To the uninitiated, “health systems citizenship” might seem to have little to do with residency training, where physicians are busy learning their specialty and, in many cases, leaving the training institution behind after graduation.
Leaders at Geisinger, however, are using the health system citizenship strategy to give physicians in training the tools they need to create impactful systemic change, not only in their training institutions but also in whatever roles they take on after their transition to practice.
“If we let our learners just graduate thinking being a good doctor is only about delivering good healthcare, they really missed their opportunity to make a bigger impact,” said Scott Friedenberg, MD, a neurologist and director of health systems science at Geisinger.
Health systems science involves understanding how care is delivered, how health professionals work together to deliver that care, and how the health system can improve patient care and healthcare delivery. It is critical for attaining optimal patient outcomes. Physicians need to know the domains of health systems science, understand how it intersects with the basic and clinical sciences and explore how it can maximize health for patients and society.
Dr. Friedenberg said health systems science is “clearly something that learners at all levels want to learn” because resident physicians and other trainees overwhelmingly “feel a compelling desire to learn how to ensure patients get high-quality healthcare in a way that also makes their lives as clinicians better.”
As part of the AMA Reimagining Residency initiative, a grant to Geisinger as part of a four-system team including the Pennsylvania State University, Allegheny General Hospital and Kaiser Permanente was applied to a project around health system citizenship in residency training. The aim was to teach resident physicians how to spot areas for improvement in their health system and then come up with solutions. The training helps residents address barriers to high-quality patient care and gives them the ability to affect their training environment in a positive way.
“Medical education often emphasizes physicians as independent, or working on small teams,” Dr. Friedenberg said. “We develop excellent caregivers, but our learners may not recognize the larger system around them. We wanted to find a way of showing trainees the depth of resources, processes, people, and technology needed to become excellent caregivers.”
Danville, Pennsylvania-based Geisinger is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Creating a curriculum that counts
The project at Geisinger started with a survey in which leaders asked residents, program directors and department chairs what they already knew about health systems science and health system citizenship. How did they apply those strategies in their work and training? Where did they see room for growth?
“Learners already do some health systems science-type work,” Dr. Friedenberg said. Awareness of that is key, “because if they're not aware of it, then they don't realize there's an opportunity to improve it.”
At the same time, Geisinger leaders used a framework for problem-solving called “human-centered design” to look beyond data at which changes could make a meaningful difference.
“We found that by creating processes where everybody saw it as advantageous, they learn health systems science while they were also doing things to improve their practice,” Dr. Friedenberg said.
The curriculum touched a nerve with resident physicians, he said, who in many cases already knew intimately where the trouble spots lay. They just needed help identifying the best way to reach a solution.
“Residents love the learning, the interactive way that we taught them and did projects with them. They were sought as the content experts, where they could say something and their opinion mattered,” Dr. Friedenberg said. “This type of engagement translated into everyone having a lot of fun and feeling valued.”
Along with basic and clinical sciences, health systems science has become a crucial “third pillar” of medical education, with an emphasis on understanding the role of human factors, systems thinking, leadership and health system improvement strategies that will help transform the future of healthcare and ensure greater patient safety. Health Systems Science, now in its third edition, was the first textbook devoted to this increasingly important branch of healthcare education. This fully revised edition addresses today’s key issues in the field and is now available for preorder.
More input, higher impact
Resident physicians may not realize that they are already acting as “a systems citizen,” Dr. Friedenberg said, whether it’s in simple ways such as relying on administrative support in clinic, attending interdisciplinary rounds in the hospital, being a part of multidisciplinary clinics or undertaking improvement processes as chief residents.
“New graduates—from probably their first to their third year—they don't appreciate that they're part of the system. They say things like: ‘I'm just here to learn medicine,’ or ‘I'm just here to take care of patients.’ They don't realize that they're developing leadership skills or they're going to be looked to as leaders,” he noted.
At Geisinger, one project related to radiology had to do with emergency department imaging requests that frequently arrived with scant data. Previously, resident physicians would simply check a box that said, “abdominal pain,” without much understanding of the way the data in the form would be used.
Radiology residents partnered with the emergency room, informaticians and other system stakeholders to develop education and a simple mnemonic for ensuring data completeness. The result was a significant drop in CT reading turnaround time, Dr. Friedenberg said, and Geisinger will examine the resulting quality metrics and physician satisfaction.
Improving the imaging referral form turned out to be a simple solution that led to better patient care, and officials are considering pursuing publication of the results of the radiology project.
“By helping them function as systems citizens and seeing how their activities tie in with other groups, they [residents] were able to identify what the root cause of the problem is and create a solution that was easy to implement,” he said.
It is critical that residents learn not just how to function as physicians, but also as members of a larger group. Geisinger has expanded the program to include all seniority levels of physicians and continues to find new ways to incorporate the curriculum.
“With the advent of technology and physicians being called up to be leaders, that skill set of being more than just a care delivery person is imperative if we want to own the change that is necessary to improve healthcare in the United States,” Dr. Friedenberg said.
Learn more about the AMA ChangeMedEd Initiative, which works across the continuum with visionary partners to create bold innovations in medical education.
