Academic medicine and, frankly, most of medicine is changing how we think about delivering care. The effective, integrated application of knowledge, science, and technology will allow us to finally deliver on the promise of personalized medicine within a framework of population health. But operating within that framework requires that we think differently. We must understand not only the needs of individuals but the broader picture of systems of care and systems-based practice.
For academic physicians, if you don’t understand it, you can’t teach it.
I admit this feels like a mind shift that will create headaches for all of us.
Some definitions to set the stage: Population health (Milbank Quarterly 2007 March;85 (1); 139-161) can refer to a conceptual framework for thinking about why some population are healthier than others; or the health outcomes of a group of individuals that include an understanding of the distribution of outcomes within the group.
Systems thinking is an approach to problem solving, by viewing “problems” as parts of an overall system. Rather than reacting to specific parts, outcomes, or events, systems thinking seeks to understand how things influence one another within the defined system.
Systems-based practice (SBP) is when physicians understand how patient care relates to the health care system as a whole; and how to use that system to improve the quality and safety of patient care. Systems-based practice can be thought of as an analytic tool, as well as a way of viewing the world, both of which can make caregiving and change efforts more successful.
How do they all relate? In order to define the systems of care and to practice effectively within those systems, we need to understand the interdependencies of a system or series of systems and the changes identified to improve care that can be made and measured in the system. Care to the individual or to a population is very sensitive to the context in which it is delivered; because care is never delivered in a vacuum.
Recently, we in Health Care Affairs at the AAMC decided that we wanted to better understand how to look at care through a systems thinking lens. Supported by the Jewish Healthcare Foundation, we invited innovators in medical education, engineering, nursing education, business, public health, and health care delivery to convene in Pittsburgh the first week in August to talk about “thinking differently.” We were fortunate to have some experts from MIT’s Sloan School of Business working with us. They have been in the systems thinking space for years and are currently working with many of the health systems in the Boston area. They are teaching teams to translate systems thinking into systems-based practice.
We used a framework for analyzing organizational systems called “Three Lenses/Three Perspectives.” This framework offers three ways of looking at an organization ―Strategic Design, Political, and Cultural ― and we applied each to analyze problems within a defined system of health care. The definition of the “system” is very important and describes the organizational and structural context within which you work. The “system” could be limited to one service line in an acute care hospital, or be as broad as a system for care for a population across a broad geography.
- The strategic design lens looks at organizations as machines. They are mechanical systems crafted to achieve a defined goal. The parts must fit well together and match the demands of the environment. Action comes through planning.
- The political lens looks at organizations as contests. They are social systems encompassing diverse, and sometimes contradictory, interests and goals. Competition for resources is expected. Action comes through power.
- The cultural lens looks at organizations as institutions. The organization is a symbolic system of meanings, artifacts, values, and routines. Informal norms and traditions exert a strong influence on behavior. Action comes through habit.
The MIT experts stressed that you can’t effectively understand real problems and potential solutions unless you look at them through all of the lenses. How quickly we often apply the old solutions to new problems. When you examine the problem through these three lenses, it becomes obvious why previous solutions have failed. Further, there are more useful frameworks for systems thinking that can be applied to address challenges identified through the three lenses.
Einstein also said, “If I had an hour to solve a problem and my life depended on the solution, I would spend the first 55 minutes determining the proper question to ask; for once I know the proper question, I could solve the problem in less than five minutes.”
What does Einstein’s quote mean for academic physicians and how we model and teach systems thinking and systems-based practice? This is a very different focus from the individualized care that we have traditionally delivered. There is significant tension emotionally and philosophically when we must decide between individual benefit and population benefit.
We are now expected to demonstrate causality and improved outcomes across broad populations for every intervention, as well as cost-effectiveness. Although it feels at times that the needs of the individual and the population are disconjugate sets, that does not have to be the case. It is difficult to have improved population outcomes without great individual outcomes. But how do we begin the conversation about what this means in the daily care of our patients, so we can model systems thinking?
More than nine years ago, Paul Miles, MD, of the American Board of Pediatrics, took the David Letterman approach. In his 2004 publication, “Systems-based practice: What every physician should know,” Miles outlined 10 questions every practicing physician should be able to answer:
- Can you define a system?
- How do you describe the system you work in ?
- How well does the system work?
- How would you analyze and diagnose where the system can be improved?
- How would you identify and prioritize change?
- Do you participate in an interdisciplinary team?
- What are the different systems your system interacts with, and how does your system interact with these systems?
- How is your system financed?
- How are new members of the team trained?
- How is medical education done successfully?
Remember, to begin the conversation, we don’t have to have all of the answers. We just need to begin asking the questions when we are rounding, consulting, lecturing, and discussing care.
Begin to think differently.
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