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Competency-Based Curriculum Resource for Preclerkship Education (using ACGME Structure):

Systems-Based Practice

Lead Authors: Rick E. Ricer, MD and William Raszka, MD

Workgroup Members
Christine Matson, MD, Chair Eastern Virginia Medical School
Scott A. Fields, MD
Oregon Health and Science University
Jeffrey Stearns, MD, Executive Committee Liaison
University of Wisconsin Milwaukee Clinical Campus
Eric Bass, MD
 Johns Hopkins University
Thomas Defer, MD
Washington University
Allan Goroll, MD
Harvard University
Larrie Greenberg, MD
George Washington University
Mary Ann Kuzma, MD
Drexel University
Steve Miller, MD
Columbia University
William Raszka, MD
University of Vermont
Rick E. Ricer, MD
University of Cincinnati
John C. Rogers, MD, MPH
Baylor Medical College
William Wilson, MD
University of Virginia

Rationale

When entering core clerkships, students must be prepared to consider how health system organization, financing, and cost control dimensions affect access to care and priorities of health care delivery. Students should be able to describe how populations of patients are just as important recipients of their care and attention as are individual patients. Students need to be able to contrast the care of individuals with the care of populations, such as how health problems of those cared for in the hospital setting differ from the types of health problems experienced by the community in general. Understanding health system and population-based issues should help students understand barriers to care.

Competency

Students must demonstrate an awareness of the larger context and system of health care.

Goals

Develop awareness of impact of health system context on clinical care.

Understand health care organization.

  • Describe basic organizational structures and financing streams of the U.S. health care system.
  • Describe the US Public Health System and role of government in improving access to health care and assessing quality of care, and disease surveillance.
  • Explain the physician's role in disease surveillance.
  • Describe principles of population-based medicine.
  • Describe the rules regarding reporting of diseases to public health officials.
  • Identify common problems that are sociologically based and are rectifiable only by systematic approaches to care.
  • Describe ways physicians in practice define ethical responsibilities to solve access problems for individual patients and populations of patients.

Describe how delivery systems differ on methods of controlling health care costs and allocating resources.

  • Describe economic and treatment limitations imposed by systems.
  • Identify how payment methods may conflict with ethical standards.
  • Describe how different methods of cost control affect physicians' relationships with their colleagues, their patients, and society.
  • Describe the strengths and shortcomings of the U.S. system for financing and delivering medical care, particularly to those from underserved/minority groups.

Describe how to assist patients in dealing with system complexities.

  • Describe barriers to accessible and appropriate care, especially those experienced by poor people.
  • Describe the influence of the pharmaceutical industry in the practice of medicine and the need for adherence to associated ethical guidelines.
  • Demonstrate practical strategies for making reasonable judgments in the face of ethical uncertainties.

Educational Methods

The knowledge and attitudes for Systems-Based Practice are best learned in an interactive environment. For this reason, a variety of strategies may be use to facilitate student learning. Basic knowledge cay be transmitted through lectures, computer-assisted instruction (such as Web-based curricula), or readings, but understanding and applying the material to actual patient care problems is best accomplished in small- group experiences with active problem solving. Additionally, Systems-Based Practice attitudes and concepts need reinforcement during clinical experiences, where students reflect on the systems issues related to patients they are seeing. Mentoring relationships with practicing physicians can reinforce the principles of Systems-Based Practice. Service learning in public and private agencies that deal with health system access, financing, and quality provide opportunities for experiential learning. Reflection on those experiences, through reflective journals or reflection groups, draws out the lessons learned.

Resources

Learning Opportunities

  • Ambulatory community family medicine rotation with exposure to business or front office staff - PBL experiences - Community health center or COPC experience - Health policy research experience - Health sciences research experience
  • Resources System-Based Practice: Current Approaches

PowerPoint slide sets describing approaches:

Additional Resources

Annotated Bibliographies

Conference Abstracts

  • ACGME/IHI Conference Abstracts
    • The Mirror and The Village: A Method for Teaching Practice-Based Learning and
      Improvement and Systems-Based Practice
    • Attaining Resident Competency In Systems-Based Practice: An Interdisciplinary
      Program of Home Visits to Vulnerable Adults
    • The Magic of Problem-Based Curriculum for System-Based Practice - The "Coat-Of-Arms Exercise"
    • http://www.acgme.org/outcome/conferences/abstract.asp

Articles

  • White J. Targets and systems of health care cost control. Journal of Health Politics Policy and Law. 1999; 24:653-96.
  • Geyman J. Myths as barriers to health care reform in the United States. International Journal of Health Services. 2003; 33:315-29.
  • Ball RM. What Medicare's architects had in mind. Health Affairs. 1995; 14:62-72.
  • McManus SM. Health care reform: past experiences and current status. Journal of Health and Human Services Administration. 1998; 21:140-61.
  • Birn AE, Brown TM, Fee E, Lear WJ. Struggles for national health reform in the United States. American Journal of Public Health. 2003; 93:86-91.

Assessment Strategies

The full application of the attitudes, knowledge, and skills for effective Systems-Based Practice requires an ongoing clinical practice where there is variability in health care delivery system structure, financing, and organization. Preclerkship students need to learn the attitudinal and intellectual foundations that can be applied later to their clinical rotations. Assessment of students' knowledge should be case-based and could include multiple-choice questions, short answers, essays, reflective journals, self-assessment, and portfolios. ACGME assessment: http://www.acgme.org/outcome/assess/assHome.asp http://www.abim.org/pubs/Residents%20Competency.pdf

Faculty Development

Faculty development should be focused on increasing knowledge about Systems-Based Practice, problem-based or case-based teaching strategies, small- group instruction, reflection activities, and print or electronic sources for population information. Faculty members often have strong opinions about health care system organization and funding based on negative personal experiences. These views need to be tempered with balanced presentations of the issues, so that students can take a reasoned approach to these contemporary problems. The hidden curriculum has a powerful impact on the attitudes students develop about Systems-Based Practice, so this aspect of faculty development needs thoughtful attention.

 

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This page last updated November 6, 2004