DOI
https://doi.org/10.1080/10401334.2011.561758

Summary
In this paper the connection of the graduate medical education programs in the United States to system-based practice (SBP) is examined.
In 2001, the Accreditation Council for Graduate Medical Education (ACGME) began requiring graduate medical education programs in the United States to incorporate the SBP competency into their curricula. Despite efforts by program directors to build systems-based care experiences into their programs, residencies continue to struggle with teaching and assessing SBP.
One major obstacle may be that the competency alone is not sufficient to support assessment. The authors believe that the foundational construct underlying SBP is systems thinking, absent from the current Accreditation Council for Graduate Medical Education competency language.
The authors first describe psychometric issues that currently constrain the development of effective curricula to teach and assess SBP behaviors. They point out that explicit definitions of constructs are critical for education, assessment, and research purposes and they conclude that system thinking is a construct that is still missing from most discussions on teaching and assessing SBP.
In general, residency programs have focused upon discrete aspects of the multifaceted SBP competency. Although residency programs have approached the task of teaching and assessing SBP from multiple perspectives, articles describing SBP curricula or assessment typically have not gone beyond the ACGME’s competency language to include systems thinking objectives.
Then, the authors examine system thinking in other fields such as aviation, natural resource management and healthcare system, where the focus has moved from the individual to consideration of the function or dysfunction of the system as a whole.
Despite residency programs’ inclusion of learning experiences designed to highlight SBP, residents often have only a partial understanding of a patient’s overall system of care. Each training site can be conceived of as a separate clinical microsystem with differing missions, goals, functions, and stakeholders (nurses, physicians, trainees, and ancillary healthcare staff). In order to fostering systems thinking the authors suggest that changes have to be done in 3 levels: faculty development, development of residents as system thinkers and residency programs.
The authors conclude that residency programs should incorporate systems thinking models into their curricula. Trainees should be taught to understand systems at an abstract level, in order to analyze their own healthcare systems, and participate in quality and patient safety activities.

Relevance for Complex Systems Knowledge
This paper is relevant with restructuring of Medical education and deals with system thinking. Through the examination of the residency programs in graduate medical education the authors conclude that systems thinking is the missing foundational construct.

Point of Strength
The point of strength of this paper is that it highlights the necessity for reforming medical education by incorporating system thinking.