VSSL Voices: Teaching Health Systems

In this installment of our “VSSL Voices” series, we caught up with Dr. Anders Chen, general internist and health systems education leader in the University of Washington Internal Medicine Residency Program.

VSSL Voices: Tell us a little about your work, including your role in health systems education.

Anders Chen: I’m a practicing primary care physician at the VA. My non-clinical work is split between population health work for the VA, policy analysis for my professional society, and health systems education for the UW Internal Medicine Residency Program. In the educational role, my work splits in two areas: I oversee the basic health systems curriculum for all IM residents, and run a “pathway” for the smaller number of residents who want a career in health systems improvement. This includes traditional quality and safety work, but increasingly residents are interested in moving into value, payment models, delivery system design and policy.

My goal is to ensure that all residents enter practice with a nuanced understanding of our health care system(s), how they came to be, what the move towards value means, and broader discussions of policy reform, from prescription drug pricing to “Medicare for All” so they can lend a meaningful voice to these discussions.

VV: How did you first get interested in education and curricula for health systems?

AC: As a resident, I found it challenging to find resources to better understand the nuances of our health care system. How did we end up in a distorted fee-for-service system? Why am I being told to admit the patient to “observation” status? How did our county/safety net hospital stay afloat? Why are prices so opaque?

It’s not that the information isn’t there, but the default is to let physicians practice clinical medicine and if they choose to engage in broader issues, that’s icing on the cake. I believe that’s a disservice to our patients and to efforts to improve our health care system, and that there is a way to educate residents about these critical issues in a way that is relevant to their clinical practice and in line with the core mission and values that drive us to be physicians.

VV: Given that interest, what health systems education projects are you currently working on?

AC: We’re continuing to refine the health systems pathway, especially the final year in the pathway which aims to help residents with professional development to launch their careers after residency. As the residents have broad interests and there is no single path forward to a health systems career, our goal is to have robust set of opportunities. We have long established relationships with our hospital and clinic leadership for those interested in administrative and quality/safety careers. We have worked with our colleagues in the Washington Health Care Authority for a few years for those residents more deeply policy inclined. This year we piloted having residents work with VSSL, for those interested in exploring how value-based models are being evaluated and implemented within a health system.

We’re also expanding our health systems training beyond just the Internal Medicine residency program to collaborate across specialties. Whether quality and safety or understanding value-based payment models, a lot of systems training is specialty agnostic and the more multispecialty and multidisciplinary the better. Our quality and safety training has included Family Medicine and Urology, and this year our policy, economics and delivery systems training included Family Medicine residents as well.

VV: Those sound like really important initiatives! Anything that you’re particularly proud of?

AC: We launched our health systems pathway 3 years ago, and we’re starting to see where the residents head in their careers, which has been exciting. Pathway residents have gone/are going into health services research, direct policy work, and health care administration. Some are staying academic, others are heavily operationally inclined, and some are interested in innovation and “start up” approaches. It’s been rewarding to see their careers take off.

The other area that has been rewarding is the warm reception residents have had to the curriculum we’ve developed in health policy, economics and delivery systems for our entire residency program. The challenge is less about what content to teach, but how to deliver it in a way that can broadly engage a diverse group of residents, with differing levels of background and interest in health care delivery systems. My biggest fear is making it dry in a way that reinforces a culture that doctors should stay in the exam room and leave the policy making to administrators, economists, lobbyists and lawyers.

VV: Given the desire to keep things fresh and moving forward, what do you think the future holds for health systems education as a topic, and those working in it?

AC: Quality and safety are important topics, with mandatory education/training mandates, and robust “off the shelf” curricula and a growing culture that this is important for all physicians.

I believe health systems training needs to expand, to not only incorporate quality and safety, but also policy, economics and delivery systems. There are small pieces of existing curricula that explore cost of care, or policy/advocacy 101 or other pieces. There are huge textbooks and Master’s programs that address this at very detailed levels.

But I haven’t seen a robust, integrated curriculum that addresses this at the right level for resident physicians. I think that’s the goal for the next few years – figure out how to make this interesting and accessible for residents at the right level of detail, and scale up a model that can be disseminated widely.