기본의학교육에서 보건시스템과학(HSS) 교육과정: 잠재적 교육과정 프레임워크 탐색 및 정의 (Acad Med, 2017)

기본의학교육에서 보건시스템과학(HSS) 교육과정: 잠재적 교육과정 프레임워크 탐색 및 정의 (Acad Med, 2017)

Health Systems Science Curricula in Undergraduate Medical Education: Identifying and Defining a Potential Curricular Framework
Jed D. Gonzalo, MD, MSc, Michael Dekhtyar, Stephanie R. Starr, MD, Jeffrey Borkan, MD, PhD, Patrick Brunett, MD, Tonya Fancher, MD, MPH, Jennifer Green, MD, MPH, Sara Jo Grethlein, MD, Cindy Lai, MD, Luan Lawson, MD, MAEd, Seetha Monrad, MD, Patricia O’Sullivan, EdD, Mark D. Schwartz, MD, and Susan Skochelak, MD, MPH

 

 

미국의 의료 서비스는 세분화되고 비용이 많이 들며 비효율적입니다.1-5 의료 서비스 품질, 지급 개혁, 제공 프로세스 혁신에 대한 책임 증대에 직면한 의료 시스템은 의료 환경을 혁신하고 있습니다.6 새로운 의료 서비스 모델은 의료 개선 협회의 트리플 목표(환자 경험과 인구 건강을 개선하는 동시에 비용을 절감하는 것)를 달성하기 위해 점점 더 전문 의료 팀에 초점을 맞추고 있습니다.7 
Health care delivery in the United States is fragmented, costly, and inefficient.1–5 Faced with increasing accountability for quality of care, payment reform, and the need to transform delivery processes, health care systems are transforming practice environments.6 New care delivery models focus increasingly on interprofessional care teams to achieve the goals of the Institute for Healthcare Improvement’s Triple Aim—to improve the patient experience and population health while reducing costs.7 

21세기 의료 시스템에서 의대생이 효과적으로 성장할 수 있도록 하기 위해 학부 의학 교육(UME)과 대학원 의학 교육(GME) 프로그램은 시스템 기반 실천(SBP)에서 교육생의 지식, 태도 및 기술을 다루어야 한다.11,14–19 
To effectively prepare medical students to thrive in a 21st-century health care system, undergraduate medical education (UME) and graduate medical education (GME) programs must address trainees’ knowledge, attitudes, and skills in systems-based practice (SBP).11,14–19 

CEPAER(Corrustable Professional Activities)에 참여하는 핵심 위탁 직업 활동
Core Entrustable Professional Activities Entering Residency (CEPAERs),

미국 의대생들은 의료 시스템, 경제, 관리된 진료 및 실습 관리에 대한 부적절한 교육을 보고한다. 또한, SBP와 관련된 문헌은 SBP의 현행 ACME 정의 및 연습 기반 학습(PBL)보다 광범위한 콘텐츠 분야에서 커리큘럼을 확대해야 한다는 통일된 요구에도 불구하고 단편화되고 제한적이다. 여러 독립적인 출처는 관리 전환, 팀워크 및 조정, 환자 안전, 정책, 비용에 민감한 관리 및 공중 보건 등 시스템 관련 콘텐츠의 중요한 부분을 식별한다.

U.S. medical students report inadequate education in health care systems, economics, managed care, and practice management.22,23 Additionally, the literature regarding SBP-related curricula is fragmented and limited despite unified calls for expanded curricula in content areas that are broader than the current ACGME definitions of SBP and practice-based learning (PBL).20 Several independent sources identify critical pieces of this systems-related content, including

• care transitions,
• teamwork and coordination,
• patient safety,
• policy,
• cost-conscious care, and
• public health.6,18,21,24–27 

확장된 SBP 및 PBL 콘텐츠를 CEPAER 및 현재 커리큘럼 콘텐츠의 격차와 연계하면 보건 시스템 과학(HSS)의 콘텐츠를 정의하는 데 도움이 될 것이다. 의료 교육자가 기초 및 임상 과학을 보완하는 잠재적 "제3의 과학"으로 간주하는 HSS는 의료 시스템 내에서 환자와 인구에 대한 의료 제공의 품질, 결과 및 비용을 개선하기 위한 방법과 원칙으로 간주할 수 있다.1
Aligning expanded SBP and PBL content with the CEPAERs and current gaps in curricular content will help define the content of health systems science (HSS).20 Viewed by medical educators as a potential “third science” that complements the basic and clinical sciences, HSS can be considered as the methods and principles for improving quality, outcomes, and costs of health care delivery for patients and populations within medical care systems.13 

방법 Method

설계 Design

본 연구는 (1) 커리큘럼 프레임워크(도메인 식별)를 개발하기 위한 제안된 HSS 혁신에 대한 콘텐츠 분석과 (2) 커리큘럼 콘텐츠 목록(하위 카테고리 식별)을 구축하기 위한 프레임워크의 적용의 두 단계로 이루어졌다. 

This study was done in two phases: (1) a content analysis of proposed HSS innovations to develop a curricular framework (identifying domains) and (2) an application of the framework to build a list of curricular content (identifying subcategories).

열구 설정 Study setting and approach

자료 출처와 수집 Data sources and collection

1단계에서, 우리는 HSS 커리큘럼 프레임워크에 포함될 수 있는 커리큘럼 도메인의 포괄적인 목록을 식별하기 위해 노력했다. 이를 위해 ACE 이니셔티브(n = 30)에 대한 모든 전체 보조금 신청서를 분석할 계획이었다. 커리큘럼 도메인이 확인되면, 주요 조사관은 각 도메인에 대해 게시된 정의를 개발하거나 수정했습니다(표 1 참조).
In phase 1, we sought to identify a comprehensive list of curricular domains that could be included in an HSS curricular framework. To do this, we planned to analyze all full grant submissions to the ACE initiative (n = 30). Once curricular domains were identified, the lead investigators developed or modified published definitions for each domain (see Table 1).

2단계에서, 우리는 커리큘럼 내용으로 프레임워크에 포함될 수 있는 커리큘럼 하위 카테고리의 포괄적인 목록을 식별하기 위해 노력했다.
In phase 2, we sought to identify a comprehensive list of curricular subcategories that could be included in the framework as curricular content.

1단계에서 식별되고 정의된 도메인을 지침으로 사용하여, 주요 조사자는 강의록과 커리큘럼 문서에서 각 커리큘럼 영역에 적용되는 데이터를 추출했다(의 보충 디지털 부록 1 참조). Using the domains identified and defined in phase 1 as a guide, the lead investigators extracted data applicable to each curriculum domain from the syllabi and curriculum documents (see Supplemental Digital Appendix 1 at ).

개념적 프레임워크 Conceptual frameworks

1단계의 경우, George Engel의 [생물심리사회적 모델]은 사회 또는 시스템 영역에서 잠재적으로 분류될 수 있는 생체의학을 넘어 HSS 커리큘럼 영역을 식별하기 위해 광범위하고 전체적인 경험적 렌즈를 적용할 수 있도록 허용했다. [생물심리사회적 모델]은 [아원자 입자]에서 [사람(생물학 계층)], 그리고 [사람에서 생물권(사회 계층)]에 이르는 스펙트럼을 포함하는 계통 이론에 기초한다. 우리는 [생의학 또는 의사-환자 상호 작용(즉, 의사와 환자 상호 작용과 관련된 모든 문제)에만 국한된 내용을 배제]하는 것으로 생물심리사회적 모델을 조작화했다. 

For phase 1, George Engel’s biopsychosocial model allowed for the application of a broad-based and holistic empirical lens to identify HSS curriculum areas beyond biomedicine that could potentially be classified in social or systems domains.37,38 The biopsychosocial model draws on systems theory, with a hierarchy spanning the spectrum from subatomic particles to the person (organismic hierarchy), and from the person to the biosphere (social hierarchy).39 We operationalized the biopsychosocial model by excluding content limited solely to biomedicine or physician–patient interactions (i.e., any issue that would relate to a physician and patient interaction).

우리는 [심리학]에서 [시스템 레벨]에 이르는 생물심리사회적계층의 후속 계층strata에 중점을 두어 포괄적인 HSS 커리큘럼 프레임워크를 식별할 수 있게 했다. 예를 들어, 학생 의사가 체중 감량에 대해 환자와 의사소통하는 방법에 대해 교육한 커리큘럼 콘텐츠는 코딩에 포함되지 않았을 것이다. 단, 학생의 의사가 보행로 접근이나 사회적 지원 구조와 같이 환자의 체중 감량 능력에 영향을 미치는 사회적 요인에 대해 교육하려고 했던 커리큘럼 콘텐츠는 인구 및 공공 보건(도메인)으로 코딩되었을 것이다.

We focused on subsequent strata in the biopsychosocial hierarchy spanning the psychological to systems levels, enabling us to identify a comprehensive HSS curricular framework. For example, curricular content that educated student physicians about how to communicate with patients about weight loss would not have been included in the coding. However, curricular content that sought to educate student physicians about the social factors that influence a patient’s ability to lose weight, such as access to walking paths or their social support structure, would have been coded as population and public health (domain). 

2단계에서는 검색된 콘텐츠 항목에 가장 적합한 문헌의 기존 프레임워크를 사용하여 각 핵심 커리큘럼 도메인의 콘텐츠를 추가로 구성했다(예: 위의 예에서 하위 카테고리가 건강의 결정 요인이었을 것이다).

In phase 2, we further organized the content in each core curricular domain using existing frameworks from the literature that were the most appropriate for the content items retrieved (e.g., in the example above, the subcategory would have been determinants of health). 


자료 분석 Data analysis

코드는 표 1과 같이 커리큘럼 내용의 도메인을 반영하였다. 우리는 단계 1의 결과를 사용하여 단계 2에서 사용할 프레임워크를 만들었다. 각 영역 내의 일부 특정 커리큘럼 콘텐츠가 단계 1에서 확인되었지만, 이러한 초기 데이터의 대부분은 하위 범주 또는 특정 주제 영역을 식별하기에 충분히 구체적이지 않았다.
Codes reflected the domains of curricular content, as shown in Table 1. We used the results from phase 1 to create a framework to use in phase 2; although some specific curricular content within each domain was identified in phase 1, the majority of these initial data were not specific enough to identify subcategories or specific topic areas.

 

 

핵심 도메인 Core domains 의료 구조 및 프로세스 55 환자 또는 환자 모집단의 요구를 충족하기 위한 의료 서비스 제공을 위한 개인, 기관, 자원 및 프로세스의 구성과 관련된 모든 문제. 이 영역에는 의료 서비스 제공에 필요한 협업 및 조정 프로세스가 포함됩니다. Health care structures and processes55 All issues related to the organization of individuals, institutions, resources, and processes for delivery of health care to meet the needs of patients or populations of patients. This domain includes the processes of collaboration and coordination required for the delivery of health care. 의료 정책, 경제 및 관리 56 특정 의료 목표를 달성하기 위해 수행한 의사 결정, 계획 및 조치와 관련된 모든 문제 및 의료의 생산과 소비에서 효율성, 효과, 가치 및 행동과 관련된 문제. 이러한 과학은 의료 시스템의 모든 구성요소와 관리된 의료의 연구를 통해 건강을 증진하는 데 사용됩니다. Health care policy, economics, and management56 All issues related to the decisions, plans, and actions undertaken to achieve specific health care goals and the issues related to efficiency, effectiveness, value, and behavior in the production and consumption of health care. These sciences are used to promote health through the study of all components of the health care system and managed care. 임상 정보학 및 보건 정보 기술 57 임상 의사 결정 지원, 문서, 전자 의료 기록 및 건강 개선을 위한 데이터 활용을 포함하여 의료 서비스 제공을 위한 정보 및 정보 기술의 적용과 관련된 모든 문제. Clinical informatics and health information technology57 All issues related to the application of informatics and information technology to deliver health care services, including clinical decision support, documentation, electronic medical records, and the utilization of data to improve health. 인구보건58 전통적인 공공 보건과 예방의학과 관련된 모든 문제들, 아픈 사람들뿐만 아니라 전체 인구에 영향을 미치는 건강 결정 요소들의 전체 범위를 포함한다. 내용에는 질병과 부상을 예방하고, 건강을 증진하고, 수명을 연장하거나, 개인(예: 국가, 지역사회, 민족 그룹 또는 기타 정의된 그룹과 같은 지리적 집단)에 대한 기타 건강 결과를 개선하기 위한 조직적인 평가, 모니터링 또는 측정이 포함된다. 여기에는 그러한 그룹에 대한 접근과 분배가 포함된다.그룹 내의 t와 건강 결과 또는 예방과 관련된 다양한 개인적, 사회 경제적, 환경적 요인들 사이의 동적 상호 관계. Population and public health58 All issues related to traditional public health and preventive medicine, including the full range of health determinants affecting the entire population rather than just those individuals who are sick. Content includes the organized assessment, monitoring, or measurement to prevent disease and injury, promote health, prolong life, or improve any other health outcome for a group of individuals (e.g., geographic populations such as nations, communities, ethnic groups, or any other defined group), including the access to and distribution of such outcomes within the group, and the dynamic interrelationships among various personal, socioeconomic, and environmental factors that relate to health outcomes or prevention. 가치 기반 관리4  의료 시스템의 성능과 관련된 모든 문제는 의료 서비스 제공 품질, 비용 및 폐기물과 관련이 있습니다. 품질 관점에서, 문제는 품질의 6차원(환자 안전, 효과, 환자 중심성, 적시성, 효과성 및 공정성)과 관련이 있다. 비용 측면에서 볼 때, 모든 문제는 의료 비용, 폐기물 구성요소 및 서비스 요구사항과 관련이 있습니다. 이 영역에는 치료와 진료 전달의 격차를 보고 분류하는 것뿐만 아니라 역학이 포함된다. Value-based care4  All issues related to the performance of a health system as it relates to quality of care delivery, cost, and waste. From the quality perspective, issues relate to the six Institute of Medicine dimensions of quality (patient safety, effectiveness, patient-centeredness, timeliness, effectiveness, and equitability). From the cost perspective, all issues relate to the cost of health care, waste components, and service requirements. The domain includes the epidemiology of, as well as seeing and classifying, gaps in care and care delivery. 보건 시스템 개선 59 모든 문제는 의료 시스템의 구성 요소의 성능을 향상시키기 위해 정책, 의료 서비스 제공 또는 기타 의료 시스템의 변경 사항을 식별, 분석 또는 구현하는 프로세스와 관련된 것이다. 본 문서의 쟁점에는 정량화 및 종결 격차(조치), 변동 및 측정(특히 의료 조치가 아닌 격차 정량화 및 종결과 관련), 데이터 분석 및 개입이 포함된다. Health system improvement59 All issues related to processes of identifying, analyzing, or implementing changes in policy, health care delivery, or any other function of the health care system to improve the performance of any component of the health care system. Issues herein include quantifying and closing gaps (action), variation and measurement (specifically related to quantifying and closing gaps, not to health care measures in general), analysis of data, and interventions. 교차 절단 도메인 Cross-cutting domains 리더십 및 변화 기관 60 바람직한 비전을 향한 목표를 만들기 위해 다른 사람들에게 동기를 부여하는 능력과 관련된 모든 문제. 학부 의학교육의 맥락에서 리더십은 팀 기반 진료, 품질 개선 프로젝트 등과 관련이 있다. Leadership and change agency60 All issues related to the ability to inspire motivation in others to create goals toward a desirable vision. In the context of undergraduate medical education, leadership pertains to team-based care, quality improvement projects, etc. 팀워크 및 전문직간 교육 협업 및 팀 과학과 관련된 모든 문제, 특히 공유된 목표를 달성하기 위해 지정된 작업에 함께 노력하는 개인의 프로세스를 통해 발생합니다. Teamwork and interprofessional education All issues related to collaboration and team science, specifically through the process of individuals working together on specified tasks to achieved shared goals. 증거기반의학 및 실습61 개별 환자의 진료, 환자 모집단 또는 의료 전달 개선에 대한 개입에 대한 결정을 내릴 때 현재 최선의 증거를 양심적이고 명시적이며 현명하게 사용하는 것과 관련된 모든 문제. Evidence-based medicine and practice61 All issues related to the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients, populations of patients, or interventions in health care delivery improvement. 전문성과 윤리성 행동을 포함한 윤리적 행동과 전문성과 관련된 모든 이슈는 일반적으로 받아들여지는 도덕적 원칙과 가치, 그리고 그러한 원칙과 가치에 기초한 전문적인 지침과 일치한다. 이 정의에는 정직과 책임과 같은 일반적인 리더십 윤리와 HSS 영역에 특화된 윤리 및 전문성이 포함됩니다. Professionalism and ethics All issues related to ethical behavior and professionalism, including conduct, congruent with generally accepted moral principles and values and with professional guidelines based on those principles and values. This definition includes general leadership ethics, such as honesty and responsibility, as well as ethics and professionalism specific to the HSS domains. 학술활동62 HSS 도메인을 조사하는 HSS 콘텐츠 및/또는 보건 서비스 연구의 학술활동과 관련된 모든 문제.  장학금은 (1) 전통적인 연구와 일치하는 발견, (2) 분야를 넘나들며 더 큰 맥락에서 전문지식을 배치하는 통합, (3) 연구와 실무 사이의 중요한 상호 작용을 보여주는 응용, (4) 교수(교육 장학금)으로 정의된다.학습자 앞에서 가르치고 배우는 것에 대한 새로운 지식의 발현 Scholarship62 All issues related to scholarship of HSS content and/or health services research that investigates any HSS domain.  Scholarship is defined as (1) discovery, which is consistent with traditional research; (2) integration, which makes connections across disciplines and places specialties in a larger context; (3) application, which demonstrates the vital interaction between research and practice; and (4) teaching (educational scholarship), which emphasizes the creation of new knowledge about teaching and learning in the presence of learners. 연결 도메인 Linking domain 시스템 사고 상호의존성의 복잡한 거미줄의 관심과 관련된 모든 문제, 부품에 대한 인식뿐만 아니라 "전체"에 대한 인식, 모든 원인과 다방향 원인-효과 관계를 인식하는 능력과 관련된 모든 문제가 또 다른 시스템 동역학의 효과로 떠오르고 있습니다. Systems thinking All issues related to the attention of a complex web of interdependencies; an awareness of the “whole,” not just of the parts; and the ability to recognize multidirectional cause–effect relationships with all causes emerging as the effect of another system dynamic.

결과 Results

우리의 분석은 (1) 코어, (2) 크로스 컷팅 및 (3) 링크의 세 가지 유형의 커리큘럼 도메인을 산출했다(표 1 참조). 그림 1은 이러한 세 가지 유형의 도메인 간의 관계를 보여줍니다. 핵심 커리큘럼 도메인의 하위 카테고리(및 하위 주제)는 이전에 발표된 개념 프레임워크를 사용하여 구성된다(표 2). 각 도메인의 컨텐츠 대표자는 표 2(핵심 도메인)와 3(크로스컷 및 링크 도메인)에 나와 있습니다.
Our analysis yielded three types of curricular domains: (1) core, (2) crosscutting, and (3) linking (see Table 1). Figure 1 illustrates the relationship between these three types of domains. Subcategories (and subtopics) for the core curricular domains are organized using previously published conceptual frameworks (Table 2). Content representative of each domain is shown in Tables 2 (core domains) and 3 (crosscutting and linking domains).

핵심 커리큘럼 도메인은 HSS와 직접 일치하는 내용 영역입니다. 이러한 6가지 영역은 의료 구조와 프로세스, 의료 정책, 경제 및 관리, 임상 정보학 및 보건 정보 기술, 인구 및 공공 보건, 가치 기반 의료 및 보건 시스템 개선을 포함한다.
Core curricular domains are content areas that align directly with HSS. These six domains include health care structures and processes; health care policy, economics, and management; clinical informatics and health information technology; population and public health; value-based care; and health system improvement.

컨텐츠가 여러 핵심 커리큘럼 도메인을 초월한 것으로 식별되면 크로스 컷팅 도메인으로 클러스터링되었다. 이 다섯 가지 영역에는 리더십과 변화 기관, 팀워크와 전문성 교육, 증거 기반 의학 및 실습, 전문성과 윤리성, 장학금 등이 포함된다. 
Content was clustered into a cross-cutting domain if it was identified as transcending multiple core curricular domains. These five domains include leadership and change agency; teamwork and interprofessional education; evidence-based medicine and practice; professionalism and ethics; and scholarship. 

마지막으로, 핵심 커리큘럼 또는 교차 컷팅 도메인을 다른 핵심 커리큘럼 또는 교차 컷팅 도메인(내부 링크)과 기본 및 임상 과학(외부 링크)과 같은 커리큘럼의 다른 영역으로 통합하거나 연결하는 콘텐츠는 하나의 연결linking 도메인, 즉 시스템 사고에 할당되었다. 시스템 사고 내용은 학생들이 의료 및 의료 문제에 포괄적인 전체론적 접근법을 인식하고 적용할 수 있도록 한다.
Finally, content that unifies or links the core curricular or cross-cutting domains to other core curricular or cross-cutting domains (internal linking) and to other areas of the curriculum, such as the basic and clinical sciences (external linking), was assigned to the single linking domain: systems thinking. The content of systems thinking allows students to be cognizant of and apply a comprehensive holistic approach to medical care and health care issues.

 

 

고찰 Discussion

교육자들은 이전에 전통적인 기초 및 임상 과학을 다양한 과학을 포함하도록 강화하는 새로운 UME 패러다임을 제안했다(기본, 임상, HSS). ACGME는 SBP를 다음과 같이 정의한다. "더 큰 범위의… 의료 시스템에 대한 인식 및 대응성" 및 "시스템 내의 다른 자원을 효과적으로 호출하여 최적의 의료 서비스를 제공할 수 있는 능력". 이러한 맥락에서 전공의는 다양한 의료 전달 환경에서 기능할 수 있어야 하고, 비용 인식cost awareness을 의사 결정에 통합하고, 최적의 진료 시스템을 옹호하며, 환자 치료 품질을 개선하기 위해 전문가 간 팀에서 일할 것으로 예상된다.

Educators have previously proposed a new paradigm for UME that augments the traditional basic and clinical sciences to include a triad of sciences—basic, clinical, and HSS.11,13 The ACGME defines SBP as “an awareness of and responsiveness to the larger … system of health care” and “the ability to call effectively on other resources in the system to provide optimal health care.”20 In this context, resident physicians are expected to

• function in various health care delivery settings,
• incorporate cost awareness into their decision making,
• advocate for optimal care systems, and
• work in interprofessional teams to improve patient care quality. 

HSS 커리큘럼은 SBP의 ACGME 정의보다 범위가 넓고 CEPAER에서 다루는 관련 주제 영역을 포함하고 있다. 여기에 보고된 도메인, 커리큘럼 콘텐츠, 개념 프레임워크 및 하위 카테고리(및 하위 주제)는 HSS 역량 및 위탁 가능한 전문 활동의 개발을 위한 출발점이다.

HSS curricula for a majority of their students that are broader in scope than the ACGME definition of SBP, and con tain pertinent topic areas addressed in the CEPAERs.20,21 The domains, working defini tions for curricular content, conceptual frameworks, and subcategories (and subtopics) reported here are a starting point for the development of HSS competencies and entrustable professional activities.

여러 연구는 그러한 프레임워크에서 고려되어야 하는 기존 및 잠재적 HSS 주제 또는 개념을 강조한다. 
Several studies highlight existing and potential HSS topics or concepts that should be considered in such a framework. 


우리는 전통적으로 UME 프로그램에 포함되었을 수 있지만 이 HSS 커리큘럼 프레임워크에서 새롭게 강조되는 지식과 기술의 몇 가지 [교차 절단 영역]을 식별했다. 이러한 교차 컷팅 도메인은 제안된 HSS 도메인의 중복과 커리큘럼의 전통적인 영역을 강조한다.
We identified several cross-cutting domains of knowledge and skills that traditionally may have been included in UME programs but have a new emphasis in this HSS curricular framework. These crosscutting domains highlight the overlap and application of the proposed HSS domains with traditional areas of the curriculum. 

공공 의료 역량의 구성요소로 이미 제안되었지만, 명시적 시스템 사고 기술은 UME에게는 새로운 것으로 보인다. 제안된 시스템 사고 기술 세트는 커리큘럼에 포함시켜야 할 중요한 부분이다. 이는 의료 시스템과 제공자가 상호 연결되고 지속적으로 시스템을 혁신하여 결과를 개선하는 [학습 조직]을 향한 의료 시스템의 진화하는 환경을 반영하기 때문입니다.

Although they have previously been proposed as a component of public health competencies, explicit systems thinking skills appear to be new to UME.46,47 The proposed skill set of systems thinking is a critical piece to include in curricula because it reflects the evolving landscape of health systems toward learning organizations, where the health system and providers become more interconnected and continuously transform systems to improve outcomes.48–50

또한, HSS의 이러한 광범위한 개념화는 미래의 의사를 교육하는 관점을 재구성한다. 우리의 결과가 미국 UME 프로그램에서 비롯되었지만, 우리는 이 HSS 커리큘럼 프레임워크와 내용이 GME 및 지속적인 의료 교육뿐만 아니라 미국 및 해외의 많은 제휴 건강 직업 교육 프로그램에도 적용 가능하다고 믿는다. 많은 의과대학과 마찬가지로 간호학, 약학, 내과의사 보조 프로그램을 포함한 다른 건강 전문가 프로그램들도 HSS 주제를 교과과정에 포함시키고 있다. 여러 당국(예: Interprofessional Education Collaborative 및 CanMEDs)은 특히 질 향상과 환자 안전 분야에서 전문가 간 역량을 점점 강조하고 있다.51,52
Additionally, this broad conceptualization of HSS reframes the view of educating future physicians. Although our results originate from U.S. UME programs, we believe this HSS curricular framework and content are applicable to GME and continuing medical education, as well as to many allied health professions educational programs, in the United States and abroad. Like many medical schools, other health professional programs, including nursing, pharmacy, and physician assistant programs, are incorporating HSS topics into their curricula. Several authorities (e.g., the Interprofessional Education Collaborative and CanMEDS) increasingly emphasize interprofessional competencies, specifically in quality improvement and patient safety.51,52

우리는 이 작업이 HSS와 관련된 잠재적인 다음 단계를 알려준다고 믿는다. 

• 첫째, 이러한 결과는 교육 방법 및 평가 조치(예: 이정표, 역량, 위탁 가능한 전문 활동)를 개발하고 학부생들이 효과적인 의료 전문가가 될 수 있도록 하는 커리큘럼을 설계 및 구현하기 위해 후속 작업에 사용될 수 있으며 사용해야 한다. 
• 둘째로, 향후 연구는 교육 프로그램에서 이러한 영역의 확산과 인식된 중요성, 전문직 간 맥락에서 적용의 실용성 및 보건 시스템의 필요성에 대한 적합성을 평가해야 한다. 구체적으로, 우리의 결과는 HSS 커리큘럼에 대한 정적 2차원 관점을 제공하지만, 관련 시간과 관련 환경에서 올바른 교육 개입을 제시하는 것이 중요할 것이다.

We believe this work informs potential next steps related to the HSS. 

• First, these results can and should be used in subsequent work to develop educational methods and evaluation measures (e.g., milestones, competencies, entrustable professional activities) and to design and implement curricula that enable undergraduate trainees to be effective health care professionals. 
• Second, future work should assess these domains for their prevalence and perceived importance in educational programs, the practicality of applying them in interprofessional contexts, and their alignment with the needs of the health system. Specifically, our results provide a static, two-dimensional perspective of the HSS curriculum, but it would be important to present the right educational intervention at the relevant time and in the relevant setting.

 

이 일에는 몇 가지 한계가 있다. 첫째, 교육과정 설계가 내용보다는 학습자 결과에서 이상적으로 시작되지만, 문헌에서 합의 중심의 HSS 학습자 결과가 없다는 점을 감안할 때, 도메인 및 하위 범주와 함께 잠재적인 포괄적 커리큘럼 프레임워크를 식별하는 것이 학습자 결과 개발을 알리기 위한 필수 첫 번째 단계라고 생각한다..12,54 

There are several limitations to this work. First, although curriculum design ideally starts with learner outcomes rather than content, given the lack of consensus-driven HSS learner outcomes in the literature, we believe the identification of a potential comprehensive curricular framework with domains and subcategories was a required first step to inform the development of learner outcomes.12,54 

따라서, 우리의 결과는 커리큘럼 내용이 완전히 철저한 커리큘럼 프레임워크를 나타내지 않을 수 있다는 점에서 몇 가지 결점이 있다. 또한 아래처럼 여러 개념에 걸쳐 상당한 중복이 있음을 인지합니다.

• 핵심 커리큘럼 영역(예: 가치 기반 관리 및 보건 시스템 개선) 및 
• 영역 내의 하위 범주(예: 의료 차이/불가능한 환자 집단 및 건강 결정 요인) 및 

다른 저자가 합의를 도출했다면 다른 결과를 낳았을지도 모른다.

Therefore, our results have some shortcomings in that the curricular content may not represent a fully exhaustive curricular framework. We also recognize that there is significant conceptual overlap across the core curricular domains (e.g., value-based care and health system improvement) and subcategories within domains (e.g., health care disparities/vulnerable patient populations and determinants of health) and that consensus building by other authors may have yielded different results. 

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Acad Med. 2017 Jan;92(1):123-131.

 doi: 10.1097/ACM.0000000000001177.

Health Systems Science Curricula in Undergraduate Medical Education: Identifying and Defining a Potential Curricular Framework

Jed D Gonzalo 1, Michael Dekhtyar, Stephanie R Starr, Jeffrey Borkan, Patrick Brunett, Tonya Fancher, Jennifer Green, Sara Jo Grethlein, Cindy Lai, Luan Lawson, Seetha Monrad, Patricia O'Sullivan, Mark D Schwartz, Susan Skochelak

Affiliations collapse

Affiliation

• 1J.D. Gonzalo is assistant professor of medicine and public health sciences and associate dean for health systems education, Penn State College of Medicine, Hershey, Pennsylvania. M. Dekhtyar is senior research assistant, Medical Education Outcomes, American Medical Association, Chicago, Illinois. S.R. Starr is assistant professor of pediatric and adolescent medicine and director of science of health care delivery education, Mayo Medical School, Mayo Clinic College of Medicine, Rochester, Minnesota. J. Borkan is chair and professor of family medicine and assistant dean for primary care-population health program planning, Alpert Medical School of Brown University, Providence, Rhode Island. P. Brunett is clinical professor, Department of Emergency Medicine, and associate dean for graduate medical education, Oregon Health & Science University School of Medicine, Portland, Oregon. T. Fancher is associate professor, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, California. J. Green is assistant professor of medicine and pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee. S.J. Grethlein is professor of clinical medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana. C. Lai is professor of medicine, University of California San Francisco School of Medicine, San Francisco, California. L. Lawson is assistant dean for curriculum, assessment, and clinical academic affairs and assistant professor of emergency medicine, Brody School of Medicine at East Carolina University, Greenville, North Carolina. S. Monrad is clinical assistant professor, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan. P. O'Sullivan is professor of medicine and director of research and development in medical education, University of California San Francisco School of Medicine, San Francisco, California. M.D. Schwartz is professor of population health and medicine and vice chair for education and faculty affairs, Department of Population Health, New York University School of Medicine, New York, New York. S. Skochelak is group vice president of medical education, American Medical Association, Chicago, Illinois.

• PMID: 27049541
• DOI: 10.1097/ACM.0000000000001177Abstract
• Purpose: The authors performed a review of 30 Accelerating Change in Medical Education full grant submissions and an analysis of the health systems science (HSS)-related curricula at the 11 grant recipient schools to develop a potential comprehensive HSS curricular framework with domains and subcategories.Results: Analysis yielded three types of domains: core, cross-cutting, and linking. Core domains included health care structures and processes; health care policy, economics, and management; clinical informatics and health information technology; population and public health; value-based care; and health system improvement. Cross-cutting domains included leadership and change agency; teamwork and interprofessional education; evidence-based medicine and practice; professionalism and ethics; and scholarship. One linking domain was identified: systems thinking.
• Conclusions: This broad framework aims to build on the traditional definition of systems-based practice and highlight the need for medical and other health professions schools to better align education programs with the anticipated needs of the systems in which students will practice. HSS will require a critical investigation into existing curricula to determine the most efficient methods for integration with the basic and clinical sciences.
• Method: In phase 1, to identify domains, grant submissions were analyzed and coded using constant comparative analysis. In phase 2, a detailed review of all existing and planned syllabi and curriculum documents at the grantee schools was performed, and content in the core curricular domains was coded into subcategories. The lead investigators reviewed and discussed drafts of the categorization scheme, collapsed and combined domains and subcategories, and resolved disagreements via group discussion.