Next Generation is a Brigham Clinical & Research News column penned by students, residents, fellows and postdocs. If you are a Brigham trainee interested in contributing a column, email us. This month’s column is written by Katherine (Katie) Rowe, BA, a medical student at Harvard Medical School.
As a medical student, I spend a lot of time thinking about systems. When a patient is short of breath, I have been trained to sequentially evaluate the possible systems involved: respiratory, cardiovascular, hematologic, or even neurologic. I practice this skill on a daily basis, with every patient I see. But what I had only begun to learn in medical school was how to apply systems thinking on a larger scale, beyond the individual patient. Very early in my education, I was looking for a tool to hone such a skill: that’s where CareZooming came in.
CareZooming, supported by Brigham and Women’s Hospital, is a web-based knowledge forum that enables sharing of quality improvement best practices across the nation. It was started by two Mass General Brigham physicians, Lisa Rotenstein, MD, MBA, and Ashley Shaw, MD, MBA and has been an important training ground for me, along with countless other students, to become systems thinkers. It has also allowed me to develop and maintain an “improvement mindset,” which may prove to be the most important piece of my training of all.
I started working for CareZooming in 2018 as a writer. My job was to interview leaders of improvement projects and to compose a framework with the “nuts and bolts” of the project — essentially, if someone were to replicate the project at their own institution, how would they do it? Project by project, I gained exposure to what makes for successful improvement work and what to avoid.
Initially, I saw projects that at first glance seemed vastly different. I spoke with the team orchestrating nurse-driven, post-hospitalization follow-up for chronic obstructive pulmonary disease patients in the Veterans Affairs health care system. I combed through the literature to learn about a mammoth care coordination program at Johns Hopkins called J-CHiP, which followed nearly 1000 high-risk patients and had a budget of millions of dollars. I also interviewed a team at Mt. Sinai that developed a virtual application for trial recruitment and had recruited enough patients for an entire inflammatory bowel disease trial in a single day. In my role as a writer, I got to take a deep dive into each project and learn about its successes and hurdles. In isolation, each project seemed unique, yet as I built my repertoire of profiles, I started to see that they often had much in common.
I soon took on a new role as the editor of our project profiles, seeing a much larger volume of projects at a higher level. This allowed me to start picking up on patterns: successful projects worked to get institutional buy-in with preliminary results early on, repurposed resources or targeted wasteful processes to be cost-saving and leveraged interdisciplinary teams to utilize the diverse skill sets across the clinical workforce. Projects that struggled included those that attempted to change too many things at once, were high-cost but did not deliver increased value to the institution or did not work to gather feedback from stakeholders involved from the beginning. Two years later, our team of two dozen student writers has produced over 100 profiles of improvement projects from across the country, and I have been lucky to edit and learn from many of those profiles.
Working for CareZooming has changed my mindset when approaching problems, both clinical and non-clinical. It has pushed me to apply the skills I have learned as a writer and editor, including identifying systems problems and seeing patterns. I have started to pick up themes in my clinical training —for example, I noticed on one surgical subspecialty service that the only two patients who missed their appointments one afternoon were trauma patients. The next week, on a different service, we again had a trauma patient who did not come to their clinic visit. Why was it that these patients were slipping through the cracks? What support could we provide to ensure this didn’t happen? In seeing patterns, I am better prepared to someday be a part of addressing larger systems issues that affect patient care in addition to taking on challenges patient-by-patient.
Most importantly, medical training rooted in quality improvement helps me to keep an “improvement mindset.” Frustrations transform into opportunities for growth. Working for CareZooming has instilled in me the value of improvement work alongside clinical work. Likewise, when CareZooming surveyed other student writers, nearly all (over 90 percent) felt they would take their learnings about health care systems innovation with them into their career — I am no exception. Ultimately, I see my improvement mindset as a form of sustenance, giving me the tools to understand and meaningfully change systems so that we can more easily provide optimal care to our patients.