Graduate Medical Education Training Research Articles

Integrating the social determinants of health into graduate medical education training: a scoping review

BackgroundThe social determinants of health (SDH) play a key role in the health of individuals, communities, and populations. Academic institutions and clinical licensing bodies increasingly recognize the need for healthcare professionals to understand the importance of considering the SDH to engage with patients and manage their care effectively. However, incorporating relevant skills, knowledge, and attitudes relating to the SDH into curricula must be more consistent. This scoping review explores the integration of the SDH into graduate medical education training programs.MethodsA systematic search was performed of PubMed, Ovid MEDLINE, ERIC, and Scopus databases for articles published between January 2010 and March 2023. A scoping review methodology was employed, and articles related to training in medical or surgical specialties for registrars and residents were included. Pilot programs, non-SDH-related programs, and studies published in languages other than English were excluded.ResultsThe initial search produced 829 articles after removing duplicates. The total number of articles included in the review was 24. Most articles were from developed countries such as the USA (22), one from Canada, and only one from a low- and middle-income country, Kenya. The most highly represented discipline was pediatrics. Five papers explored the inclusion of SDH in internal medicine training, with the remaining articles covering family medicine, obstetrics, gynecology, or a combination of disciplines. Longitudinal programs are the most effective and frequently employed educational method regarding SDH in graduate training. Most programs utilize combined teaching methods and rely on participant surveys to evaluate their curriculum.ConclusionApplying standardized educational and evaluation strategies for SDH training programs can pose a challenge due to the diversity of the techniques reported in the literature. Exploring the most effective educational strategy in delivering these concepts and evaluating the downstream impacts on patient care, particularly in surgical and non-clinical specialties and low- and middle-income countries, can be essential in integrating and creating a sustainable healthcare force.

Changes in attitudes, beliefs, and experiences related to pregnancy during graduate medical education training from 2005 to 2021.

Today, 50% of medical students are women, and residency and fellowship training years overlap with peak times for starting families. The authors describe attitudes toward pregnancy during residency and fellowship and report pregnancy rates and complications for female residents and resident partners across several decades. A web-based survey was emailed to 1,057 residents in 2005 (period 1) and 1,860 residents in 2021 (period 2). Anonymous surveys were sent to all trainees including pregnant trainees, affected co-trainees and trainee partners. Resident attitudes and pregnancy characteristics were compared between groups using the chi-square (χ2) test for categorical variables and the Kruskal-Wallis test for ordinal variables. A total of 442 residents (41.8%) responded to the 2005 survey, and 525 (28.2%) responded to the 2021 survey. Most residents who covered for a pregnant resident had positive feelings about covering for their colleagues during both time periods, although more positive attitudes were present during the period 2. Only about 10% of residents received compensation for their coverage during both time periods. Among residents with a pregnancy during training (i.e., themselves or partners), most characterized having a baby in training as "somewhat difficult" or "very difficult" at both time periods. Pregnancy complication rates were 33% and 44% for training years 2005 and 2021. As medical education evolves, training programs should be proactive in creating structured support systems for pregnant residents and resident partners to minimize adverse maternal and fetal outcomes and to improve training programs. Future studies are needed to elucidate the causality of higher-than-expected pregnancy complication rates.

Physicians' lifelong learning journeys: A narrative analysis of continuing professional development struggles.

Despite tenacious efforts of continuing professional development (CPD) developers and educators, physician engagement in CPD is fraught with challenges. Research suggests that these educational interventions and the maintenance of professional competence systems that mandate them are often seen as impractical, decontextualized and check-box activities by participants. This study explores physicians' learning post graduate medical education (GME) training across their CPD journey to understand how they (a) conceive of themselves as learners and (b) engage in lifelong learning across the course of their professional careers. Using narrative inquiry and holistic narrative analysis situated within a social constructivist orientation, we carried out individual interviews with physicians from across a large children's hospital network including academic hospitals, community hospitals and primary care practices. Timelines and story arcs were used to support the narrative analysis's re-storying. Twelve physicians from six different sub-specialties were interviewed. We identified three noteworthy challenges as particularly salient across participants' re-storied narratives: (i) train-on-a-track to treading water, (ii) learning takes a backseat, and (iii) learning through foraging or hunting and gathering. Participants described significant change when transitioning from GME to CPD learning. While participants identified as learners, they described the disorienting impact of losing GME's formal supports and structures. They articulated that patient care trumped learning as their top priority. They lamented having limited insight into their learning needs (e.g. little feedback data) and so resorted to engaging in CPD activities that were readily at hand-but not necessarily relevant-and to finding learning resources that might not be formally recognised for CPD credit. Physicians' learning journeys post-GME are challenging, and the systems created to support that learning are ill equipped to meet the needs of physicians transitioning from GME to CPD. To encourage meaningful learning, the complex interplay of factors impeding CPD engagement should inform future innovations.

Creation of a sustainable longitudinal women in Leadership Development (WILD) curriculum focused on graduate medical education trainees

BackgroundAlthough women comprise the majority of medical students, gender disparities emerge early and remain at the highest levels of academia. Most leadership courses focus on faculty or students rather than women graduate medical education (GME) trainees.AimTo promote the leadership development of women GME trainees through empowerment, community building, networking and mentorship, and concrete leadership skills development.SettingUniversity of California, San Francisco.Participants359 women residents and fellows from 41 specialties.Program descriptionA longitudinal curriculum of monthly workshops designed to support leadership development for women trainees. Sessions and learning objectives were designed via needs assessments and literature review.Program evaluationA mixed-methods evaluation was performed for 3 years of WILD programming. Quantitative surveys assessed participant satisfaction and fulfillment of learning objectives. Structured interview questions were asked in focus groups and analyzed qualitatively.Discussion23% of invited participants attended at least one session from 2018 to 2021, despite challenging trainee schedules. Surveys demonstrated acceptability and satisfaction of all sessions, and learning objectives were met at 100% of matched sessions. Focus groups highlighted positive impact in domains of community-building, leadership skills, mentorship, and empowerment. This program has demonstrated WILD’s longitudinal sustainability and impact for women trainees.

Rapid Root Cause Analysis: Improving OBGYN Resident Exposure to Quality Improvement and Patient Safety Curricula.

Introduction Each year, millions of patients in the United States experience harm as a result of the healthcare they receive. One mechanism used by health systems to learn how and why errors occur is root cause analysis (RCA). RCA teams develop action plans to create and implement systemic changes in healthcare delivery in order to prevent future harm. The American Council on Graduate Medical Education (ACGME) recognizes the importance of analyzing adverse events, and it requires that all residents participate in real or simulated patient safety activities, such as RCAs.Often, institutional RCAs necessitate the assimilation of participants on short notice and demand considerable time investment, limiting the feasible participation of graduate medical education (GME) trainees. This presents a gap between ACGME expectations and the reality of resident involvement in patient safety activities. We present the first iteration of a quality improvement project encompassing a three-hour resident physician training course with simulated RCA-experiential learning. The purpose of this project was to produce a condensed, educational RCA experience that adequately trains allGME learners to serve as informed healthcare safety advocates while also satisfying ACGME requirements. Methods The course ("rapid RCA") was conducted during protected weekly academic training. All residents of the San Antonio Uniformed Services Health Education Consortium (SAUSHEC) Obstetrics and Gynecology (OBGYN) residency program who had not previously participated in a real or simulated RCA were required to take the "rapid RCA." Pre- and post-course surveys were completed anonymously to assess baseline knowledge, new knowledge gained from the course, and attitudes toward the course and its importance to resident training. Results Fourteen OBGYN residents attended the "rapid RCA," indicating that 64% (14 out of 22) of the program had no previous experience or opportunity to participate in a real or simulated RCA. Participation in the course demonstrated a significant gain of new knowledge with an increase from 0/14 to 10/14 (71%) residents correctly answering all pre- and post-course questions, respectively (p < 0.001). Additionally, on a Likert scale from 1 to 5, with 5 indicating "expert level," residents indicated they felt more comfortable on patient safety topics after taking the course (mean pre-course score 1.85 to post-course score 3.64,p < 0.001). All participants indicated they would prefer to take the "rapid RCA" as opposed to the only available local alternative option for a simulated RCA, currently offered as a full-day intensive course. Conclusion A meaningful increase in patient safety knowledge and attitudes toward topics covered in an RCA was demonstrated through the implementation of a "rapid RCA" in OBGYN residents. We plan to incorporate this into our annual curriculum to satisfy ACMGE requirements. This format could be adapted for other specialties as applicable.

When Taking Pay off the Table: A Qualitative Study of Gender Equity for Academic Leaders in the US Military.

Although gender inequity persists globally in academic leadership positions, the United States Military has equitable pay and, in academic pediatrics, has equitable gender representation in leadership positions. To better understand how the US Military framework affects physician leaders, pediatricians were interviewed to illuminate the factors that facilitated their success and what barriers they faced in their career. In 2022, following institutional review board approval, semi-structured interviews were conducted with 13 total participants (69% female, 31% male) serving as general pediatricians or pediatric subspecialists in the US Military. These pediatricians were in leadership positions of military academic medicine across seven graduate medical education (GME) sites. The interviews examined the leaders' perceptions of facilitators and barriers to their success. The authors analyzed the interviews using Acker's theory of gendered organizations as a theoretical framework, which explains embedded gender roles within work environments. Drawing on the theory of gendered organizations, the authors identified that participants described several facilitators to their success, including the availability of mentorship/sponsorship, inclusive leadership, and early and persistent exposure to women leaders in GME training and beyond. Because medicine's ideal worker was normed around the traditional roles of men, men observed and women experienced barriers to leadership success around issues related to childbearing, maternity leave, and microaggressions. This study revealed that equitability for pediatric GME leadership in the military heavily relied on structures and support created by former leaders and mentors. Isolating these structures within a unique context of military academic medicine can illuminate physicians' experiences to address barriers and better support equitable leadership roles in both military and civilian academic medicine.

Impact of Medical Training Programs on Time-to-Fill Physician Vacancies at the Veterans Health Administration.

The Department of Veterans Affairs (VA) provides the largest Graduate Medical Education (GME) training platform for health professionals in the United States. Studies on the impact of VA GME programs on physician recruitment were lacking. To examine the impact of the size of residency training programs at a VA facility on the facility's time-to-fill physician vacancies, and whether the impact differs by the socioeconomic deprivation and public school quality of the geographic area. We constructed an instrumental variable for training program size by interacting the facility clinicians share with the total training allocation nationally. Our evaluation used national data on filled physician vacancies in the VA that were posted between 2020 and 2021. The outcome evaluated was time-to-fill physician vacancies. Our explanatory variable was the facility-year level number of physician residency slots. For positions posted in 2020, an increase of one training slot was significantly associated with a decrease of 1.33 days to fill physician vacancies (95% CI, 0.38-2.28) in facilities in less deprived areas, a decrease of 1.50 days (95% CI, 0.75-2.25) in facilities with better public schools, a decrease of 3.30 days (95% CI, 0.85-5.76) in facilities in both less deprived areas and better public schools. We found similar results for positions posted in 2020 and 2021 when limiting time-to-fill to <500 days. We found that increasing the size of the residency program at a VA facility could decrease the facility's time-to-fill vacant physician positions in places with less socioeconomic deprivation or better public schools.

An Ideal System of Assessment to Support Competency-Based Graduate Medical Education: Key Attributes and Proposed Next Steps

Competency-based medical education (CBME) is the future of medical education and relies heavily on high quality assessment. However, the current assessment practices employed by many general surgery graduate medical education training programs are subpar. Assessments often lack reliability and validity evidence, have low faculty engagement, and differ from program to program. Given the importance of assessment in CBME, it is critical that we build a better assessment system for measuring trainee competency. We propose that an ideal system of assessment is standardized, evidence-based, comprehensive, integrated, and continuously improving. In this article, we explore these characteristics and propose next steps to achieve such a system of assessment in general surgery.

'The program director's word … it's stronger than the word of God': Epistemic injustice revealed through narratives of remediated graduate medical education residents.

Though graduate medical education (GME) residency training provides positive experiences for many trainees, it may also result in major stressors and negative experiences, particularly for those requiring remediation. Residents requiring remediation may experience feelings of dismay, shame and guilt that can negatively affect their training, self-efficacy and their medical careers. Power differentials between educators and residents may set the stage for epistemic injustice, which is injustice resulting from the silencing or dismissing a speaker based on identity prejudice. This can lead to decreased willingness of trainees to engage with learning. There is a paucity of literature that explores GME experiences of remediation from the resident perspective. To synthesise the narratives of physician experiences of remediation during residency through the lens of epistemic injustice. Between January and July 2022, we interviewed US physicians who self-identified as having experienced remediation during residency. They shared events that led to remediation, personal perspectives and emotions about the process and resulting outcomes. Interviews were analysed using narrative analysis with attention to instances of epistemic injustice. We interviewed 10 participants from diverse backgrounds, specialties and institutions. All participants described contextual factors that likely contributed to their remediation: (1) previous academic difficulty/nontraditional path into medicine, (2) medical disability or (3) minoritised race, gender or sexual identity. Participants felt that these backgrounds made them more vulnerable in their programmes despite attempts to express their needs. Participants reported instances of deflated credibility and epistemic injustices with important effects. Participant narratives highlighted that deep power and epistemic imbalances between learners and educators can imperil GME trainees' psychological safety, resulting in instances of professional and personal harm. Our study suggests applying an existing framework to help programme directors (PDs) approach remediation with epistemic humility.

A Transition to Practice Curriculum for Anesthesiology Fellows.

Graduate medical education trainees must be well-versed in practice management principles and how the application of this knowledge affects their patient care. The lack of exposure of anesthesiology trainees to practice management topics remains an ongoing concern nationally. Given similar feedback regarding education on practice management and financial literacy topics across all of our department's fellowship specialties, a novel pilot curriculum comprising a virtual lecture and workshop series was delivered to anesthesiology fellows throughout the academic years 2020 to 2023. Lecture topics included (1) personal finance and contract negotiation, (2) interview preparation and well-being, (3) conflict management, and (4) diversity and inclusion lectures.

Using Their Words to Shape Curricula: Targeted Well-Being Programming for Graduate Medical Education Trainees.

Using Their Words to Shape Curricula: Targeted Well-Being Programming for Graduate Medical Education Trainees.

Critical Care Ultrasound Competency of Fellows and Faculty in Pulmonary and Critical Care Medicine: A Nationwide Survey

Purpose: Competency assessment standards for Critical Care Ultrasonography (CCUS) for Graduate Medical Education (GME) trainees in pulmonary/critical care medicine (PCCM) fellowship programs are lacking. We sought to answer the following research questions: How are PCCM fellows and teaching faculty assessed for CCUS competency? Which CCUS teaching methods are perceived as most effective by program directors (PDs) and fellows. Methods: Cross-sectional, nationwide, electronic survey of PCCM PDs and fellows in accredited GME training programs. Results: PDs and fellows both reported the highest rates of fellow competence to use CCUS for invasive procedural guidance, but lower rates for assessment of deep vein thrombosis and abdominal organs. 54% and 90% of PDs reported never assessing fellows or teaching faculty for CCUS competency, respectively. PDs and fellows perceived hands-on workshops and directly supervised CCUS exams as more effective learning methods than unsupervised CCUS archival with subsequent review and self-directed learning. Conclusions: There is substantial variation in CCUS competency assessment among PCCM fellows and teaching faculty nationwide. The majority of training programs do not formally assess fellows or teaching faculty for CCUS competence. Guidelines are needed to formulate standardized competency assessment tools for PCCM fellowship programs.

International Medical Graduates and the Shortage of US Pathologists: Challenges and Opportunities.

Physician shortages are affecting many communities across the United States and all medical specialties, including pathology. International medical graduates (IMGs) make up a significant proportion of US physicians and graduate medical education (GME) trainees, including pathologists. However, noncitizen IMGs continue to face great challenges in entering the US health care workforce. To show recent and historical data on noncitizen IMGs in pathology GME training and current limitations on them remaining in the US health care workforce. Compared with applicants who do not need a visa, applicants who need a visa to train in the United States have a greatly reduced chance of matching to a residency program. After completion of residency and fellowship, noncitizen IMGs with J-1 visas face the 2-year home country residence requirement unless they obtain a waiver. H-1B visas facilitate the transition to independent practice but have limited availability. Job announcements for pathologists often do not indicate whether J-1 and H-1B visa holders are considered, which makes the job search process difficult for noncitizen IMGs. Academic and nonacademic institutions with departments of pathology should increase awareness of the pathologist shortage in the United States and the rules and regulations that limit hiring of non-US IMGs. Such institutions should also actively educate policymakers to promote durable solutions to these issues. One potential solution to these shortages may be to make it easier for noncitizen IMGs to access GME and join and remain in the US physician workforce.

Teaching Clinical Reasoning inthe Preclinical Period.

Developing the clinical reasoning skills necessary to becoming an astute diagnostician is essential for medical students. While some medical schools offer longitudinal opportunities for students to practice clinical reasoning during the preclinical curriculum, there remains a paucity of literature fully describing what that curriculum looks like. As a result, medical educators struggle to know what an effective clinical reasoning curriculum should look like, how it should be delivered, how it should be assessed, or what faculty development is necessary to be successful. We present our Introduction to Clinical Reasoning course that is offered throughout the preclinical curriculum of the Uniformed Services University of the Health Sciences. The course introduces clinical reasoning through interactive lectures and 28 case-based small group activities over 15 months.The curriculum is grounded in script theory with a focus on diagnostic reasoning. Specific emphasis is placed on building the student's semantic competence, constructing problem lists, comparing and contrasting similar diagnoses, constructing a summary statement, and formulating a prioritized differential diagnosis the student can defend. Several complementary methods of assessment are utilized across the curriculum. These include assessments of participation, knowledge, and application. The course leverages clinical faculty, graduate medical education trainees, and senior medical students as small group facilitators. Feedback from students and faculty consistently identifies the course as a highly effective and engaging way to teach clinical reasoning. Our Introduction to Clinical Reasoning course offers students repeated exposure to well-selected cases to promote their development of clinical reasoning. The course is an example of how clinical reasoning can be taught across the preclinical curriculum without extensive faculty training in medical education or clinical reasoning theory. The course can be adapted into different instructional formats to cover a variety of topics to provide the early learner with sequential exposure and practice in diagnostic reasoning.

Establishment ofthe Clinician-Scientist Investigator Opportunity Network to Develop Military Medical Research Leaders.

The ability of military clinicians to conduct military medical research is often limited because of competing priorities and a lack of research mentorship. The Clinician-Scientist Investigator Opportunity Network (CSION) was developed with the intent of training clinicians how to engage in requirements-driven research within the DoD. Three to five academic medical faculties were selected from a pool of applicants each year to participate in a 2-year research fellowship. To be eligible for the CSION program, applicants had to meet the following criteria: (1) Completed residency graduate medical education training, (2) not be currently enrolled as a graduate medical education trainee, and (3) obtained permission from their department leadership to focus 25% of their duty hours on CSION participation to include didactic and research efforts. The remaining 75% of fellows' time was dedicated to clinical duties. Monthly didactics, intensive mentorship, and consistent support were offered to each fellow by the CSION leadership team. Metrics were recorded to include both research and clinical productivity. Between January 2019 and December 2022, 12 CSION fellows graduated from the program (four in the class of 2020, three in 2021, and five in 2022). From 2019 to 2021, the 12 CSION fellows initiated 204 research protocols, generated 489 publications/presentations, and secured 33 research grants. All graduates of the program remain active in clinical research with multiple graduates currently assigned to research positions. The CSION research education program is a 2-year additional duty research fellowship producing clinician-scientists conducting military-relevant medical research and publications and may be considered a low-cost/highly efficient alternative to achieve the reported benefits of the MD-PhD tract. The expansion of the CSION program may improve the quality of military medical research and health care.

Flourishing and the Prioritization of Workplace Elements in General Surgery Residents

IntroductionTo explore and begin to operationalize workplace elements that influence general surgery (GS) resident wellbeing. Tailoring workplace wellbeing interventions is critical to their success. Occupational science has revealed that a person-centered approach to identifying positive and negative workplace influences can inform tailoring while accounting for individual differences. To our knowledge, this approach has not been applied to the surgical training environment. MethodsA national sample of GS residents from 16 Accreditation Council for Graduate Medical Education training programs ranked the importance of workplace elements via an anonymous survey. Latent profile analysis was performed to identify shared patterns of workplace element prioritization and their relation to levels of flourishing, a measure of global wellbeing. ResultsGS trainee respondents (n = 300, 34% response rate – average for studies with this sample population) expressed a hierarchy of workplace element importance which differed by gender and race. “Skills to manage stress” and “a team you feel a part of” were prioritized higher by non-males than males. Residents of color and residents underrepresented in medicine, respectively, prioritized “recognition of work/effort” and “skills to manage stress” more than White and overrepresented in medicine residents. Flourishing prevalence varied by 40% with small differences in the specific profile of workplace element prioritization. ConclusionsDifferences in prioritization of workplace elements reveal subtle but important differences that may guide the design of wellbeing interventions for different populations within surgery.

It Takes a Village: Optimal Graduate Medical Education Requires a Deliberately Developmental Organization.

Coaching is proposed as a means of improving the learning culture of medicine. By fostering trusting teacher-learner relationships, learners are encouraged to embrace feedback and make the most of failure. This paper posits that a cultural shift is necessary to fully harness the potential of coaching in graduate medical education. We introduce the deliberately developmental organization framework, a conceptual model focusing on three core dimensions: developmental communities, developmental aspirations, and developmental practices. These dimensions broaden the scope of coaching interactions. Implementing this organizational change within graduate medical education might be challenging, yet we argue that embracing deliberately developmental principles can embed coaching into everyday interactions and foster a culture in which discussing failure to maximize learning becomes acceptable. By applying the dimensions of developmental communities, aspirations, and practices, we present a six-principle roadmap towards transforming graduate medical education training programs into deliberately developmental organizations.

Consensus recommendations on peripheral blood smear review: defining curricular standards and fellow competency.

Graduate medical education training in hematology in North America is accredited by the Accreditation Council for Graduate Medical Education (ACGME). Trainees routinely review peripheral blood smears (PBS) in providing clinical care. Competency in PBS review at graduation is required by the ACGME. However, there are no consensus guidelines on best practices surrounding PBS review, education, or competency. We describe the generation of proposed theory and the consensus recommendations developed through a multi-institutional focus group, developed using constructivist grounded theory and a modified nominal group technique. Eight academic hematologists, spanning classical and malignant hematology, enrolled and participated in 2 one-hour focus groups. All routinely worked with fellows and half had formally instructed trainees on PBS interpretation. Focus group data were analyzed using mixed-methods techniques. Tenets of emerging theory were identified through inductive coding. Consensus recommendations (CR) were generated. Participants reviewed CR in an iterative fashion until consensus was reached. Strong consensus was reached on multiple aspects of PBS education. All agreed that trainees should learn PBS review through a systematic approach. Group discussion focused on disorders of red and white blood cells. The diagnoses of acute leukemia and thrombotic microangiopathies were most commonly discussed, with specific emphasis on disorders in which prompt recognition was required to avert significant patient morbidity. These CR offer external validity to future research and curricular development for both PBS review and other visuospatial tasks in medical education.

How Does TIMELESS Training Impact Resident Motivation for Learning, Assessment, and Feedback? Evaluating a Competency-Based Time-Variable Training Pilot.

As competency-based medical education has become the predominant graduate medical education training model, interest in time-variable training has grown. Despite multiple competency-based time-variable training (CBTVT) pilots ongoing in the United States, little is known about how this training approach impacts learners. The authors aim to explore how their CBTVT pilot program impacted resident motivation for learning, assessment, and feedback. The authors performed a qualitative educational case study on the Transitioning in Internal Medicine Education Leveraging Entrustment Scores Synthesis (TIMELESS) program at the University of Cincinnati from October 2020 through March 2022. Semistructured interviews were conducted with TIMELESS residents (n = 9) approximately every 6 months to capture experiences over time. The authors used inductive thematic analysis to develop themes and compared their findings with existing theories of learner motivation. The authors developed 2 themes: TIMELESS had variable effects on residents' motivation for learning and TIMELESS increased resident engagement with and awareness of the program of assessment. Participants reported increased motivation to learn and seek assessment, though some felt a tension between performance (e.g., advancement through the residency program) and growth (e.g., improvement as a physician). Participants became more aware of the quality of assessments they received, in part due to TIMELESS increasing the perceived stakes of assessment, and reported being more deliberate when assessing other residents. Resident motivation for learning, assessment, and feedback was impacted in ways that the authors contextualize using current theories of learner motivation (i.e., goal orientation theory and attribution theory). Future research should investigate how interventions, such as coaching, guided learner reflection, or various CBTVT implementation strategies, can help keep learners oriented toward mastery learning rather than toward performance.

Breaking Down Silos Between Medical Education and Health Systems: Creating an Integrated Multilevel Data Model to Advance the Systems-Based Practice Competency.

The complexity of improving health in the United States and the rising call for outcomes-based physician training present unique challenges and opportunities for both graduate medical education (GME) and health systems. GME programs have been particularly challenged to implement systems-based practice (SBP) as a core physician competency and educational outcome. Disparate definitions and educational approaches to SBP, as well as limited understanding of the complex interactions between GME trainees, programs, and their health system settings, contribute to current suboptimal educational outcomes elated to SBP. To advance SBP competence at individual, program, and institutional levels, the authors present the rationale for an integrated multilevel systems approach to assess and evaluate SBP, propose a conceptual multilevel data model that integrates health system and educational SBP performance, and explore the opportunities and challenges of using multilevel data to promote an empirically driven approach to residency education. The development, study, and adoption of multilevel analytic approaches to GME are imperative to the successful operationalization of SBP and thereby imperative to GME's social accountability in meeting societal needs for improved health. The authors call for the continued collaboration of national leaders toward producing integrated and multilevel datasets that link health systems and their GME-sponsoring institutions to evolve SBP.