Successful Practice within Health Systems Science among Entering Residents: A Qualitative Study

Background: The American Medical Association has defined the field of health systems sciences (HSS), viewed as a “third pillar” of medical education, alongside the basic and clinical sciences. Because a shared competency framework is lacking between undergraduate (UME) and graduate medical education (GME), entering residents are unprepared to implement HSS concepts in the workplace. The UME-GME transition is a critical timeframe to prepare trainees with skills for safe and effective care and foster a dedication to improving the health care system. This study investigates GME faculty observations of knowledge, attitudes and behaviors that define successful practice within HSS. Design and Methods: This study is an inductive-deductive qualitative study of phone interviews of Vanderbilt residency program directors, associate program directors and core faculty representing programs that train year-one residents. Interview questions were piloted and revised. Interviews were performed by a trained qualitative researcher, audio-recorded and transcribed. An initial codebook was developed, and de-identified transcripts were independently analyzed by two qualitative researchers using inductive and deductive approaches to identify themes and subthemes. All codes were discussed and reconciled for agreement. Results: Seventeen interviews were completed (17/39, 45%), representing a variety of specialties. Faculty described a developmental framework involving inputs, core workforce skills, HSS-related skills, and outputs. Inputs represent pre-curricular preparatory experiences common to well-prepared residents (ex. professional degrees, work experience, extracurricular involvement, medical school exposure). Successful residents exhibit core workforce characteristics and behaviors, for example, a growth mindset, curiosity, initiative, and desire to learn the system. While GME faculty often feel unprepared to teach or assess HSS concepts, they describe specific HSS-related skills unique to specific learning environments that characterize successful practice among entering residents. “Systems thinking” involves integrating skills across multiple domains and results in high-quality, person-centered care and systems improvements. Discussion: Faculty observations of the behaviors, knowledge and attitudes that define successful practice within HSS has highlighted the importance of pre-curricular experience including medical school curricula; core workforce characteristics and behaviors; and describes entry level skills within each of the HSS domains that characterize successful practice. This study provides an initial description of successful practice within HSS for entering residents.