Introduction to Health Systems Science

To everybody who is here thank you so much for coming this is our first peaceful ancestor in several years we've undergone attend but kenzie have a wonderful new Dean we have Dean is very interested in prioritizing Tulsa to the science so for the next at least two years our Dean's forums will be focused on Health System science it's all the different things that we need to learn and understand about the topic now we understand that there's a very large faculty development component to bringing Health System science here to that to school and I hope system and appear not we are working together to develop a plan so that we understand what we're trying to convey to our learner to across our organization so without further ado I will introduce the endearment who will introduce thank you very much sherry it's a pleasure to see many faces that I know and many who I haven't met yet a lot of a chance to say hi as we wrap up later so I'll say it's been just a moment talking about why are we focusing on Health System sign and some of you have heard this from me before others have not but you know in medical schools our mission of course is to train future physicians to be ready to practice effectively and also to have enjoyable careers in medicine and that's generally what we do in medical schools our medical school at Virginia Tech chameleon has an its mission statement to train future thought leaders and that's that's a pretty substantial thing to think about is what's it take to train future a thought leader so we we work on their curiosity and their unison and their interprofessional education a lot of wonderful things that will prepare them for leadership but one thing that we can take a more explicit look at in our curriculum is a collection of competencies that are called health system Sciences contains a lot of stuff but it's a kind of stuff that helps our students develop systems thinking so that when they graduate and when they find themselves in practices in health systems and hospital settings they may have a little more insight because of how we prepare them and how to take on those challenges from a systems perspective instead of just thinking of themselves as an individual it isn't linked to his system so that's why we're trying to talk about how to make us some curriculum innovation some analysis of science and I am absolutely delighted that to launch our faculty development efforts in this regard that we have this special guest dr. Jeff Gonzalo he was our top choice for launching the new Dean seminars under the topics of health Sciences legette thank you for being here today this evening and tomorrow morning for the three feta and the trifecta pardon me and as you know the teach sessions sometimes they were just repeated each time to make sure as many people as possible can attend them in this case just providing specific and tailored talks to meet some of our needs right now in terms of where we are about to implement some some curricular innovation so we appreciate that as well so this is the part where Jim gets all embarrassed because I have to talk about him there aren't any family members here to correct me so so dr. kids all graduated from the University of Scranton in 2002 with a bachelor's degree in biology and philosophy and was recipient of the Frank O'Gara gold medal award for achieving the highest GPA no smart guy until he received his MD degree from the Penn State College of Medicine in 2006 where he was inducted into the AOA Honor Society and chosen by his peers as the classmate you would most want to be see as your physician so that means a lot right it's more than just being a smart guy right a lot of other things we're Internet he couldn't he plays well with others one my decisions number nine he completed his internal medicine residency and chief residency at the Beth Israel Deaconess Medical Center in Boston where he was instructed Harvard Medical School and there he was awarded the Lowell McGee award given to the resident who most demonstrates the fundamental importance of teaching to the spirit and substance of being a physician in 2012 dr. Gonzalo completed a fellowship at the University of Pittsburgh and general internal medicine a medical education training a Masters of Science in medical education and clinical research he then returned to Penn State College of Medicine we have risen through the academic ranks to become associate professor of medicine and public health sciences and associate dean for health systems education his word focuses on the intersection of education and health systems he and his team led the implementation of pilot programs health system science education at over a dozen medical schools as part of the AMAs accelerated change initiative and this work has garnered recognition from multiple news outlets including Walton Washington Post Wall Street Journal and many other dr. Gonzalo's many scholarly achievements include first doctor ship of highly cited publications most notably a series of articles in academic medicine introducing health system science and addressing both the theoretical and practical implications for medical education his 2017 publication educating for the 21st century health care system and interdependent framework of basic clinical and system sciences has been cited in nearly 70 subsequent peer-reviewed publications for most of us as we get to 10 we think that we're starting to make sort of a difference in the international conversation 70 is a pretty pretty big number after only about a couple of years his work has been funded by AMA mm C hersa thoughtful translational science initiative managers I have a CA foundation and if you're not already exhausted imagining how listening he must be dead also mentors more than 25 students Restless and faculty per year so he's very busy and we're very appreciative that he can be here he's going to be giving these three sessions and the first one is going to introduce us to Health System science in the context of the evolving identity of academic health centers to paraphrase from a recent publication by Jen and a colleague from Dartmouth we're going to learn how delicious is serving properly beside we look forward to a delicious meal dart pen so please join me in welcoming can you hear me okay in the back well that was a lengthy introduction so I'm happy to transition right into the talk pleasure to be here privilege thank you thank you for coming and thank you for the hospitality that the ladies and the team have been such great people and setting all this up so I really appreciate it so I'm gonna start with my team at home this is my wife Tiffany she's a family practice nurse practitioner she sees 18 to 22 patients per day we have three kids Sam is five-and-a-half Elinor's three and a half and caroline is one and a half so I just want to give a shout out to my wife even though she's not here she allowed me to come today she battled to get the kids out to daycare which I'm just appreciative but I can be hear from her and this is some of the team at Penn State I won't go through everybody here but literally every slide that I have in the sessions today on this evening and tomorrow comes from scholarship there's a book chapter a book an article that comes from it and certainly I did not do this alone this is coming from a team of people that are really passionate about this and scholarship and advancing the field learners Bobbie Johannes Keith at University Park doing social demographics we've got a bunch of mecha-suit right now interns a third year medical student a cardiologist now an intern and Hopkins a research associate these are these are bright people who have helped advance the agenda which applies to your medical students here there's a lot of smart people these medical students would highly coveted individuals in the workforce and we bring them in and sometimes I think we dampen them out to the side they're smart they can do it this is case in point the team for all the work that you've done so here's some objectives over the next couple minutes I'll define what what is this help system science and you can case you're wondering articulate some significant events highlight some of the curricular components at Penn State and I haven't spent a lot of time on that and then discuss an evolving identity of academic health centers so this is the three pillar model of medical education that the top is health system science and we live in this basic in clinical science model now for over a century the definition of health system science I have here the principles methods and practice of improving quality outcomes and costs of the care delivery for patients and populations within systems of medical care this paradigm is a new paradigm of the third pillar and that's really what I'm going to dive into the next segment or particularly the next slide and I did this slide David's here David and I were in a professional development program in December's I built this slide because it came out of discussions I was having with folks and I just felt the need to come up with a historical past because I think a lot of people might think you just this is a fad this is a new thing and it's really not it's been built upon a centuries worth of evidence and data I'm going to do a brief set up HSS milestones if you will is representative it's not comprehensive I'm also one is a flexor report started over a century ago Abraham Flexner found at the 2+2 model of basically clinical Sciences should be built on scientific inquiry classroom going the apprenticeship model and from that time came forth the two pillar model of basic and clinical sciences and certainly it goes all the way through 2020 because that's our model now and it should never go away being a patient center physician who can listen to the heart and lungs that come up with the diagnostic plan is critical while so - earnest Tamara common it's an individual and anesthesiologists at the Harvard Medical School was identifying that we were looking at outcomes for patients when they left the operating room but we were primarily also looking at only what was happening in in the the surgical suite itself and he saw the long game he's saying look to having poor outcomes but we're really not looking down the road so up spraying the end results card system he started documenting on cards the events that patients were having after the fact and people began to look at quality metrics down the road so from that came the morbidity and mortality conkers but progenitor comes from this work and Jayco our Joint Commission looking for standardization of quality metrics across different systems so what every common and the group of their team really focused on structures drive outcomes that we get and if we don't look at the structures we're not really going to be reaching the outcomes that we want milestone 3 IPE in Europe interprofessional education has has been around now for decades it's a started in Europe your medical school has had a very significant focus on this you should be proud of it because I think it's a focus that is does not in many medical schools but the IPE movement started in the 60s made its way to the United States and 90s I think really took root with George t-bo's work and the macey foundation and we're beginning to increasingly see that team-based care is associated with good health outcomes so that's why the IP is part of the LCME our accreditation process and part of the impart the actv accreditation processes as well but interprofessional collaboration who made its way onto the landscape here over the past 50 years and increasingly each journal you open now these days there's more and more data suggests that diverse teams are associated with better health outcomes and as educators we have to see how to be treated in to that agenda milestone for Department of humanities this is a local one for us at Penn State we were a new medical school broke ground in 64 first medical students came in in 67 we had the first Department of humanities in the u.s. Medical School certainly medical schools after that have taken suit they either have a department a group of people who are focused on humanities but Health Humanities has become a critical part in fact it's part of the LCME a lot of the stuff that you see in the LCME from the accreditation processes lives within the health humanities agenda but that formed this third pillar you're gonna see them going back between three and four pillars because this is where we currently are I met at but when I went to med school at Penn State I lived the three pillar model basic clinical sciences and health humanities you see this fourth pillar is coming in to integrate all the above milestone five is angled biopsychosocial model of a psychiatrist in the 70s who began to identify that we cannot just look at the biomedical diagnosis of an individual patient there's social context matters their behaviors their motivations their family their their degree of social isolation the community in which they live these are factors that matter as much as the biomedical components and data has increasingly identified this as well but the biopsychosocial model is a in my mind a progenitor framework for health system science for us to look just beyond the diagnostics and therapeutics and integrate it with this larger context of patient care so it really laid the groundwork of patient centered framing for care delivery milestone 6 Libby Zion anybody want to comment on the Libby Zion case a Braves whole I was across town when she died sign a very tired resident provided here didn't follow love adequacy and she was given cross medication and cause nineteen year old lady comes in gets is has an injectable Nadia Roger you get she's on penalty in the home gets Demerol all across reaction he goes into a serotonin like syndrome and and dies within 12 hours of a mission her father's a reporter for one of the New York newspapers gets onto the national stage of course court cases go on for nine years luckily all the I say it's my perspective luckily the all the clinicians involved in the case were removed from any any punitive blame because what it identified was a structure in the system of our health care system led to those new goals those at a time on Edie Edie said not need to be staffed by attending physicians this was an AV resident didn't need formal transfer processes if you had a medication reconciliation a contraindication you go down seven flights pull up a manual book open the book and see if there's a contraindication with those medications it really was a paradigm shift not only for health care delivery but medical education it was a pivotal moment for us to think differently and I have it here as patient safety in examining structures their safety issues that happen all the time and rarely do we look at the structures or the system that leads to those outcomes in the Livi's iron case was an instrumental case and there's certainly many other cases just having any one that was highlighted pretty significantly the harvard medical practice study this is in the nineteen mid 1990s workout a harvard that was looking at hospital admissions across three states and looked at all those emissions for adverse events and four percent of hospital admissions had an adverse event fifteen twenty percent of those result in death and the data that has existed since since this is how many years now twenty five years there's additional more studies adverse events and medical errors are one of our top leading causes of death and in US healthcare systems and it's partly because of the structures of the system that we have designed that lead to those results so that data transparency i think started in the harvard medical practice study and really shown some light or shine some light on unsafe care and quality outcomes milestone eight assistance based practice competency in nineteen ninety nine most people struggle operationalizing the assistance based practice competency you asked most people they say this is the one core competency in the residency that we cannot tap but what it did it did open up a space for systems based learning in a wake of all these decades worth of work and it's really a remarkable thing so health system science really is extending the great work of systems based practice into the next 2.0 version the IOM reports the Institute of Medicine reports there's dozens that have come out a year instrumental reports particularly at the turn of the century in the wake of all this clinical data in the 90s suggesting that we have all these adverse events and medical errors and up crossing the quality chasm to urge human really set the framework that we doing things right can you US healthcare how do we shift that and education is right in that same equation are we educating appropriately to get the outcomes that we want in that system so the iron eyeline report particularly on patient safety spawned a whole bunch of patient safety curricula so if you did a search on patient safety curricula it starts here they primarily start here one of the first GE patient safety qi fruits would occur in Oh - no not by a big surprise because in the wake of this data data and transparency was driving a lot of what was happening in medical education miles on 10 - mm see there's not a lot of requirements and medical schools the short of the LCME accreditation standard but in 2007 the double AMC put forth a strong recommendations for medical schools to begin to focus on social determinants of health I left medical school in oh six there was two hours on social determinants of health if if that - but when I came back in 2012 to Penn State that six-year gap there was a significant curriculum and social determinants of health every medical school has some kind of social determinants of health as the progenitor systems coursework to me it really stems from this milestone in the recommendation from the devil IMC milestone 11 the college of population health the first college of population health Thomas Jefferson University Sidney Kimmel Medical College David Nash is a national leader on pop health they have three to four hundred students a year they started the work in O seven they launched a no nine and the whole purpose is for these individuals that take on health systems roles focused on population health improvement and management when Thomas Jefferson has a significant curriculum impart and Health System science with a pop health Flair or a pop health flavor but what it did if you also fall pop Health frameworks in medical education they follow subsequently from this movement in the late 2000 2009 a milestone 12 is waist in value this is don't work by Don Berwick identifying how much waste we have in our healthcare system I mean it's it's tremendous on 18% of our GDP push in nineteen ninety percent in twenty by twenty twenty two it's a significant degree and we're increasingly itemizing where that waste and cost is coming from of which clinicians and frontline clinicians are responsible for this is in our purview a lot of it is not a good chunk is but this data transmitted to the event I think has driven a lot of the value curricula if you look at the value work in medical education that's really the past five years has been a more recent push so we coined HSS and 2015 you can see we're kind of like a fishnet we're pulling all these things that have existed for decades we're pulling it into this new pillar from their share fourth pillar we wrote the first text books in 20 and 17 now we're we're on one book for right now around health system science and then milestone 15 HSS and SVP the next thing that the next movement is assistance based practice and blending HSS assistance based practice together to make a more smoother transition from unit unit whirlwind tour I appreciate you sticking with me but why am I even focusing on this part of it's frustration when people say to me this is not about patience I came to you know I've been a physician for for 30 years I mean this is I'm here about patience yes health system science and systems based practice to me is as patient centered as you can possibly be it's as patient-centered as you can possibly be and I challenge you to think about that right your narrative because you don't believe in that you're hearing at least one perspective that I believe on the 180 and a lot of systems leaders would suggest and medical educators and a lot of people they believe in that too and certain people don't there's a little bit of attention but but the history is built on evidence and it's focused on patients anything I can clarify any reflections on that you can disagree too more brave souls okay you have another challenge come up in a minute - so here's the framework there's 12 domains the main one is in the center patient and community in six core you can see them we just went through the history but valued cause patient safety population health and social determinants of health informatics and technology which really has been I would say the orphaned curricular area the past decade there's small pockets and people do the work but it's really I'm not taking off significantly and improvements been around and then there's these cross cycling ones of leadership team in change management ethics and the cohesive glue to it all assistants thinking the philosophy the mindset the set of tools that allows one to see the interrelatedness of twice there's really the glue and the foundation of HSS is the core framework twelve domains and HS s HS s is not Qi HSS is not valued HSS is a comprehensive third or fourth pillar depending upon your model of medical education so I do have the grids in front of you I try to make sure that everybody had a drip this is a paper that's coming out and I just I hope you take this plate take it back to your desk maybe take it back to your results meetings immerse yourself in a little bit the interest that's domains that are across the top everything in that green bar those 12 domains and the light blue so what we're doing here is a crosswalk you're not going to go in detail mess but it's gonna make them highlight on the column the first column of every accepted accreditation system set of EPA's for medical schools competencies citizens based practice milestones other David Nash's textbook and we're trying to crosswalk to show you the comprehensiveness of HSS again which is across the top two dots is significant one dot it's just a little bit dimension so you're like looking for two dots so help me out with what some observations you're seeing in this grid general observations thank you some problems have the water or something so which calls do you think are a pretty prominent day only as very tiny social Commons yes so there's loading on some of the columns and you just came into my punch on my next slide here I highlighted some of these where they really load are in the transitions of care so a lot of medical schools focus at least on a transition of care somewhere on the line SDH we know why it's in place was a recommendation no 7 patient safety and Qi partly because it was some main focus in GME that spread us we're in the ume I'm an interprofessional education partly because for over a decade that's been on the accreditation Center for the LCME any other observations reflections amount of white space thank you so where is Xena like what what where where might you identify something this is sue the Swiss cheese grid by the way informatics informatics is a huge gap measure scholarship measurement on the evaluation component leadership on the leadership area so these are certain C's domains of the opposite there's gaps and then totally across the board and the last observation I would make when you look left to right any one of the except it's that just look at FCT the SVP milestones look at the Swiss cheese you than the SPP milestones there's white space to dodge white space to dots HSS is pulling it together in a comprehensive way and so why does that matter but I have just some oh this is your four pillar model by the way this is you again you should be proud of this this this four pillar of interprofessionalism exists so if I actually reflect on this so looking at the grid in front of you with this four pillar model what are your blood of your thoughts I'm seeing these hand gestures it helped me interpret what does that mean that the visions of professionalism learning covers a very small part of things yeah yeah you should be proud that this is a pillar I just want to highlight that like you are you're ahead of the game for those medical schools looking for 2025 it's this it's in this grid like how do you comprehensively do it so why does it matter like why I mean I'm I'm not pushing an agenda by the way I'm trying to improve patient outcomes so but why so this is this like the comprehensive framework ensures that core competencies are not marginalized I hear this almost every week Hsss oh we've been doing Qi for a long time let's let's apply it to the grid you're going to see a lot of white space there's a lot of Swiss cheese in that Q line it accounts for related competencies in curricular design so if you have an IP session somewhere in that first year and then you have some other pop health session in year 2 and patient safety how they integrated how do you account therefore the relationship between them and how do you help evaluate their learning across the spectrum if you have popcorn like things that are existing in the grid and then it provides that clear learning pathway I think GME is gonna shift a little bit probably five right years down the road but you mean we're gonna where you need to be more seamless so by being more comprehensive it's gonna shift even more into clear even the clear reporting residency's to identifying four or five different domains it's not just from a value for example it does facilitate a shift towards a national standard and relax one we talked about this morning and our small team meetings as there's a new healthcare professionals of professionals in our system citizens system citizenship HSS and SBP is not just a set of knowledge areas or a skill this is a little risky to say but it's a new professionalism and health care system citizens this idea that we're individuals part of a larger system in a healthcare landscape that we are mutually responsible for caring for improvements in care population health why social determinants of health matters it's a paradigm Hsss is a harbinger for that okay thoughts reflections on that so this is just my brief snapshot of Penn State again I'm not gonna spend a lot of time on this but I think your main takeaway I hope you get is that this is not a curricular elective this is a significant footprint in the medical school u.s. medical schools have not figured out the right balance so our first year we focus on social determinants of health pop health health care delivery interprofessional collaboration and we place them in student patient navigator rules and talk about that tonight at 5:30 it's a longitudinal role where they are embedded and interprofessional care teams they're linked with patients who have gaps in care they are not linked with patients who want to speak with students or our marker is who has high no-show rates who who has patient safety events who do we think is unsafe at discharge but puts the student patient navigators in that case go figure it out identify those social determinants of health barriers communicate to the interprofessional care team and close the gaps so totally different model that's year one year two we really focus on evidence-based medicine patient safety Qi this is where they get white belts and lean and operational excellence they show up they attend they take they take their tests they get a white belt certification if we wanted to do white belt certification on effects would be a thousand bucks they come into the course they get their white belt they go into their clerkships this is where it gets Spy because you need buy-in and leadership to totally believe in the framework and there's heterogeneity so we have certain workshops where they exist and then we try to do some core things it's really hard come back to the fourth year we have a great fourth year course two weeks all about the application of HS s principles they do team-based projects with a clinical coach from the clinical environment if it's the third sentence on their Dean's letter 80% of students come back and say this is what they talked about the residency interview on that project I have the contact hours a couple of our papers have it in there this is significant this is not six hours I mean this is a four pillar model of Penn State basic science clinical science humanities and systems and it's it's an equal partner by weight of the curriculum publishing Jeanne is also tricky is probably much more tricky than you and me we do a couple things cork across all programs we have a resident immersion week we we ask programs to send one to three residents to this one-week course it overlaps with our fourth year course so we've 142 students sitting in a room with 30 residents and the students are head and shoulders above the residents it's actually a reverse trouble like how do we put them together the resins like I've no money of this what's going on and it's that there's a cognitive dissonance that goes on it's a remarkable thing that we didn't quite anticipate and then we're focusing our new work in the GME space workforce the work for peat workforce pieces is not just a unique added curricular piece it's gotta address GME and the workforce and the clinicians in there and in 2016 we started our HSS Academy this is a year-long professional development program it's interprofessional nurses chaplains therapists one of your graduating medical students Chris McLaughlin who's a resident now he's in the program he's amazing so kudos to you for doing a great job and it's a great Academy they learned the HS s principles we use the textbook same textbook that led us into the National Academy so we're in our second year of a National Academy through the AMA that's where I met David we have 84 applicants this past December that's 60% of us medical schools who are sending people who have roles like assistant dean of health system science associate dean help system science director to come learn how to look at the comprehensive whole so it's it's it's more than a movement I mean this has already happening the bus has left the station on this piece now we do a number of seminars things and then workforce initiatives my main takeaway here is it's not a curricular elective and it's not small ethics probably have too extreme you know this many medical schools that be at the other extreme and there's potentially is a sweet spot any thoughts on this we've learned from as evidence-based medicine at that moment it came into play audio couplet the notion quality human play there's been a lot of culture change that's needed as I seen value work being done here a lot of physicians that have integrity bought into this model are are getting burned out by at least my throne admission we know that's going to happen in any sort of massive change like this and you're describing and emphasizing this is a massive change have you thought of any new ways to acculturate people that weren't trained in this system we don't think it's their job as a physician to every way is difficult yeah I don't think there's a technical fix for that the real challenge you hit nail on that it's a complex adaptive challenge that requires numerous strategies and patience and a lot of work that's why we did the professional development programs to begin that identify the early innovators have their skills develop change evaluation forms if it's primarily coming from the system too though I mean I shared this morning that it's not just an education agenda it's a system to generate value based care access these are not it's not that's on education speak that's patience be from the system's perspective this is education systems aligned so I think that education quite frankly is on the beginning of a journey of further integration with the health system and I think that's where we're gonna get some of the answers that they have the question you're asking I'm gonna get into that a minute to actually okay so I'm just gonna briefly hit on three big ideas I had like 49 but I just tried to hide that actually I probably have 149 but I just want to highlight three that I thought were most applicable to you or in general for the current stage that you're at so the first is this idea of an expanding educator bench the second already hit on so I'll just briefly review that again and the third is informing the evolving identity of academic health centers which I do think applies directly to your school of medicine so this is a paper that you know I thought when I walked into the job years ago I thought of the 80/20 mean eighty percent me sitting at my desk doing the work twenty percent going out there collaborating with people in building things and of course I was totally wrong with the split was an 880 my wife can vouch for that it's 80 percent sitting at my desk doing that stuff but it's 80 percent building bridges with other individuals so how do you build the system's tricked them at that breath I mean you saw the contact owners there's not one individual in our health system in the system leadership position who has not sound a meeting with me for me reached out and say this is what we do can we talk about potential collaborations that we can do and I was going to every nook and cranny of the health system I still do it if you're in a medical school they're teaching at the GI course think about where your GI clinicians physicians right now in educators there is some kind of GI suite gastroenterology suite somewhere and even do GI bleed we're gonna do a video you're gonna do GI physiology and at all once we not so much for health societies there isn't one natural home these are the chief quality officer the chief medical officer doesn't need a physician in the cardiology group who just has a passion for evidence-based medicine and high-value care and cost and saying there's there's too many stress sets that we're doing that that is not evidence-based so he helps with the value pieces you got to go out and find them that's why the concept of the expanding educator bench it's a paper that we wrote last year in academic medicine is that medical education for the past century has really focused on internal intra professional education here they're touched by a PhD I bless you or an MD around traditional doctoring skills but what helps us of science is doing is expanding the educator bench of a US medical school to where we're diversifying who are our faculty that they have faculty appointments 96% of our learners in the student patient navigator program are mentored by non physicians care coordinators nurses physician's assistants none of them have faculty status our advantage of educators in u.s. medical schools is rapidly evolving and it's a really unique concept when you think about it deeply and this is a grid from Ron Hardin that we use in that paper just to hide the fact that you might think the educator is the person who develops the curriculum or the lecture in front of the room doing the session for the faculty attending on on rounds but these are all the educator roles this is written in 2000 by the way there's another great paper that came out two years ago about the expanding educator roles for 2025 by Karen Merck dan T and she highlights how those roles are evolving but I just want to make the point that it's everybody this is the entire educator community I don't know literally anybody in this room I don't know your titles but in some way health system science impacts you you might be mentoring as a student or a training you might be a researcher who might be providing research mentorship you might be a ward attending right now in the medicine service mentoring it impacts everybody so for long term success it's got to be addressed with the strategy that it addresses all the educators that live along this spectrum and there's going to be great diversity and how much people engage in this so I just have some examples this is from a different paper that we did that in many ways it may not be new rolls they may be evolving rolls so if you're a hospitals physician facilitating a small group maybe you're facilitating Health System science group the Director of Nursing ambulatory care leads social determinants of health workshops these are people the people I've been interacting what they have never taught a medical school before and they're totally excited to be with us and they'll say that I don't know what a learning objective is you're gonna have to teach me how to do that and that's that's good chunk of my job so there's new roles and evolving roles and how do we address that is something that Penn State and Virginia Tech needs to do so the couple implications and new educators are already here people call me on the phone and say we don't have any people who can teach this I totally get that ank's and I have zero doubt there in your community you gotta go we gotta go find them you don't have a suite of G item you might not have that GI suite but they are there and you might need to coach them and bridge them educationally we can help develop the skills of these educators you through professional development and other means and we can help incentivize them whether it be through faculty status recognition acknowledgement of their teaching just a unique concept of the educators in u.s. medical school their shift it's no longer the lecture from the basic science lab if that matters that's critically important too but it's just evolving and transforming this is that seconding idea a system citizenship there is a question for you let me tell you where I came from I was talking to an admissions dean one time from a university in the south and he asked me on the phone he asked me this question kind of took me aback on what he was asking me his medical education is designed to be transformative for example a physician as a refined alloy produced from the ore of a medical student or out of it she is the same person but with highly enhance skills in science technology and humanities somebody said that's a great question it was because I didn't have an answer at the time what do we think yes Oh judicious middle ground anybody else thoughts what do you think the faculty are here how do you think they would answer this question I think we'd like to think it's the latter but we act you act as if it's the former you want the latter yeah I think we do try to change people and don't at interesting any other thoughts on the other side each one of them very unique and I'd like to try to as their own personal skills but I can see how the second ladder they are the same person and but they bring their personal skills and those personal skills are enhanced yes that's good I've tried to find the middle ground transformation might be person that's great before into this idea professional identity information and now we want to say are we in the business because I wouldn't turn this a business but as medical education I would I'll be provocative are we a training ground for the wards we had training ground to give them the knowledge in there this backpack and technical skills to go out and do a job and I think that's something that everyone here needs to write their narrative on maybe some of you already have I'm not in that box I think that that's important I think knowledge is critical and technical skills are important but when I leave my kids in the morning I don't walk in thinking I'm gonna help this training do better on the boards I want them to take care of patients better hold better outcomes in 2025 and 2026 when your incoming medical students are practicing I can do that I think does require them to evolve their professional identity to be quite a bit different than just the technical skills order if you they have to view their role in a certain way to help I mean if you're a hot day many hospitals here right now this helps us to approve a matter to you when your shouldn't matter and doesn't matter to Unionville I mean I wanted service on Monday what what he wanted to tell the group on hospitals across the country blurted and their identity that it's their identity as part of their internal vijnana they should care about a crewman in that if you did a cross-sectional assessment of all hospitals in the country do you think all hospitals would agree no way they would say this is a positive experience Medical School is going that rule and we only shift the circle Europe you're an early adopter that's a rarity so I think this is a narrative that we need to write about what's our what's our mission of a medical school we additive knowledge and skill people we try to transform a new professional identity it's a loaded question by the way I'm clear that there isn't a right answer but I'm not sure it's binary either way falou psychically discipline this is about angle give us a lot chefs know we haven't imagined soon systems facilitation you know we always try to rehab in fact this hybrid more different and receive it as important so this is not really it was something you know you yeah so if you look at the grid so I would agree with that right there's early pockets hot pockets that exist everywhere does pop health matter to you what about all those other domains and I think that's that's one of the questions that after asked me to reflect on a little bit because I'm just not sure that that we most current day clinicians have not been trained in a paradigm like this comprehensively so I think there are pockets this is the last time my last point about system citizenship this is a grant that worked we just got funding from the AMA to tackle on I just want to highlight where it's going in the next the next couple of years for the 2 million dollar grant we teamed up with Kaiser Permanente Geisinger an Allegheny Health to tackle assistance based practice we didn't kind of worked in you mean you found the unique space we're trying to enhance that spectrum into the GME space this is the title of the grant systems based practice for the 21st century healthcare system developing residents assistance it is so assistance based practice I kind of have been alluding to this but it's the one core competency area that to me is a most on the end of a spectrum that is not about knowledge transfer that's about socially constructed learning in the clinical learning environment itself the deal with ambiguity and uncertainty in that clinical space and to grapple with complex adaptive challenges it requires you to have good clinical learning environments like a hospital it's like that guy right there to mentor the learner through ok we have this challenge right now how are we going to go through this piece it's not something that you can sit down and get a lecture on many times so you got to transform that clinical learning environment the clinical space for the 21st century healthcare system why we teamed up and curling's probably in that box I've heard of the term - as a juggernaut of clinical operations and it's really forward-thinking in certain Hot Pockets I don't know that I'm just telling you what I'm seeing on your website from the discussions there's there's hot pockets in really good clinical systems or assistance based practices being learned and practicing how do you find them and how do you build off that to transfer to the next unit with a next clinical piece so that the system's based practice can be in hand we have early innovators you got to go find them to make it transfer to the next client in that system citizen people system citizen piece is the evolving profession what we're working on we're working on the concept piece of this new professionalism most difficult product I've ever been involved so more data to come this is my last comment and I'm really zooming out 40,000 foot you can film the details on how this applies to you I've been able to piecemeal together a little bit of the Research Institute School of Medicine I find I'm understanding a little bit more of the history so this is the figure of the academic infrastructure how the teaching hospital and the faculty practice plan in the School of Medicine are related to each other there's five general models that exists in u.s. academic health centers and they kind of run that spectrum and it's almost never static if you did it one year in assessment all 120/240 of medical schools they might need a different category the next year and it's moving pretty fast particularly in the last five or seven years so at the far end you have a fully integrated model in 1919 90s 40% of med schools were probably in that fully integrated model all one and that number is now decreased in 15 or 20% and shifted that 20% of different area I think you are here is that right so there's probably variation across one four and five are probably the most predominant models in US healthcare systems so this comes from one of the deans at University of Arkansas he says tripartite missions three different lines of endeavor that act synergistically to advance a unified purpose that of a healthier future for all just talking about the three missions three traditional missions of an academic health center of Education Research and clinical operations they should work lockstep with each other to get better out of health outcomes so it's kind of like a provocative question for you how are we doing with three missions being kill the Internet so we did a research study this is a year and a half ago we wanted to explore the current academic health center landscape with the goal of identifying barriers and opportunities for a productive tripartite mission alignment how how can academic health centers come better together can better align their missions so we're not living in three tripartite pieces especially as systems evolve rapidly everyone here knows healthcare is evolving so fast where does that leave Medical Education is in the equation because I could think there is a risk education usually follows the clinical operations and the research mission kind of sit there in the back but how do we make sure that there's a line in our DNA and the construction of our everyday work or education research and clinical operations are aligned so we did electronic surveys use exploratory qualitative methods we did five institutions and we loaded on the most common models so there's a couple independent models here eighty still in the University of Colorado which has a great interprofessional curriculum three and four is Nebraska and the City Kimmel Medical College in Penn State is five so we did one the purpose of sample but diverse across places we did stakeholder perspectives we didn't ask just systems leaders we asked everybody except patients so we're looking for how systems can come together so there's two key findings that I'll highlight here and the first is co-production and co-creation is required with this idea that the system as it evolves needs to be at the same co-construction table with education research working together understanding our mutual shared model if there is one and working collaboratively now how often does that happen if you're building a new clinic or a new hospital there's a new hospital building going on right here at the cardiovascular right right here in the parking lot yeah so how much co-construction of co-creation is going on in it right now between the medical school and that bill the co-creation model would say that we need to be working collaboratively we understand you've got 41 medical students you've got nursing students ba students where is the academic identity fit in there and how do we add value to the clinical system it works both ways the same with research co-creation is required a lot of people write about it I think a lot of people say that we have not reached our full potential there and then there are unifying concepts to use as a roadmap this is the last key finding that we found and here's what they were these are the areas that we can collaborate I mean they should look familiar right yeah it's this grid HSS is not an educational framework it's a unifying framework for healthcare it's just that we are coming through from an education lens so it adds value to the education mission but we have to think she's teaching me on how it can add value to an evolving identity of academic health centers the research agenda and clinical operations and this is the figure that just pulls it together there's these triple helix if you will of the traditional academic health center and the embodiment in you know fifty years ago I had another sighting here I actually have it here the embodiment 15 years ago was this a individual person who kind of spread clinical GME research they did a little bit of all three the triple-threat lived in one individual person and there's an ammonia studies the past 20 years that says that's really that has a waning decades ago there's very few people who can truly live that that Triple Threat so how do we construct the Triple Threat tripartite mission alignment not through individuals not all your name is but not through you doing all three but us collaborating where our work is co-constructed across these three missions and that's what this triple helix is trying to reflect how does your Research Institute Karelian Clinic the school of medicine how do you co-create together across these bridge builders if you blow up the system's principal we're gonna have to figure this out with the financial pressures and a lot of changes that are happening and I can so I hope I accomplish these objectives and the goals please take the grid take a back reflect in questions or comments you can feel free to disagree I got on my plane tomorrow.