Health systems science education: The new post-Flexner professionalism for the 21st century

Figures & data

Figure 1. Transition of health care in the United States. The figure depicts four components of health care in the United States, with the corresponding transition from past or current state toward a future state. These components highlight the burning platform for change in the learning areas in medical education. Copyright American Medical Association. Used with permission.

Figure 2. Health systems science curriculum framework. The figure depicts the 12 domains within the health systems science framework developed by the American Medical Association Accelerating Change in Education initiative. At the center are the patient, family, and community, since optimizing individual and population outcomes is the driving motivation. The seven domains around the center are core foundational learning areas. The four domains in the middle circular rim (e.g., leadership and teaming) are the cross-cutting domains, which intersect with all other learning areas. The systems thinking domain surrounds and encompasses the whole framework, demonstrating the importance of a systems-based framework which integrates all parts of the model. The individual domains and their integration are critical to the new curriculum and new professionalism model which emphasizes a comprehensive, systems, and team-based approach. Copyright American Medical Association. Used with permission.

Table 1. American Medical Association’s Accelerating Change in Education Consortium collective scholarly outputs in health systems science (HSS) (2014–2020).

HSS Textbook (1st and 2nd editions) – The first textbook of its kind provides foundational learning in all of the core HSS domain areas (Figure 1). The 2nd edition further explores the concept and skills in systems thinking and the application of HSS to situations such as the COVID-19 pandemic (Skochelak et al. 2017, 2020).

HSS Review Textbook – The HSS Review book provides several hundred, board-format multiple-choice examination questions. Using clinical and system-based vignettes, questions explore the core tenets of systems principles in all HSS domains, including social determinants of health, systems thinking, population health, health system improvement, and high-value care (Ehrenfeld and Gonzalo 2019).

NBME HSS Subject Examination – The National Board of Medical Examiners and the AMA Accelerating Change in Medical Education Consortium collaborated on developing a 100-item HSS examination. The structure of the questions is similar to standard board examination questions. The ‘blueprint’ of the examination includes the core HSS areas, inclusive of evidence-based medicine, patient safety, quality improvement, and teamwork. Subsequent iterations will expand the items to also include population health, high-value care.

HSS Learning Series – With the goal of providing evidence-based asynchronous learning methods for all health care clinicians, the AMA Accelerating Change in Medical Education Consortium created a series of 12 online interactive modules. The modules allow learners to engage in better understanding the core HSS concepts. (https://edhub.ama-assn.org/health-systems-science.)

HSS Scholars Program – Starting in 2018, the National HSS Scholars Program has been providing education for HSS education leaders at U.S. medical schools in the design, implementation, and evaluation of HSS curricula. Led by medical educators at medical schools in the AMA’s consortium that are innovating in HSS, the program creates opportunities for networking and sharing best practices for medical curricula.

HSS Thematic Meetings – Each year, the AMA’s Accelerating Change in Medical Education Consortium co-hosts thematic meetings to explore specific topics in greater depth. Since 2015, three thematic meetings have been held to explore HSS areas including: (1) HSS Along the UME to GME continuum (Penn State College of Medicine, Hershey, PA, 2018), Student-Led Conference on Leadership in Medical Education (University of Michigan, Ann Arbor, 2017), and Health Systems Science Assessment (University of Nebraska, originally scheduled for 2020 but moved to October 2021).

HSS Publications and Presentations – Across the AMA’s Consortium, educators have published over 50 peer-reviewed articles and presented over 200 peer-reviewed abstracts at national meetings focused on HSS.

Table 2. Representative health systems science curriculum examples from U.S. medical schools.

Medical school	Brief description
Brody School of Medicine at East Carolina University	Required 4-year longitudinal HSS curriculum for all medical students integrated throughout the curriculum in relevant courses and all required clerkships. Introduction to interprofessional care, health systems, improvement science, and patient-centered care begins the first week of medical school, and additional concepts related to patient safety, value-based care, evidence-based medicine, population health, social determinants of heath, and systems thinking are expanded throughout the curriculum. Each clerkship provides clinical application of these concepts to reinforce learning. The curriculum culminates with expanded HSS sessions and advanced skills during the transition to residency capstone. An optional three-year distinction track was designed for students to gain deeper skills in HSS.
Emory University School of Medicine	Standardized instruction on quality improvement and patient safety across Emory’s medical education continuum, which includes all of Emory’s medical students, residents, fellows, faculty, affiliated physicians, and interprofessional colleagues. As part of this standardization, a set of related milestones for medical school, graduate medical education, and practicing physicians and a database of past and current quality improvement activities have been created to promote collaboration across the continuum.
Dell Medical School at University of Texas Austin	Four-year longitudinal leadership and interprofessional education (IPE) courses form the curricular backbone of HSS. Curriculum including value-based care, population and community-based care, social determinants, informatics, and health care structures and policies are woven throughout the leadership and IPE curriculum. Health care equity competencies have recently been added to expand the scope of the curriculum. Application and assessment of these competencies is assessed in pre-clerkship small group work, clerkships, and senior electives.
Mayo Clinic Alix School of Medicine	Required four-year longitudinal course in HSS (Science of Health Care Delivery) on two campuses (Minnesota and Arizona) with six HSS-related domains (leadership, high-value care, team-based care, person-centered care, population-centered care, and health policy, economics, and technology). Faculty use flipped classrooms, simulation, and experiential education strategies, and provide formative assessment as students apply concepts and skills.
Michigan State University College of Osteopathic Medicine	‘First, Do No Harm’ curriculum incorporates patient safety concepts longitudinally across undergraduate and graduate medical education. Planned learning activities begin in year one of medical school, continue during clerkship, and culminate with synthesis-level projects in the first year of residency, leveraging the Institution for Healthcare Improvement Open School online modules.
University of Chicago Pritzker School of Medicine	VISTA = Value, Improvement, Safety, and Team Advocates includes early hands on interprofessional team experiences, multidisciplinary discharge OSCE, patient safety horror room and event reporting training, screening for cost non-adherence, and ongoing value curricula
Penn State College of Medicine	All 12 HSS competencies are longitudinally integrated into all phases of the medical school curriculum. Complemented by an early experiential role within health systems, the first two years focus on systems thinking, delivery systems, high-value care, policy, interprofessional care, population/social determinants of health, evidence-based medicine, patient safety and improvement science, and operational excellence. Each clerkship provides clinical application to allow for spiraling of learning. The post-clerkship phase includes a two-week application course of all HSS concepts, culminating with team-based, specialty-specific projects. Remaining experiences include HSS electives and research work and a transition to residency course that involves several core HSS learning areas.
The Warren Alpert Medical School of Brown University	There is a required Health Systems Science course for all medical students during the first semester, with engagement in relevant clinical activities such as a Navigator program, free clinics, and homeless care. A subset of students in the dual degree (MD/ScM) Primary Care – Population Medicine program continue with HSS II, HSS III, leadership course, 3^rd year longitudinal integrated clerkship (LIC) program with integrated HSS didactics, and additional research courses with a thesis requirement (topics related to HSS)

Table 3. Key challenges to health systems science education and potential strategies to facilitate change.

Challenge	Strategies to address challenge
Comprehensive standardized, integrated curricula	Integrate material from the basic and clinical sciences to include HSS insights Longitudinal inclusion of HSS content through the 4 years of medical education and from UME to GME Identification of most applicable content and skills for trainees across training phases Leverage best-practice curricula across medical schools
The development of HSS curricula is relatively new and must compete with other priorities and limited time in formal curricula.
Faculty knowledge/skills/comfort with HSS	Introduce faculty development interventions that address faculty knowledge and skills Introduce HSS content education for existing/new faculty Grasp opportunities to label existing HSS-related content/skills and help students make connections Frame HSS as a new model of physician professionalism Focus on synergies with basic/clinical sciences, often with ‘on-the-job’ informal training in HSS competencies Improve faculty understanding and expertise in these areas
Most faculty learned in educational programs that focused on a two-pillar approach, which may limit the knowledge and skills of faculty responsible for the role modeling and teaching for trainees.
Trainee receptivity to HSS	Emphasize HSS as a third science and part of physician professionalism in student recruitment Integrate HSS (curricula and assessment) with basic and clinical sciences Build an HSS ‘academic home’ akin to those in basic and clinical sciences Develop and track HSS-related student assessment and HSS-specific curriculum evaluation metrics Support transparent collaboration between medical schools on a national level Encourage students by demonstrating that mastery of HSS is critical to successful functioning in clinical settings
Trainees can view HSS learning areas as less important, or they can report lower satisfaction or engagement with concepts given competing priorities and the paucity of questions on the USMLE.
Hidden curriculum	Engage health system leaders, many of whom understand the importance of HSS intuitively, as teachers/mentors Authentic application and role modeling of HSS competencies in clinical care Overcome engrained culture of medical education by focusing on relevance to current and future challenges (e.g., COVID-19 and structural racism)
The cultural tensions in academic medicine and degree of support within the system influences traction gained by initiatives.
Buy-in and alignment of HSS within the health system	Promotion guidelines that reward HSS competency Incentive structure for faculty to teach Buy-in from academic health systems around goals and ensuring adequate resources and opportunities Demonstrate return-on-investment
For optimal success, HSS needs to be aligned across missions within the health system and have the buy-in of leadership at all levels; HSS must have a presence and a ‘home’ within a medical school to reach optimal impact.
Competency assessments across education continuum	Close collaboration with testing and assessment organizations Sharing of assessment tools between medical schools Utilization of competency and milestone frameworks
Frameworks and tools for assessing HSS knowledge, attitudes, and skills, including workplace-based assessments
Value added to system and student education	Develop and assess educationally sensitive patient outcomes Fund research teams and projects dedicated toward exploring system/patient-level outcomes
The impact of HSS initiatives on trainee learning and patient health is an ideal goal. The investment in starting and sustaining programs is significant, and work must address the impact of programs on systems and patients.

Skochelak SE, Hawkins RE, Lawson LE, Starr SR, Borkan JM, Gonzalo JD. 2017. Health systems science. Philadelphia (PA): Elsevier.

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Skochelak SE, Hammoud M, Lomis KD, Lawson LE, Starr SR, Borkan JM, Gonzalo JD. 2020. Health systems science. 2nd ed. Philadelphia (PA): Elsevier.

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Ehrenfeld JM, Gonzalo JD. 2019. Health systems science review. 1st ed. Philadelphia (PA): Elsevier.

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