outbreak management tools. A full understanding of what an EHR can do has allowed them to be used to develop scripted triaging, electronic check-in, standard ordering and documentation, secure messaging, real-time data analytics, and telemedicine capabilities. Clinical informatics has also allowed those responding to the pandemic to adjust the EHR as needed in response to new information and changing conditions13 and has underscored the need for ever greater connectivity, effective communication, and actionable data.
Structural and social determinants of health
An understanding of the structural and social determinants of health has also emerged as critical to controlling this pandemic because the impact of COVID-19 is hugely inequitable. Across the country, minorities are disproportionately infected and dying from COVID-19, including patients who are black, Latinx, and Native American.14,15 In April 2020, the Navajo Nation had the third highest per capita cases of COVID-19, behind New York and New Jersey.16 The structural, social, and economic factors that contribute to health inequities are not new, but the COVID-19 pandemic highlights the acute need to address them in order to decrease the risk of infection and illness for the U.S.17,18,19
Systems Thinking
Systems thinking, the bedrock of all health systems science domains, is critical for those working at every level of this crisis to understand and influence the spread of infection and its numerous consequences across a community.20 Systems thinking allows those working to end this pandemic to know when to lead and when to follow, how to connect with multiple levels of the health system and different types of professionals throughout the health system in order to implement patient safety protocols, how to connect the right people into the right teams, how to utilize clinical informatics to the fullest potential, and how to quantify the impact of the structural and social determinants of health and how to best address them, when possible.
This list is not exhaustive, but it does demonstrate how those who know and apply the domains of health systems science can improve the response to this pandemic now and other emerging health threats in the future.
Access Chapter 17 for free: Looking Ahead: The Dynamic Nature of Health Systems Science, Future Trends, and the Role of Learners as Change Agents
References:
The first edition of the Health Systems Science textbook, published in December 2016, provided a groundbreaking framework for this nascent discipline. The second edition, published May 2020, builds on the first with updated material, additional exercises, insightful sidebars from experts on the ground, and new chapters on systems thinking, health care structure and processes, and ethics and legal issues.
Learn more about Health Systems Science, 2nd Edition here.
Article by Jesse M. Ehrenfeld, MD, MPH and Jed D. Gonzalo, MD, MSc, editors of Health Systems Science Review
Health Systems Science Review is the first book to help learners prepare to be assessed and faculty to develop assessments in this emerging discipline. Health systems science—the study of how health systems deliver care, how patients receive and access that care, and how care can be improved—is increasingly the third pillar of medical education alongside the clinical and basic sciences. Assessment is critical to its increasing implementation.
We started working on this book soon after the publication of the first edition of the textbook, Health Systems Science. This textbook provided a framework for this area of study, but it quickly became apparent that a study guide was needed to assist students and faculty working in this new area. We recruited leading experts in their fields to write questions, answers, and full explanations on health care delivery and processes, health care policy and economics, clinical informatics and technology, socio-ecological determinants of health, population and public health, value in health care, patient safety, quality improvement, teamwork and collaboration, leadership in health care, and systems thinking.
Each chapter is organized into cases followed by questions. Answers and explanations are at the back of each chapter. This structure facilitates quicker study for learners. Faculty can also use this book to improve their own knowledge in this area and develop assessments.
The Health Systems Science Review book is the latest in the ongoing work to integrate health systems science into medical education. A second edition of the Health Systems Science textbook is under development.
Jesse M. Ehrenfeld, MD, MPH is the Joseph A. Johnson Jr. Distinguished Leadership Professor at the Vanderbilt University School of Medicine in the departments of anesthesiology, surgery, biomedical informatics, and health policy.
Jed D. Gonzalo, MD, MSc is the associate dean of health systems education at Penn State University College of Medicine and associate professor in that school’s department of medicine and department of public health sciences
Health Systems Science (HSS) emerged from the American Medical Association’s Accelerating Change in Medical Education Consortium and is now the third pillar of medical education. Health Systems Science is the fundamental understanding of how health care is delivered, how health care professionals work together to deliver that care and how the health system can improve patient care and health care delivery. Health Systems Science was published in December 2016 and is the first comprehensive, practical reference for learning this emerging science of healthcare delivery.
The authors describe the importance of each of the three pillars, stating that, “The basic sciences are essential for a physician or other health care professional to understand the human body and its function. The clinical sciences are essential to translate that understanding into care for the human body. HSS is essential for physicians and other health care professionals to help insure that patients, communities, and populations achieve optimal health outcomes.”
Dr. Blackford Middleton, Chief Informatics and Innovation Officer of Apervita, Inc., a Chicago based health analytics platform recently reviewed Health Systems Science in the Journal of Biomedical Informatics. He walks through the 15 chapters of the 228-page book and concludes that, “…this is an extremely readable and well thought out book that presents a comprehensive set of well written and referenced chapters pertaining to the emerging field of health systems science – the new third pillar of health professions education.” Read the full review on ScienceDirect.
Learn more about Health Systems Science here.
Sample a free chapter here.
Watch now: Drs. Luan Lawson, Dan Wlopaw, & Richard Hawkins share their insights about the importance of educating today’s students on this evolving topic.
