Evolving the Systems-Based Practice Competency in Graduate Medical Education to Meet Patient Needs in the 21st-Century Health Care System.

Medical education is increasingly recognizing the importance of the systems-based practice (SBP) competency in the emerging 21st-century U.S. health care landscape.

Contributions of Health Professions Students to Health System Needs During the COVID-19 Pandemic: Potential Strategies and Process for U.S. Medical Schools.

The COVID-19 pandemic poses an unprecedented challenge to U.S. health systems, particularly academic health centers (AHCs) that lead in providing advanced clinical care and medical education.

The Exceptional Teacher Initiative: Finding a Silver Lining in Addressing Medical Student Mistreatment.

Problem: The Penn State College of Medicine (PSCOM) faced escalating reports of learner mistreatment in 2013-2017. As systems were implemented to gather and respond to student reports, faculty members expressed concern that these were creating a culture that focused on negative behaviors to the exclusion of acknowledging outstanding teaching that was also occurring.

Approach: The Exceptional Teacher Initiative was introduced in August 2017 to attempt to shift the institutional conversation around learner mistreatment by balancing reports of mistreatment with reports highlighting examples of excellent teaching considered in-line with organizational values.

Curricular Transformation in Health Systems Science: The Need for Global Change.

In this Invited Commentary, the authors propose a counterperspective to the article by Borkan and colleagues, who advocate for a circumscribed, piloted, choice-focused approach to introducing curricular redesign options in undergraduate medical education, particularly in the area of health systems science. In making this case, Borkan and colleagues cluster several kinds of innovative curricular changes that the authors of this commentary believe are best separated by the scope of change and associated educational strategy: (1) innovations customized to student interest and motivation, which are best served by focused programmatic interventions; (2) innovations such as longitudinal integrated clerkships that represent creative and needed educational strategies but may be difficult to expand because of complex barriers; and (3) innovations that are truly transformational, with critical connections far beyond the boundaries of the medical school curriculum, which must be addressed in a comprehensive approach-despite the challenges, frustrations, and difficulties. The authors situate health systems science squarely into the third category, and address three important questions addressing the nature and demands of this change.

Evolutionary Science as a Method to Facilitate Higher Level Thinking and Reasoning in Medical Training.

Evolutionary science is indispensable for understanding biological processes. Effective medical treatment must be anchored in sound biology. However, currently the insights available from evolutionary science are not adequately incorporated in either pre-medical or medical school curricula.

Value-Added Clinical Systems Learning Roles for Medical Students That Transform Education and Health: A Guide for Building Partnerships Between Medical Schools and Health Systems.

To ensure physician readiness for practice and leadership in changing health systems, an emerging three-pillar framework for undergraduate medical education integrates the biomedical and clinical sciences with health systems science, which includes population health, health care policy, and interprofessional teamwork. However, the partnerships between medical schools and health systems that are commonplace today use health systems as a substrate for learning. Educators need to transform the relationship between medical schools and health systems.

Educating for the 21st-Century Health Care System: An Interdependent Framework of Basic, Clinical, and Systems Sciences.

In the face of a fragmented and poorly performing health care delivery system, medical education in the United States is poised for disruption. Despite broad-based recommendations to better align physician training with societal needs, adaptive change has been slow. Traditionally, medical education has focused on the basic and clinical sciences, largely removed from the newer systems sciences such as population health, policy, financing, health care delivery, and teamwork.

The status of evolutionary medicine education in North American medical schools.

Background: Medical and public health scientists are using evolution to devise new strategies to solve major health problems. But based on a 2003 survey, medical curricula may not adequately prepare physicians to evaluate and extend these advances. This study assessed the change in coverage of evolution in North American medical schools since 2003 and identified opportunities for enriching medical education.

Expressing clinical reasoning and uncertainties during a Thai internal medicine ambulatory care rotation: does the SNAPPS technique generalize?

Background: SNAPPS is a learner-centered approach to case presentations that was shown, in American studies, to facilitate the expression of clinical reasoning and uncertainties in the outpatient setting.

Aim: To evaluate the SNAPPS technique in an Asian setting.

Methods: We conducted a quasi-experimental trial comparing the SNAPPS technique to the usual-and-customary method of case presentations for fifth-year medical students in an ambulatory internal medicine clerkship rotation at Khon Kaen University, Thailand.

SNAPPS-Plus: an educational prescription for students to facilitate formulating and answering clinical questions.

Purpose: To analyze the content and quality of PICO-formatted questions (Patient-Intervention-Comparison-Outcome), and subsequent answers, from students' educational prescriptions added to the final SNAPPS Select step (SNAPPS-Plus).

Method: Internal medicine clerkship students at the University of Minnesota Medical Center were instructed to use educational prescriptions to complement their bedside SNAPPS case presentations from 2006 to 2010. Educational prescriptions were collected from all eligible students and coded for topic of uncertainty, PICO conformity score, presence of answer, and quality of answer.

Student uncertainties drive teaching during case presentations: more so with SNAPPS.

Purpose: To compare the nature of uncertainties expressed by medical students using the six-step SNAPPS technique for case presentations (Summarize history and findings; N>arrow the differential; Analyze the differential; Probe preceptors about uncertainties; Plan management; Select case-related issues for self-study) versus those expressed by students doing customary presentations and to elucidate how preceptors respond.

Method: The authors performed a secondary analysis in 2009 of data from a 2004-2005 randomized study, comparing SNAPPS users' case presentations with other students' presentations. Authors coded transcriptions of audiotaped presentations to family medicine preceptors for type of student uncertainties, nature of preceptor responses, alignment of preceptor responses with uncertainty types, and expansion of preceptors' responses beyond addressing uncertainties.

Using SNAPPS to facilitate the expression of clinical reasoning and uncertainties: a randomized comparison group trial.

Purpose: When medical students present cases to preceptors, they focus mainly on factual information and reveal little about their diagnostic reasoning or uncertainties. Do third-year students using the six-step, learner-centered SNAPPS technique (Summarize history and findings, Narrow the differential; Analyze the differential; Probe preceptor about uncertainties; Plan management; Select case-related issues for self-study) for case presentations to family medicine ambulatory care preceptors express clinical reasoning and learning issues more than students not trained in the technique?

Method: The authors conducted a posttest-only, comparison groups, randomized trial in 2004-2005 with 64 students in three groups: SNAPPS training, feedback training (controlling for training time), and usual-and-customary instruction. SNAPPS training combined brief faculty development with more extensive learner development followed by practice during a four-week family medicine rotation.

Population medicine in a curricular revision at Case Western Reserve.

Inclusion of population medicine in a medical school curriculum has received growing attention. Recently, the Association of American Medical Colleges has highlighted this issue through support of the Regional Medicine and Public Health Education Centers initiative. The Case Western Reserve University School of Medicine joined this consortium while implementing a new curriculum in which population medicine would be an underlying theme woven with the classic science elements of disease.

SNAPPS: a learner-centered model for outpatient education.

The unique character of medical education in the outpatient setting has created challenges in teaching and learning that cannot be solved by the adaptation of traditional inpatient approaches. Previous work and the authors' own observational study describe a relatively passive learner focused on reporting history and physical examination data to the preceptor. Based on the work of Bordage in cognitive learning, and that of Osterman and Kottkamp on reflective practice for educators, the authors have developed a collaborative model for case presentations in the outpatient setting that links learner initiation and preceptor facilitation in an active learning conversation.