Systems Thinking and Systems Citizenry

Hey everyone thank you so much for joining us for today's health system science open Forum session we have with us as our presenter Dr Arthur olendorf he's the associate Dean for graduate medical education and a professor with health system science or health systems and implementation science and OB GYN at VTC Som he's also the designated institutional official with curling Clinic Dr olindor thank you so much for being here I'm going to go ahead and turn the session over to you awesome well thanks and thanks for inviting me and I'll do the most difficult part of this is trying to share my screen on a different platform that you can actually see things so let's see if this works so tell me if you're in the am I in the right view or the wrong that looks like the editing view right now if you just go into your presentation View I can totally how does that look did that affects it perfect yes sir excellent sorry okay it's all it's all downhill from here so Bill thank you for um give me time to speak with you guys because actually preparing this has actually been really helpful for me in in terms of reflection because I think a lot of this is about reflection um and not because Dr Gonzalo is now here but the topic was put down a systems thinking and system citizenry um which might require some definitions it might require some level setting which I'm really excited to do so um you already know who I am but if you have any questions please reach out to me I love talking about this stuff but one of the fun things about coming to BTC and being in a department about health systems and implementation science um and I have no Financial disclosures but I think Just In fairness I have two leadership positions one is I'm the president of APCO the association professors abandoned college and obstetrics fortunately we actually have mapped every undergraduate medical objective to a health system science objective so app goes organization is really into this and I'm also the OB co-chair of the Virginia natal perinatal collaborative which is how I get my sister items thinking fix out so once again I'm talking about what I believe not what these two organizations believe but I suspect they would totally totally overlap um so if we do nothing else in the course of the next you know 45 minutes or so there are three things I'd love for you to get out of this and one is describe what system seducity is especially with an academic medicine distinguish different terms and one of this is distinguished systems thinking from systems-based practice and depending if you're on the um the gme side that will make more or less sense then my really aspirational goal is that if you haven't done so already is how do you employ assistance approach into something that you do in your teaching or your practice and if you could do that that would be you know that may be super super happy and make this totally worth the time so um so I'm going to start with some definitions and the definitions is a little bit for level setting because I think you know this Pro for the people that I saw here we have a lot of people that do undergrad and medical education or graduate medical education or just education in general um I think depending on where you sit um some of these definitions may have different meanings and you know just for the purposes of this discussion I'm going to set some definitions just so we're all kind of talking about the same thing um I think that's that's pretty helpful and the three things I really want to Define separately initially there'll be some other definitions along the way just knowing that we have sort of a nice um kind of cross-section of people um and they that do different things across the health system and the school um is talk about system space practice systems thinking and system citizen degree or system citizenship I will use them interchangeably um because they actually are pretty important so we'll start with system-based practice and this is if you are a gme person and obviously as um the the designated institutional official for currently in and I did that in my former job and former residency program director I think about this definition that the acgme gives us and they talk about you know residents and fellows they must demonstrate an awareness of and a responses to the larger context and systems of health care including the social determinants of Health the ability to call effective and other resources provide optimal Health Care this is a sort of a working definition that the ACG and he gives us their others this is not the only one but this is the one that I commonly think of and once again because I fully recognize I live in gme circles and that's what's going to happen the other definition I'm going to throw out there just to start a systems thinking um and there are two definitions one is actually um this is Guy Richmond who has sort of given the the moniker of the one that sort of popularized the term and the way he described it is the Art and Science of making reliable inferences about Behavior by developing an increasingly deep understanding of underlying structure and that's really that that almost had five why's type of thing it's like you know why why why and not just looking at things at face value but really trying to find you know the bigger picture to it um the other definition I really kind of like is I found a Wikipedia so you know it's hard to to denote it it's not the most academically way to do it but it actually makes a lot of sense to me it's a way of making sense of the complexity of the World by looking at it in terms of holes in relationships rather than just putting it down into its parts um it's for that big Global way of looking at things and when I think of systems thinking that way it really kind of helps me think like am I getting too narrowly focused about not looking at the bigger picture um and has that bigger picture really do and you know it seems like the five y's would be kind of antithetical that but they actually the deeper you go sometimes the broader you get and that's actually not a bad thing lastly we'll design system citizenship and unfortunately someone named Gonzalo is the one who coined this term I wouldn't say unfortunately but we all know Gonzalo um and this is from pretty well cited piece but they're talking about approaching everyday Care by seeking the work through a systems thinking lens and taking a proactive approach to system errors it also involves recognizing how one's way of approaching gaps in care is an obligatory part of the professional identity they say we refer to as being a system citizen um obviously the things in red the proact and obligatory or thing that I'm highlighting out of this quote as well as the whole idea of systems errors because I really think most errors are system errors and not individual errors and we'll talk to more how I got to that conclusion over the course of the talk um but I think this is sort of a very different approach um to the way we how we've traditionally thought about things um I think an incredibly important one so as I got these definitions together to help kind of guide this talk he kind of gave me a rubric of how to think about it um and the rubric that I kind of came up with is this conceptual model that I did share with Dr Gonzalo and he you know he didn't disagree with it so that I take it as a win um but I you know system space practice really to me is an assessment um you know and I sat on the Milestones committee I mean I'll say for practice based learning Improvement but also the OB Milestones 2.0 for OD um and a lot of this when we're talking about this there really are assessments so I think assistance hpac is an assessment um I think systems thinking is a fundamental skill I think you know in it's it's can be taught it definitely can be um fostered um so that's how I think about it and I really think as system citizenship or system citizenry as an identity um and identities you know come about from lots of different things um and how that develops over time is actually quite fascinating and something we can definitely have great conversation about because there's a lot of opportunity and a lot of grid opportunity that's already happening here both at PTC and currently and around that so so from this conceptual model I actually came up with sort of three questions I think I would like to answer together um and hopefully have some dialogue so if people have questions or or you know rebuttal I'm totally open to that so share that in the chat or any other way you want to do it but as an educator um who's also very much into you know health system science there are really three questions I have I mean I have more but these are three that I that I've been thinking about a lot lately so one is does systems-based practice as an assessment accurately measure the skills or behaviors we seek in our Learners and I might be a little bit more focused on gme when I ask that question because that is one that we're asked to um do consistently every six months actually of all of our learners the other question is how should we teach the skills of system thinking then lastly how can we make system citizenry a core component of professional identity formation and that might be a lot more lofty um than some of the other um questions we might have so let's start with this first one first okay does system size practice as an assessment and taking that as sort of a you know my definition of course does that really measure the skills that we're looking for in our Learners so once again we'll do a little more level setting for those who don't live in the gme world like I do so what does compensate-based medical education or cbme cbme is an outcomes based approach the design implementation assessment evaluation of medical education program using an organized framework of competencies so it's not based on being there for a certain period of time it's really about if we can Define the necessary skills attitudes um and then we can measure them that's how we want to show um you know sort of progression through the system that very much linked with something called a milestone so a milestone in the gme context once again um and I'll quote this is from Laura Edgar who's you know who's run all the Milestone committees um for the last oh nine or ten years with the acgme she will call us a professional development tool with a focus on the competencies required of residents and fellows and ensuring they match societal and patience needs in a variety of critical ways you know and this was actually very sort of shocking for people like we're just not looking at how smart they are we're just not looking about how well they do surgery like there's more that we should look at other than those two type of things and as we talk more about the competencies that have become really ubiquitous um you know when I was a program director when they first came up with competencies in the Milestones this was like whoa this is weird I think we've gotten a little bit better since then that like hey this is really important because if you know I look at education as especially medical education as a social construct a contract um this becomes a really important part of that the thing about a milestone it's a snapshot okay it's a snapshot of the overall skills needed to allow that continuous thing continuous growth and monitoring and quality improvement in gme so once again you can have competency in a milestone and then you can fall backwards it's where you are in that moment um and it's not ever supposed to be comprehensive so the people who don't like the milestones in general are saying well there's so many more things that are important to be a physician agreed we just can you know we choose different things and you know I will use a terrible movie reference have you ever seen the movie Dodgeball if you can dodge a wrench you can dodge a dodgeball um well you know when we talk about this in the OB milestones for example we can say if you can do a really hard cesarean section you can probably do a really hard laparotomy right they're very similar so you don't have to measure each different surgical skill you have to say you know what is really difficult and what can then be sort of used to imply that you have other skills and abilities and the other thing about the Milestones is they are not the assessment tool they're actually the summative evaluation of what has came from other sources and that's been a huge problem in medical education that we actually use the Milestones to assess the Milestones where that's actually not the point um why is that not the point um it's not the point because of the core competencies so these are the six core competencies I hope they're familiar to most of you um medical knowledge patient care interpersonal communication skills professionalism assistance-based practice practice-based learning and Improvement this list is helpful to put up there for number one just once again for level setting um secondly because we all love you know acronyms and initials so you can see what academic initials we've chose for these um an acknowledgment that the systems-based practice and the practice-based learning and Improvement especially in a health system science context has an incredible amount of overlap um and very interesting when they did what we call the harmonized Milestones which are the ones in red was where the ACG me realizes that a lot of these are not very specially specific there are some special specific issues in these but in general we should have some general things that we're looking at in all residents and fellows um and these harmonized Milestones exist for that reason I served on the pbli Milestones committee systems-based practice meant first and they got to Define what they wanted to do first and then we took what was left over and you know the ultimate part of that is practice-based learning and prove it became two what we call streams or sub-competencies evidence-based practice and reflective and reflective practice that's what we took from pbli and everything else that might seem like an overlap kind of fell into SVP so how do gmus programs assess SBP and I would probably say it's all over the board number one they look at many different number of sub-competencies so in average if you look at all the different Specialties um in residency and fellowship the medium number of system space practice sub-competencies are for hand surgery and congenital cardiac surgery only have one and Interventional Radiology has 10. so it's kind of interesting like everyone has a different approach I can tell you for OB OB has taken the harmonized milestones and a lot of those previous ones are pre-harmonized Milestones because the harmonizations happen over the last you know one to three years these are the brand new OB Milestones that this came out in July and we used the harmonized milestones and patient safety quality improvement coordination of care transitions of Care community and population health and Physicians role in the Health Care system this pretty much mimics a health system science overall rubric um but it does differ and it can't differ and we actually did not take the exact wording um that the harmonized Milestone said because we kind of focused it towards Women's Health why is that important now let's look at Internal Medicine residents they'd only have three or four system-based practice milestones but we can you know so just so you know how Milestones work every residency and fellowship program every six months puts the milestones in for each of their residents or fellows um and the idea is that competency although not strictly defined we suspect a resident or fellow completing their program should be at a level four that's sort of how we set the milestones and sort of the aspirational goals in that shared mental model um well this is what we see for two of this this is the international data um for Internal Medicine residents across the board and I gotta tell you when I see data like this I'm a bit suspicious because I am not sure what why either navigation of patient-centered care or Physician's role in Healthcare Systems will actually improve linearly with increasing pgy level this looks a little bit like hey you're the next level you probably are better at it let's assess it my other suspicion about this and this is part of a journey you know Milestones are a journey just like conferences or a journey the other thing is when we actually look back is how do Internal Medicine residencies and there are a lot of internal medicine residencies across the country how do they actually evaluate this this is what they suggest these are the tools they suggest in their companion document or we call the supplemental guide of how to look at systems based practice direct observation chart audit feedback you know an oski portfolio simulation that can be a lot of different things this is not standardized by any stretch right and I think there's a lot of variability both within and across programs and you could say the same thing is true with system space practice three the positions role in Care Systems you know once again is it as a second year resident much less in general because in a third year resident perhaps but I'm a little bit suspicious of how that log looks like and having been in clinical competency committees and looking at resident evaluations sometimes we sort of give them that sort of benefit of like well you got to be there because you're about to finish the program or because you're one year further and I'm not convinced we're measuring it yet in the way we want to and that whole part comes to based medical education we have to have the right assessment tools and I think we're still working on that so I'll say that is you know does assistance based practices and assessment actually measure the skills behaviors we seek in our Learners and I'll say maybe you know I'm not going to say they don't because I think we're doing a much better job in this but once again without a gold standard without having you know sort of validated tools that we all can use I think it's very hard to make that Global assessment although I think each program likes to think we do and I think hopefully at curling of course we do right because I have to say that among other things let's go to the next question so the next question is how should we teach the skills of system thinking and with your permission I'm going to go a little bit of a tangent here and this is a tangent I would suggest to go on because one thing I was asked this talk is like how to become a systems thinker um and that can be some time to reflect so I this is a a very rough timeline of my journey as a systems thinker before the term systems you know health system science was actually coined and used to any degree but my career has sort of Fallen that way because I think it's my general interest so the story might seem familiar to those of you who you know grew up in a certain time where things were not as formal but um I'll talk about a couple things really big so like kind of high level I'm not going to go through each of these things but um there are a couple of really interesting parts of this for me so number one you know you know I came through help to health system science and systems thinking through evidence-based practice and that was for me was when I was a third year resident fourth year resident my program director at that time Sharon Dooley was very much into this like she felt like this was the way to to approach things and she said hey I want each of you to pick a pro a topic of something we do In Obstetrics I want you to challenge it to make sure there's actually evidence behind it so I pick which I did not know at the time was sort of the the rabbit hole of all things um in evidence-based practice um that's electronic fetal heart rate monitoring and for those of you who ever had a child you got hooked up to a monitor during your labor and I can safely tell you by looking at the data that has no outcome positively on your pregnancy we have not shown any evidence that babies are better off from it and we've increased sources they're in section rate four-fold that is what I learned in studying this for a year and it's continued to show that data we still use it and that's where implementation science and how you unimplement things becomes fascinating to me I kept that Evan space practice interest going forward um and I got to spend a week at McMaster University in Hamilton um and they you know they're sort of the North American Home of weapon space practice there's a course about teaching evidence-based practice and it was really interesting about how you know that time we were still sort of convincing people why evidence-based practice and evidence-based medicine was important um it's just really great to be among other people that kind of helped me think like okay I'm not crazy other people believe in this too it's not just me and there are people from all across the country who want to learn about this and learn from people at McMaster and it was incredibly valuable for me um and then I have a you can see at the bottom here in 2004 roughly 2004 I think with an asterisk on it um and that's when I was given the chance of saying hey no you really like evidence-based medicine at University of Cincinnati that's what UC stands for you know we really believe in it too you know you're one of our faculty members do you want to develop a longitudinal evidence-based medicine curriculum from year one to your four in the medical school I'm like yeah it sounds great don't know much how to do curriculum I'm six years out of residency but hey let's try it um and it's during that development of that as we sort of deconstructed biostatistics and deconstructed some other things that we did to make it more clinically relevant there was an aha moment and just hold on to that aha moment for a second because I will share with that aha moment was for you and then through a series of early fortunate events I was able to do things on a more of a Statewide level through the American College of OB GYN I was on the Ohio Governor's task force and infant mortality which made me think about um disparities in a way that you know I'm still figuring out um I got I moved to North Carolina I would start working with Medicaid and start doing big picture things with Medicaid about how we actually improve prenal care across the states um I was then the maternal Project Lead for the for the prenatal quality collaborative North Carolina and I still do that work now in Virginia because I've been you know once you get the reputation of a quality collaborative person you can never really leave it on learning um and then I always try to harmonize my things between things I like so people always you know a lot of my friends like you do a lot of work I go I do but they're all related I love evidence-based practice I love systems thinking I love education so I learned how to combine them so when the Milestones people were looking for a way um or looking for volunteers and like that sounds great I love education I think like a systems person I love quality improvement can I merge them all together and when you find the right group you can so I've been able to do that I've been serving on um I serve on North Carolina maternal mortality Review Committee which is a really big way of looking at systems and I serve on the one in Virginia as well um and these all kind of work together in a way for me that's been able to sort of Bridge interest but also move things forward but also kind of you know fulfill that need for me to figure out systems and how do you think through systems and how do you connect people um and connect groups of people together so here's the asterisk this is 2004. this is so this is the evidence pyramid it hasn't changed sorry I did not attribute it to anybody I've had this slide forever and it probably looks like it looks a little dated doesn't it so I'm gonna get kind of classic but this is you know the evidence period for evidence-based medicine about as you you know what is the better level items going from in vitro test tube research animal research to cohort studies and obviously obviously in the end rcts and then meta-analyzes um and the example I always use for this when I was first learning this and describing this to people when I was teaching is you have to delineate what you do to the level of evidence that you need more specifically the example I use I'm a general Libby GYN I should be doing things that are higher level than that in that pyramid I am taking care of relatively common conditions that have actually incredibly good data around them and I don't have a lot of reason to start deviating from that obviously with patient preference and my birth my definition of evidence-based practice is the best clinical evidence using the experience of the proprietor that meets the needs and cult and desires of the patient so there are a lot of things it's essentially a challenging thing um but I use my friend Dina who is my lab partner Medical School who's human geneticist at National Children's and is dealing with things that I've only been seeing once or twice ever in the in the history of medicine she lives in ideals editors and opinions and case reports and she should right but as I thought about that more and I was doing more systems type practice I realized that you look at the evidence pyramid a different way when you have higher quality evidence you have to apply that to a large number of people it becomes far more valuable and far more impactful when you do that and this also kind of helps me realizing that if you look at the Cochrane database and the Cochrane database their logo is an odds ratio diagram showing over time the value of a certain intervention that wasn't used that was actually giving endocorticosteroids to women in high risk or pre-term delivery right that took forever for us to do because we didn't realize that you know we need to push this out to the system it wasn't just like hey I'd actually know this is good for you we got to like tell people we got to get out in the mountaintops make sure it gets done so when I realized this that's when I really became a systems thinker I realized like hey I can take the best evidence and the better the evidence is the more applicable it is the wider populations we better get that going so that was sort of my aha moment and it all kind of went from there so thanks that interlude and that's opportunity for me to reflect um but when I think about systems thinking I also realize this is not new okay so my wife's a family physician um and family medicine has long and I'm saying mid 20th century probably even longer than that they always said you can't understand the patient without knowing their situation at home right that's that's a systems thinking approach it's not about the patient it's like public health Public Health very much realizes that three to five percent of a patient's outcome is what happens in the doctor's office is everything else that drives it that's systems thinking right just culture you know I used to be a peer review chair um at a hospital and we use just culture and just culture realizes that you have to change your focus from errors and outcomes to system design and management of Behavioral choices people don't come to work try to do a bad job they're sometimes in situations and systems that allow them to do the wrong thing you have to change that so they will do the right thing and make it more easy to do the right thing and that's a lot of the implementation world that I'm beginning to dive into and then the clear program and yes we're having a clear visit with the ACG me a week from today so it's very unfortunate in this discussion but the acgme realizes that you cannot train residents effectively if they're an environment that's siled from other parts of the hospital or is not providing high level care so they recognize that even the education realm you have to say Hey you have the greatest teachers and the greatest physician but they're in a place where you're not communicating and things are crazy and you know there's not good um you know psychological safety nothing's going to get done so that that word for thinking in a larger context once again totally not new um but it always helps me to understand that that you know this is something that you know we're articulating differently um that's really been there for a long period of time foreign teaching you know I like to try to be logical and this is something I found giving another talk recently about the hierarchy of intervention Effectiveness and if you know we have you know people that are part of human factors team they know this for sure you know part of this is logic and makes sense right if you're thinking about systems like Education and Training that's like the lowest level of Effectiveness if you want to be effective you really have to force the system to think differently and move differently so when you start forcing functions and sort of automating automating things and standardizing things that's a way to think more systems related and that's what I do in my prenatal quality work you know once again we know what best practices we know how to take care of a hemorrhage we've got to make sure people do it and prepare for it so how do we standardize it so when you have a hemorrhage if you in Labor delivery once this month or 25 times this month you know how to do it right and once again I'm looking individual it's looking bigger and broader and when you start thinking about that way it's like oh that's going to make a difference um so I think the logic is sometimes helpful when we try to socialize this so when I think about how we're going to teach systems thinking to get back to the conversation and handle the question I posed to everybody you know I think it's really important to the concepts and terminology really in the training products of socialization part of it is that we're all working through a same set of definitions and that really helps to have discussions because people kind of think I have this feeling I can't really articulate it but to give them the terms and you kind of make it something that you can talk about they're much more able to talk about it um and I think it's all about experiential learning I mean I love systems thinking and health system science because it is a applied thing you know you can talk about it theoretically you actually do it and I would argue that we're doing it every day as per as providers we just don't understand it and we don't know how to describe it but I think you know simple things you know Eminem conference if you change your morbidity mortality conference from an individual error focus to more of a systems Focus you will develop systems thinkers they will no longer think oh you know when I you know we had that patient who came in and didn't get their you know didn't get their TPA in time it's because you know I didn't put the order in it's like okay well why did you have system when hey here's someone that's coming in with a stemi it automatically happens once you activate the chain of command so those are the type of thing when you start changing that idea and how you think about it it really does help you think like a systems thinker when you actually do it in your day-to-day process um have people active Learners actively participate in things that already exist you know we have especially at curling we have an incredibly Adept team that looks at safety problems they look at quality and it's so much easier when you can put Learners into well-functioning teams and see what it looks like when it works well rather than trying to have to go through the pain initially themselves now they may see that in practice where we don't have such good setups we have a curling in um but I think when you're trying to teach them you're trying to teach Learners you want to put them in the best possible environment and when you have these really good teams that are out there that are experts in this and have human factors teams and patient safety teams looking at this get Learners involved in that make it part of what they do every day and then once again it becomes much easier than to do it continuously in practice wherever they wind up going and then advocacy plays a big role in this as well because when you start seeing things that are that are important you want them to advocate for it so how they can be part of advocacy I'm not talking about legislative advocacy I'm talking about being a voice of what they believe both at a community level or a state level that really kind of helps reinforce that education especially when it comes around things that really do Drive care you know be around disparities be it around you know you pick your favorite topic that you know being involved and actually being able to be the voice and Learners are great at this I mean when I speak with state legislators they love when I bring residents um they like talk to them more they like talking to me um probably for a variety of reasons but I mean their impact isn't immense but also what they learn from the process is immense so I think it's another easy way to a relatively easy way to get Learners involved and really start talking about systems um and systems of care so so I think we can teach skills of systems thinking and there are many other ways those are the some that you know that I tend to employ and I'll ask my and I'll ask my third question um how can we make system citizenry a core component of professional identity formation um so we have to step back um why would you even think about that why should being a system citizen be a part of you know a professional core identity um and I've learned a couple of things and it's something actually Dr Pat Dean lehrman has sort of reinforced or reminded me um is that when you have things that are really difficult sometimes going back to sort of a basic construct is really helpful um and you know the ethical framework and it's very basic and it's not always perfect but you know medical ethics is based on four principles beneficence to do good non-maleficence to not harm Justice basically what is right and autonomy you know the patient being able to make decisions for themselves and system citizensry really takes the first three it's the right thing to do you don't want to do harm and it's the overall smart thing to do it's actually the most Equitable and fair across um Society so to me you know being a system citizen makes total sense it's part of the advocacy role we have is part of the obligation we have to improve things so I don't think it's a foreign concept so I don't think it's a why we should do it I think it's more of a how we should do it um professional identity is really interesting so um I realized that my teaching style has always been more around professional identity and it's another one of these Reflections that I've had um being able to do lately especially when you switch jobs later in your career um you know I've long I've long quote Bill Parcells the former I will say Giants coach also Cowboys coach but he was a Giants coach first in my mind he says I do not teach I change behaviors and values and I think that's kind of what I do I put constructed things for Learners and you know I I tend to you know I think we talked to Residents I tend to relate better to third and fourth year residents the way I teach I'm really trying to put things in perspective and who you want to be and how you want to do it and really you know you'll figure out the knowledge yourself how do you frame it um in that and that's kind of what I enjoy doing and that's kind of how I've always been as an educator um and that's what professional identity really is to some degree it's not so much the facts it's the you know it's learning how to think it's learning how to be a be a professional or be a physician at this point um I think it's another way of finding it um this is from Cruz it's an individual Journey from who they are to who they wish to become um and that who they wish to become is based on a lot of different things that they see but a lot of it's what they see in front of them and the mentors and the other people that are around them in the in the situation they're in much like a queer visit they're in a positive environment you're more likely to become a positive um role model for others um and it's really interesting as you really study this it's really about socialization and there's actually a way that this occurs in stages and this is something I learned from this talk so I always love giving a talk and this is once again from this is from Keegan who really looked at you know human development and then this has been modified for professional development for Physicians um there's a process for this right it starts off by being very much involved in the self-interest and you've actually get less concerned about how you perceived by others and eventually you really start thinking independently of others um and it's just really interesting how professional development really can be defined in a medical school and in residency you're kind of seeing them go through this whole process right here they're going to go through the different ways and in different stages but they all go through it and I think understanding that you know where are they in that Journey are they in a self-reflection role are they in the more the emotional role are they in the you know in the I can understand complex relationships well and really think like a systems thinker um you know that's going to develop so much different times based on past experience based on a little bit of their self-interest but I think recognizing that is really important um it also makes you realize that there's sort of a you know you can tell I'm a visual learner here's my he's my third different visual um your identity is based on your actions but also the socialization what you see around you right um I think about this with my daughter my daughter's a third year law student about to go under criminal law you know she has learned more working with other people who do criminal law because she sees what that's all about that's her identity she gets to do things in criminal law in law school and that for her is really reinforcing her identity as someone who really wants to represent people who are in the you know in the criminal justice system um without the ability to do it and without the ability to see other people who do it that'd be much more difficult for her to develop that identity and I think the same is true for our medical students they will you know I have I used to use a picture all the time of the mother duck and the baby ducklings behind it and as much as I don't want that to be what medical education is as far as some aspects in many aspects it really is that role modeling and at mentoring and what they see is so incredibly important that's part of socialization how do you socialize it and how do you describe it and sometimes how do you have to articulate it so so how do we move ahead um we have to acknowledge and I think this is a really important thing that there's a gap in understanding of systems thinking between Learners and faculty especially here we do such a great job with our students talking about systems thinking and doing that and we have our Scholars who are learning it but when you look at this at the bigger picture and you talk to providers that they're seeing around the hospital or in the outpatient setting not everybody is quite at the systems thinking level it may never be the system thinking level and that's fine but it's that proactivity you know how do you like when I see something wrong how do I feel obliged to change it that's a really big thing I think some people don't know how to do it or just too burnt out to do it but we I recognize that that's not everybody wants to fix that and I learned that clearly when I work with Medicaid I go out to practices and give them data and here's an opportunity to improve like yeah we do fine like you really you know there just weren't at that point where they can do it and then we have Learners in that system you know once again we have to realize there's a gap right now and as we start getting more people-based systems thinkers and more proactive and more like being system citizens our Learners won't see it a lot easier to be done so for the people here that are part of the hsis cohort thank you because you are starting to take that moniker on um and really helping move things and drive things I think the other thing is you know we have innately curious Learners and you know I talk to my other friends who are Educators either College professors or you know like and I my my friends who are Middle School teachers I just feel sorry for them that's just a hard job um you know we have these incredibly motivated and neighborly curious people I had to say you just leverage that you know we have students and residents and fellows you know you know something else makes sense I'm making Mass the five lies like make them use that Curiosity for good when you get to that like oh wow we're back to that same core problem like yeah well what we do to fix that you know is it might be communication it might be how we set a system up like and leverage that Curiosity you can do that in real time it doesn't take that much work to do when you have a moment and that really gets people like said like okay there's something here we can actually maybe fix it we can bring things down to you know once again maybe a very broad problem but once again we can find the right cohort of people to get it done and I think you guys start the social socialization process early you know BTC is great because we haven't integrated curriculum hsis we have a whole department around hsis um so we're we know we're having that you know it's okay to talk about it it's not like the secret thing that you shouldn't talk about we need to talk about it it's the fourth leg of a stool it is incredibly important but I think that's a really important part of this moving ahead and pushing systems Thinking by saying it's okay to talk about systems thinking it's not something you should hide um or something which actually really talk about and be you know super excited about so with that hopefully there'll be a lot of time for dialogue and questions this is my backyard another reason why I'm happy I moved here so um that's my dog looking at I'm assuming it is as a system thinker there's got to be a deer somewhere what he's looking at because that's what he always gets all into so with that I will pause and see questions comments and I will stop sharing the slides because I have nothing to really add to the slide so I think Murray was just appreciating the sun over the mountains I think that's that was the look he may have done that too but he's looking in the wrong direction he's looking at Deer I know it thoughts questions comments this was a great overview thank you so much I love uh how you emphasize the the real practical elements of um health system science and systems and citizenry it's a hard work it's a hard work thoughts Dr olendorf I have a question for you so uh towards the end of your talk you mentioned um uh being proactive as a systems thinker a system Citizen and being proactive in your approach to system errors um and you also talked about if you're in an environment maybe we're folks they're like yeah we're doing great um and that productivity is not maybe as well received as as you as a system citizen uh or emerging system would like for it to be um what would you say to encourage someone who finds themselves in that place um to continue uh making that effort and pushing that forward yeah I think the simplest thing is you know the easy thing to do is first report it if you see something that doesn't make sense you know once again it's not always your obligation in that moment to fix it right but if you never mention it to somebody else you can't get things you can't get people working together to try to fix it so the simplest thing is just you know admit there's something that needs to be done I see something I don't like it you know we have you know call Seven safe do safe watch I mean that's that's a simple part of it I think a lot of it also is um you know as Learners it's hard right and there's so many other things you want to do um you know and everything obviously I will tell you I think quality improvement in healthcare science and taking care of women is the most important thing in the world but there are other really important things too and students get caught in that it's not what you know it's what's important and what's tubal at the time so I think a lot of it is saying hey you can have this identity and maybe you can't do something right now but don't get discouraged keep thinking about how you can provide a little bit of help because in aggregate everyone helps make the mission better and that's what system things a lot about every we have something to offer it's not it's not the one person who's going to bring us to the end of this it's going to be a lot of people working together and where's your role what role can you play in that at the moment because that moment changes and your ability to do things change especially when you're going through training scrolling through the comments no comments or questions in the chat right now well I'll admit it you caught me mid-typing and I hate to see gaps in the Q a while I type it into the box I'm just going to say it I'll start by reading what I was going to say uh thanks Dr olendorf you've said a great example by sharing some of the key milestones in your own Journey to the identity of system citizenship the sense I was about to type was that I can imagine how interesting it would be to gather together these stories of folks that have come to this identity before it was called anything specifically and understand what lessons we might learn around for professional identity formation that would help inform us on what to feature for our students and our residents based upon our own experience of that journey I think I've seen I've seen some of the work and if Jed's here I'm sure he could tell us where to find it in terms of the uh some of the work on the qualitative work on identifying the aspects of systems and citizenship but there's so much wrapped up in each individual's story about that that I I really thought that when you shared that it was just such a great example for us all to think about and to develop some scholarship out of that as well thank you no thanks for training that Dean Lerman I mean I think medicine is so much about stories I mean it's how we you know we take histories from patients we talk to patients we learn from their stories you know once again that's how we develop our empathy right because we're never going to live our patients experiences we have to listen and and how we share those stories about them obviously in safe places but how we share our stories um is actually a really great way of you know you know the data helps data and stories are even better so you combine the two and it becomes super super powerful so yeah we got to find a way to do it um I I elect Dr Gonzalo to help us figure that out it looks as if uh Brian Unwin has a question or comment Brian I I was just uh pondering you know I've been on medical school admissions committees and I'm always um you know I can't remember a medical school application statement that said that a Health Care System saved my life or helped my mom or helped my grandmother or something like that and um it's always about the individual actions of the doctor the Journey of the of the patient and um I was just wondering regarding the pondering uh more than anything else you know how do we uh get our earliest Learners to recognize that it's not the individual action that um uh in some ways matters the most it's the collective action that matters the most so just a pondering Brian's that's a great question because I mean it's you know I gave a talk about patient shaping quality I was looking through some old talk this is an old one this is a Cincinnati original um you know talking about health self Healthcare quality and I had three images I had like the Physicians like not my personal position but Physicians who in society you know I had some identity and one was Marcus wealthy everyone's like Marcus Welby he knew everything I'm totally dating myself you don't know Marcus Holby as I apologize um one was Hawkeye Pierce from Mash you know once again totally flawed but worked in a great system um and you know and what I've realized since is that systems of care make individual Physicians better um so it works together and it sort of also goes something that you're kind of hitting hinting to Brian at least from what I'm hearing is that it's the opposite of like when we look at system error for individual errors like how do you how do you allocate blame when something happens in a team right you know say you have a bad outcome in a team well you want to look at it and we're so used to looking at where is it in the individual that's the wrong question right we always want to attribute you know how do we attribute success well it's a team successful we have somebody that sucks for everybody I think you're asking like that opposite question right how do we kind of explain people like yes the success and the failure of the individual and the patient yeah the patient can't think of a system right the patient thinks of the people who they see um we have then kind of with our Learners to say okay that's what the patient sees but here's everything behind that right it's like you know going to a Broadway show you know you go to a Broadway show you see the actors on stage you might hear the orchestra there's so much happening in the background to make that play amazing and you don't know it until you see it our residents get to see that our lawyers get to see that the patients don't always get to see that and that's okay um but then we have to use our ability to tell stories um to put that in context and perspective um and it's hard it's one more thing to do but it's I think it's a really important thing to do totally biased of course looks as if uh Natalie carp attached a few two articles in the chat Natalie do you want to say anything about those articles no I just want to share them because they fit with the sort of literature request and um so folks might find them interesting in the one sort of centered on gme and one centered on ume awesome thank you uh so you'll just double click on those if you want to access them and then they'll download um and then you can access them from there thank you for sharing those Baba you have a question you have your hand raised I actually did not have a question I just had another comment uh I wanted to share the same thing that uh Dr olendorf said and that's it's so important that stories um with individuals are defining that yet at the same time systems are you know the ones that have the large impact and if we don't um understand that um it's always going to repeat itself right and I remember when I was looking at residencies um the one I chose was the one that was uh led by a guy who was from the Mayo Clinic he was MD PhD and I said you know hey you know what's going to make this better than going to you know another institution and he said the reason Mayo does so well is because the systems are in place and that they recognized that early on everybody there at Mayo is vested whether it's the environmental services staff or whether it's the nursing staff or whether it's the education or whether it's you know the Physicians or the teams or the pharmacists everybody's he said if you work at Mayo you can't fail people everybody everybody's going to stop you along the way and say this is a knucklehead thing to do and he said if you don't do that then you're going to have to invest in learning systems and Building Systems so I just wanted to share that story but great that's great yeah that makes total sense I mean and you know obviously they're further in that Journey um and sometimes you know it comes at the expense I think it's very rigid but sometimes that rigidity actually leads to some benefit I think it's learning to see both sides of that which is really nice to see um in the chat Sherry Hartman says who's analyzing whether Medical Care delivery is amenable to this broader systems of care approach I feel like I need a little more context or Focus that question if that could be provided Dr Hartman do you want to unmute yourself you have the ability to do so yeah um I get to do I'm in Psychiatry and I uh was able to push forward a model here that's comprehensive integrated care and I feel like we're able in that kind of model to use the the systems of care approach and consider social determinants and we get all as all persons on the team to consider a broader perspective but it was a push to get to get this in place and to convince the powers that be that this was cost effective it was you know best practice um because really in in most of our care we're really locked into not teaming this way you know into being intervention oriented you know you do your thing and um and you're evaluated for that um and I I just uh wonder if um there are is there a field in medicine really devoted to looking at how we reinvent Medical Care System delivery so that it's more aligned you know with the systems of care approach yeah I mean I think thank you for clarifying that because that actually helped me a lot I mean I think there are groups like The ihi Who that's what that's their national identity how do they push those conversations about how do we look at systems and how do we look at you know measurements is a double-edged sport right I think you know measurement's great you have to measure to improve it's very easy to get focused on any one measure to be sort of that you know that answer when there's really no one measure um I think the other thing you have to realize is that you don't have to prove superiority you have to prove that it's at least as good because it's at least as good and there's logic behind it then it's probably better because evidence-based practice is once again it's you know it's the best evidence you have with all these other things the evidence is the same then you use you know the aggregate you know provider wisdom and What patients enjoy then that actually makes a lot of sense um but trying to prove outcomes is really hard right we've been doing this in OB for a while you know I worked in North Carolina and we did we've been training for social determinants in North Carolina since 2012 and we started doing directed Care Management based on what social difference that we saw we actually realized some social determinants are better respond better to Care Management as an intervention like if you were a smoker you know yeah that's a social determinative health but Care Management didn't help that but if you were homeless or you had food insecurity Care Management did really well at improving outcome of being pre-term versus area infection rate um things like that so I think a lot of it's just you know looking at data but looking at it openly um but also realizing it's complicated and it may not be direct you know it may be more indirect um but I think that's the frustrating part and I think you know we're still in that very awkward state where we're going from fee for service to fee for Value um and I think once we took once again to more Global care you know I I tell a lot of people I love the time I was the chief of GYN at the Cincinnati VA for 10 years and the VA understands systems of care because they take care of these Veterans for their life they will make investments that are short-term expensive their long-term benefit and they were the easiest people to deal with that's around women because they were still learning like what are these women that are in the VA they were actually very trusting at the time and they were able to do really good things because they were able to look much broader they weren't looking at a short-term outcome they were looking more long-term and that's sometimes a hard thing a to measure because you have to actually keep track of people but also you know what's the motivation of the organization to look at that you know they no longer might patient or no longer in my health insurance system um so yes our people are looking at it but I think it's also a challenge to look at um and I just know from the obstetric perspective but it's probably happened a lot of other places I just don't know uh Rebecca Pauley typed in the chat it might be fun to compare the medical student applicant personal statements with those as part of fourth year students applying for residency do they mention systems more in which case oh that would be a very interesting question yeah there's a danger in that Rebecca I'm not you know I had a program director who suggested that she would read their personal statements at graduation and that did not go over very well so you'd have to do that in a very safe space because um but I'd be curious I mean I think you know do they see you know do they see else can they articulate it right and I think you know this also might be a good survey tool too like you survey people in their in their thoughts and attitudes when they first come in and then be able to do it later is there you know is there a way of measurable change in systems thinking that when you actually ask them because they may not be able to articulate in quite the same way or they may not need to in a personal statement um you'd hope they would but that may not be what the applicable thing is and personal statements are all over the board too as we all know it's a great idea someone should have via The Bravery to do that one I like it I like it anybody else any other thoughts or questions concerns this has really been a lovely conversation Arthur thank you so much and as you all anybody who knows Arthur knows that he will continue love to continue this conversation Beyond Today Beyond this session um he's easy to reach um just go ahead and email him or give him a call um and he would love to talk this through I have a great question to say that right yes you have my question to say that and thank you for letting me share this um anyway yeah any questions or thoughts or ideas food at any level small or large I I'm up that conversation as are many other people in our institution so which is great absolutely what a great Organization for doing so thank you all so much and I hope you have a wonderful and safe day.