Michele E. Long, MD, Aaron R. Danielson, BS, UC Davis School of Medicine, Sacramento, CA; Noelle V. Johnstone, MD, Elizabeth Stuart, MD, MSEd, Stanford University, Palo Alto, CA
Background: Of the six ACGME core competencies, systems-based practice (SBP) has been recognized as one of the more challenging to teach and evaluate (Moskowitz & Nash; Varkey et al.) In broad terms, SBP incorporates aspects of care coordination, patient advocacy, patient safety and quality improvement. Although fourth-year students inevitably engage in these components of systems-based practice, their explicit learning goals, as recorded in individualized learning plans, rarely address SBP. To better understand students’ learning in this area, we explored themes in students’ written reflections on the subinternship experience. Study Objectives: 1. Determine the extent to which subinterns address systems-based practice in written reflections on learning. 2. Determine what aspects of systems-based practice are most salient for students at the subintern level. Research Methods: Students submitted a 1-page reflection at the end of the subinternship rotation. Instructions were to think about the transition from student to intern and how it feels to be in the new role of patient care “manager,” with the option of specific reflection on systems-based practice. The authors performed a qualitative analysis of 13 student essays, independently coding phrases according to naturally-emerging themes. Discrepancies among coders were resolved by consensus and discussion. Results: Important SBP-related skills for subinterns included arranging consults, coordinating discharges, and managing the ‘intern pager’. Students often reflected on systems-related issues that had a negative impact on patient care, including rigidly applied policies, provider miscommunication, and challenges in transitioning across care settings. Students also noted a link between SBP and Interpersonal Communication, recognizing systems-based knowledge and skill as a key component of effective communication with patients and colleagues. Discussion: Students readily identify learning issues related to systems-based practice in written reflections on the sub-internship experience. The most salient aspects of SBP for subinterns appear to involve care coordination and functioning as part of a health care team. Understanding that students gravitate toward these aspects of systems-based practice may be useful in designing approaches to teaching and evaluating SBP at the subintern level.