DeWaters Ami L, Banerjee Somalee, Bruce James, Cooney Rob, Ellison Halle B, Haidet Paul, Mazotti Lindsay, Reilly James B, Gonzalo Jed D
Penn State College of Medicine, Hershey, Pennsylvania, USA.
Kaiser Permanente, Oakland, California, USA.
Clin Teach. 2025 Feb;22(1):e13840. doi: 10.1111/tct.13840. Epub 2024 Nov 6.
Systems-based practice (SBP) has been a competency in US graduate medical education for over 20 years, but it is not well implemented. SBP is loosely defined as physician's responsiveness to the larger system of healthcare. The aim of this study was to describe healthcare professionals' perspectives regarding: (1) their knowledge and beliefs about SBP and (2) their beliefs regarding factors in clinical learning environments (CLE) that facilitate or hinder operationalisation and learning of SBP.
Semi-structured interviews were conducted between November 2020 and April 2021 with 42 individuals from four health systems. Participants were healthcare professionals involved in graduate medical education, including physicians and interprofessional clinicians (e.g., nursing staff). Interviews were transcribed and coded using a social constructivist, codebook thematic analysis approach and themes were agreed upon through discussion amongst the research team.
Five themes were constructed: (1) SBP remains a challenge to define, (2) SBP may be intuitively understood, particularly when framed at the microsystem level, (3) SBP aligns with the Health Systems Science framework, (4) SBP learning must be intentionally integrated into the CLE, through training such as onboarding and (5) multidisciplinary settings and work processes are critical to engage in SBP. Workload compression is a barrier to SBP implementation.
Healthcare professionals highlighted that current CLEs are not designed to prioritise SBP. Graduate medical education programmes may benefit from focusing systems content at the microsystem level and purposefully integrating onboarding procedures, clinical settings and rotations specifically designed to teach SBP into their residencies.
基于系统的实践（SBP）在美国研究生医学教育中作为一项能力要求已有20多年，但实施情况并不理想。SBP的定义较为宽泛，指医生对更大的医疗系统的响应能力。本研究的目的是描述医疗保健专业人员对以下方面的看法：（1）他们对SBP的知识和信念；（2）他们对临床学习环境（CLE）中促进或阻碍SBP实施和学习的因素的信念。
2020年11月至2021年4月期间，对来自四个医疗系统的42名人员进行了半结构化访谈。参与者是参与研究生医学教育的医疗保健专业人员，包括医生和跨专业临床医生（如护理人员）。访谈内容进行了转录，并采用社会建构主义的编码本主题分析方法进行编码，研究团队通过讨论确定了主题。
构建了五个主题：（1）SBP的定义仍然是一个挑战；（2）SBP可能可以直观理解，特别是在微观系统层面进行阐述时；（3）SBP与卫生系统科学框架相一致；（4）SBP学习必须通过入职培训等方式有意地融入到CLE中；（5）多学科环境和工作流程对于开展SBP至关重要。工作量压缩是SBP实施的一个障碍。
医疗保健专业人员强调，当前的CLE并非以优先考虑SBP为设计目的。研究生医学教育项目可能会受益于将系统内容聚焦在微观系统层面，并将专门设计用于教授SBP的入职程序、临床环境和轮转有意地融入到住院医师培训中。
