Systems-Based Practice: An essential way forward for family medicine
My decision to become a family physician was driven by a desire to improve health and wellbeing, especially among the most vulnerable. For many years I saw my role as focused around individual patients and sought to improve their wellness on a case-by-case basis. However, over time, I have become acutely aware of how little impact I am having, as so many of the challenges my patients face are systemic. This has been especially evident with the COVID19 pandemic which has further emphasized gaps in our system and the need for “systems change.” Over time, it has become obvious that as a practitioner, I function as part of a system, not in isolation, and my ability to effect change is interdependent on the system in which I find myself.1
A system is “a set of interdependent parts that share a common purpose”; a physician is therefore only one of those interdependent parts.1 “Systems thinking” involves being able to see “all elements in a given environment as interrelating” while systems-based practice (SBP) involves the way in which “systems thinking is applied in medicine”.2 One definition of SBP is “an awareness of and responsiveness to the larger context and system of health care, including the social determinants of health, as well as the ability to call effectively on other resources to provide optimal health care.” 3 SBP is therefore essential in understanding the factors that have the largest impact on health, namely the social determinants, and “for maximizing the quality and safety of patient care.” 4,2
In the United States, the Accreditation Council for Graduate Medical Education has included SBP as on of the six core competencies for graduate medical education.5This means that all residency programs must demonstrate how SBP is included in their educational curricula and provide evidence that competency has been attained.5In Canada however, although SBP may be taught informally and aspects are included in certain parts of residency training, there seems to be an unmet educational need as learners and faculty often lack an educational grounding in SBP.1 In order to ensure that physicians understand system challenges and are equipped with the skills to effectively address these, education around systems-based practice (SBP) is essential.
Although medical education aims to prepare learners for practice, it has traditionally focused on patient care competencies versus practice improvement or system-based competencies.6 Although SBP is widely recognized as an important competency, “there is no consensus on best practices for teaching systems thinking in medicine or the health professions.”2 Some of the challenges include knowing when and how SBP should be taught, and the best methods of assessing competency.2 Furthermore as many staff have not received any formal training in SBP, there is also a need for continuing education so that preceptors can more readily incorporate systems teaching when interacting with learners.
Ensuring that SBP is incorporated as a core competency in family medicine training will help to prepare our residents for current and future challenges. Furthermore, as family practice increasingly moves to a team-based model to meet growing primary care needs, designing our systems with intentionality, and being able to apply systems thinking to challenges, will be essential in providing optimal patient care.
Eileen Nicolle is a family physician working with St Michael's Academic Family Health Team in the Department of Family and Community Medicine in Toronto. She has an interest in supporting vulnerable populations and is currently pursuing a Master’s in Public Health with a focus on planetary health. She is hoping to work in the area of systems change to be able to ensure that patients receive optimal care in a sustainable system.
References
1. Kilo CM, Mejicano G. Systems-Based Learning in Continuing Professional Development. In: Rayburn WF, Turco MG, Davis DA, editors. Continuing Professional Development in Medicine and Health Care: Better Education, Better Patient Outcomes. Walters Kluwer 2018. p. 281-292
2. Plack MM, Goldman EF, Scott AR, Pintz C, Herrmann D, Kline K, et al. Systems Thinking and Systems-Based Practice Across the Health Professions: An Inquiry Into Definitions, Teaching Practices, and Assessment. Teaching and Learning in Medicine, 2018; 30(3):242-254
3. Castillo EG, Isom J, DeBonis KL, Jordan A, Braslow JT, Rohrbaugh R. Reconsidering Systems-Based Practice: Advancing Structural Competency, Health Equity, and Social Responsibility in Graduate Medical Education. Acad Med, 2020 Dec; 95(12): 1817–1822.
4. Mikkonen J, Raphael, D. Social Determinants of Health: The Canadian Facts. Toronto: York University School of Health Policy and Management; 2010. 63 p.
5. Martinez J, Phillips E, Fein O. Perspectives on the changing healthcare system: teaching systems-based practice to medical residents. Med Educ Online, 2013; 18(1): 1-5. Available from: www.tandfonline.com/doi/full/10.1080/10401334.2017.1398654
6. Prunuske, A., et al. "Alignment of roles of near-peer mentors for medical students underrepresented in medicine with medical education competencies: a qualitative study." BMC Medical Education; 2019. 19(1): 417.
