The sheer number of efforts aimed at improving the quality and efficiency of the U.S. health care system -- ranging from portions of the national Affordable Care Act to local programs at individual hospitals and practices -- reflects the urgency and importance of the task. One aspect that has received inadequate attention, according to three physicians writing in the January 2013 issue of Academic Medicine, is training the next generation of experts needed to help lead these efforts. In their Perspective article, which has been released online, the authors propose a framework for career development in what they call "health systems improvement," a term that encompasses a broad range of activities -- including management, research and public policy -- to improve the quality and efficiency of our systems of care.
"My co-authors and I each had experience in nonclinical fields such as government, consulting or law before entering medical school, leading to countless conversations with our classmates and co-residents about atypical career paths," explains Clay Ackerly, MD, MSc, management and policy fellow at Massachusetts General Hospital and the Massachusetts General Physicians Organization, a co-author of the Academic Medicine article. "During these conversations most trainees echoed common themes of wanting to have careers that allow them to improve the quality of our care delivery systems. However, most of them also had difficulty articulating their exact interests, and it became clear that we lacked a common lexicon to discuss their specific interests and potential career opportunities."
The authors -- also including Ami Parekh, MD, JD, medical director of Health Systems and Innovation at the University of California, San Francisco, and Daniel Stein, MD, senior medical resident at Brigham and Woman's Hospital -- write that while a few academic medical centers have developed programs addressing health systems improvement, many medical trainees "may become overwhelmed by the sheer number of, and lack of clarity among, possible career paths." Since many of today's health care leaders reached their current positions through what the authors call "circuitous and often serendipitous career paths," their ability to guide and advise young physicians may be limited.
Based on a series of conversations with medical students, residents and leaders in health systems improvement, the authors put together their framework. It starts with three core focus areas -- research, policy and management -- defines three intersections -- policy advising, policy translation, and implementation science -- and includes examples of potential careers, such as academic administration, health services research and government relations.
"The framework is largely a collection of definitions -- a new taxonomy, if you will -- and while some may disagree with the dividing lines, we wanted to put some structure around the passion so many trainees feel for improving the care of patients," Ackerly explains. "We hope this framework can help anyone with that passion -- from any background, not just MDs -- find productive ways to develop their interest and have an impact."
Ackerly and his co-authors suggest that trainees interested in careers in health systems improvement take a few simple steps to help guide their early career development. Some are as basic as reflecting on their own preferences, including whether they want to practice clinically, and identifying one core area on which to focus, as well as one to deemphasize. Trainees may also consider the possibility of additional formal training -- such as research fellowships or advanced degrees in public health, business, health administration or public policy. Noting that their proposed framework needs validation, the authors plan to monitor how it is used by both trainees and their mentors, refine their recommendations, and expand the examples of career options included in the paper.
"We need to bring as much talent as possible into this field. But until we have better defined career paths for trainees who want to engage in this work, many of them may become, at best, confused and, at worst, demoralized," Ackerly stresses. "We hope that making those career paths more explicit will lead to an energized workforce and will attract the needed institutional investments in time and resources. The struggle to improve the quality of health care should never end -- patients deserve nothing less."
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