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Strategies For Successful Implementation of HSS in Health Professions Education

The last session was moderated by Lomis and consisted of an open discussion among planning committee members, speakers, and participants. The goal of the dialogue was to discuss barriers and opportunities for implementing health systems science (HSS) into health professions education and explore open questions about implementation, including the following questions raised by planning committee members:

• What is the current state? What are the gaps?
• What is needed to truly make HSS the third pillar?
• How do we, as educators, anticipate the bottlenecks? What are some strategies for success?
• Who should teach HSS, and how do we build capacity in this area?
• What are curricular options along the arc of HPE, and what are approaches for reaching different learners?
• What are the curricular goals? What should proficiency in HSS look like at the preclinical, clinical and professional levels?
• What type of institutional support is needed to actualize the implementation of HSS?

WHAT HEALTH SYSTEMS SCIENCE IS NOT

One major barrier to implementing HSS in health professions education, said Lomis, is getting stakeholders to agree on what it is—and, perhaps more importantly, what it is not. There are misperceptions that HSS is relevant to areas such as health care administration or quality

improvement but not to those providing care. This is not what HSS is, said Lomis. Instead, it is a “shift in professional identity formation” and a new way to see the world and one’s place in it. It is an acknowledgment that no matter how skilled a provider is in their specific field, optimal patient outcomes will not be attained unless the provider understands the system and how everything works together. HSS is not just content, it is a “unified framework” and an acknowledgment that the “system” is not a separate entity; it is made up of all the people and organizations within it. With empowerment and the right tools, said Lomis, these people and organizations have the power to change the system.

HOW HEALTH SYSTEMS SCIENCE IS PRESENTED TO LEARNERS

The concepts within HSS can be “overwhelming” in both number and complexity, said Andrea Pfeifle, forum representative from the National Academies of Practice. Learners often enter training with an aspiration to be the best provider they can be and may be dismayed to learn that the system is bigger, more complex, and more difficult to navigate than they thought. Pfeifle wondered how HSS can be presented to learners in a way that is empowering rather than overwhelming. Bushardt replied that during the pandemic, learners demonstrated flexibility, creativity, and willingness to rise to challenges. This is a “generation of change makers,” and they will thrive if given the opportunity to make a difference. Furthermore, it would be a great disservice to both learners and the communities they will serve if educators do not prepare them to be “citizen clinicians” who can use systems thinking to assess and navigate the complexities of practice. Mark Merrick, who represents the Athletic Training Strategic Alliances, agreed that this generation of learners “wants the world to function better than it does” and is determined to be part of the solution. Thinking in a systems way comes naturally to them, but they have not had it described in a formal and structured way. Empowering these learners to be agents of change is important, he said, and they need to view themselves as capable of making changes. Halaevalu Vakalahi, the forum representative from the Council on Social Work Education, added that students are sometimes thought of as “empty vessels” but in actuality are people with perspectives and ideas who need to be at the table.

PUTTING PEOPLE AT THE CENTER

At their core, systems are made up of people, said Kennedy. Centering people, and the relationships between them, is essential for understanding systems and being empowered to change them. Learners benefit from a focus on people and their lived experiences; when teaching HSS concepts,

it is important to use specific case examples and encourage students to link their clinical work with what they are learning in the classroom. Grounding students in a person-centered systems lens will allow them to walk through the world seeing it differently. Lomis agreed that authentic, experiential activities should be the core of HSS education because such real-world experiences allow students to “grab onto” the content they have learned in the classroom. Learners need an opportunity to see that improving the system is not for the benefit of the system itself but for the people at the center of it.

One way to emphasize the centrality of people in the system, said Threats, is to “think of ourselves as persons first before our profession.” An interprofessional team is made up of professionals with different education and training, but ultimately, it is people working in relationships together. Threats encouraged stakeholders to not let “professionalism get in the way of your own humanity.” This notion was supported by another participant, who agreed that professional labels can stand in the way of being open to learning and growing and that, ideally, teachers and students should be learning together. Immersive experiences like those discussed at the workshop can be enormously powerful because they allow all participants to learn while contributing to the health care experience and improving it, she said.

SELECTING THE RIGHT LEARNERS

As discussed, some health professions learners are resistant to HSS education and complain that it is a waste of time, said Gonzalo. Participants have considered strategies for engaging them and convincing them of the importance of the systems lens. Gonzalo offered a “provocative” question: “Are we matriculating the right students into our professions?” He then added that if health professionals, educators, and society want the workforce of 2030 and 2040 to think differently about the health care system, do the assessment criteria for entry into these education programs need to change?

Lomis looked at this issue from a systems lens and asked if we have created a selection system that fosters the behaviors we want? The system that socializes prospective learners may be emphasizing traits that are not aligned with HSS and collaborative, interprofessional practice. For example, it is possible that learners may have already developed an individualistic mindset by the time they enter training, leading them to resist the system lens that we hope to impart. Jody Frost, representative of the National Academies of Practice, added that they come into the health professions expecting to learn what they have been told they will learn. She looked at the published descriptions for different health professions and reported that none of them included information about the importance of systems-based

or interprofessional work, so it is “no wonder” that students arrive focused only on the clinical side of health care.

FINDING SPACE FOR HEALTH SYSTEMS SCIENCE

With already crowded curricula in health profession education, Peter Cahn from MGH IHP wondered when and how to best introduce HSS-related material to learners. He said that some stakeholders have the “urge to cram more into prelicensure curriculum,” but adding more required credits can create barriers by making programs longer and more expensive. He suggested that it may be more effective to place HSS content into continuing education. Lomis countered that introducing HSS topics as early as possible is ideal. “Instilling that systems thinking orientation is critical before people get too acculturated,” she said. Starting the educational path with a systems lens will help learners think critically about the systems and processes they are exposed to during training. Deeper skills can be layered on as learners progress through the training path.

EMBRACING COMPLEXITY

A participant asked panelists about the relationship between HSS and complexity theory (an approach to understand complex systems as more than the sum of its individual parts). Gonzalo responded that health professionals, particularly physicians, tend to “live in a paradigm of a fix-it mentality.” Providers want to identify the patient’s problem and fix it. However, said Gonzalo, many problems are far too complex for this paradigm and require a broader, more holistic approach. Systems thinking can help health professionals embrace the complexity of patient care and health care systems as a whole. Moving away toward a systems lens, he said, will require a major paradigm shift from practitioners, educators, and learners.

After thanking the planning committee, the speakers, participants, and staff, Talib adjourned the workshop.