Here’s something you might not have spent much time thinking about: Systems-Based Practice. Ever heard of it? I hadn’t up until recently. Like me, you might have been ignorant of this concept by name, but I’ll bet you all the money in the world you’ve actually been doing some of it in practice already. This week, let’s talk a bit about the background behind this concept and what it is. Next week, we’ll follow up with a couple of case examples from my clinical practice to elucidate how these principles and processes may be applied to podiatric medicine.

First, a little background. The ACGME (American Council on Graduate Medical Education), the accrediting body for the allopathic medicine residency community, has over the past few years, modified how it evaluates its trainees. They now have six Core or General Competencies for which allopathic trainees must demonstrate their skills. These are:

1. Communication/Interpersonal Skills
2. Professionalism
3. Patient Care
4. Knowledge
5. Systems-Based Practice
6. Practice-Based Learning and Improvement

Most of these six competencies are pretty intuitive to understand. For example, sleeping with your patients would obviously not be professional. On the other hand, the last two competencies on this list are a bit more difficult to pin down. Number 5 on our list – what we’re talking about today – is the toughest one.

So, let’s take one small step back yet again and define what a “system” means in this context. A system is a “set of interacting, interrelated, interdependent elements that work together in a particular environment to perform the functions that are required to achieve the system’s aim”¹.

Every healthcare provider is embedded within this larger system of medicine, and we all rely on each other for various outcomes. For example, if one of the functions of our national medical system is to improve the health of our citizens, then podiatric physicians are an integral part of that system. Without our care, for instance, the rates of major limb amputations would increase, thus diminishing the health of our citizens. Similarly, an operating room is a microsystem in which the surgeon would be unable to successfully complete a procedure without an anesthesiologist, scrub tech, circulating nurse, materials supplier, OR nurse manager, preoperative and postoperative nursing, janitors, and a host of others. We are all part of this system, and we all rely upon each other. We are all interrelated parts of a whole.

To think of medicine in this way requires each of us to understand a few systems-based thinking principles. These are^2-4:

• The whole has one or more defining functions.
• Each part can affect the behavior or properties of the whole.
• Each part is necessary but alone is insufficient to carry out the defining function of the whole.
• Behavior of one part of the system depends on behavior of at one other part of the system.

These may appear reasonably straightforward and obvious, but when you think about it, many podiatrists do not function in this way. Historically, podiatry has been an office-based referral practice and remains this way for many of us. Changing this perspective may require a paradigm shift in thought. It may also be important to note that many hospitals now have systems-based practice as one of its components of staff privileging and appointments.

If systems-based practice is so important what exactly are its components? Here again, the ACGME can provide us some easy information. You can follow this link to view The Complete Systems-Based Practice (SBP) Taxonomy table⁵ listing the six expectations of a current medical resident in training. Those of us beyond residency training, though, can also use this as an instructive guide to understand just what the important systems-based skills are.

As a final note to our discussion, ask yourselves the following questions to see if you already function using a systems-based approach.

1. Can you define a system?
2. How do you describe the system you work in? (Can you draw a picture?)
3. How well does the system work?
4. How would you analyze and diagnose where the system can be improved?
5. How would you identify and prioritize change?
6. Do you participate in an interdisciplinary team?
7. What are the different systems your system interacts with, and how does your system interact with these systems?
8. How is your system financed?
9. How are new members of the team trained? (How does the system renew itself?)
10. If your system is involved in medical education, how is medical education done successfully?

Taking this approach to the practice of medicine changes our focus from the myopic “how do I treat this one patient” to a broader view of our health system in general. Next week we’ll discuss a couple of patient examples that brings these concepts into clear relief.

Best wishes,

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

1. Bertalanffy LV. General System Theory: Foundations, Development, Applications. New York, NY: George Braziller, Inc; 1968.
2. Ackoff R. Redesigning the Future. New York, NY: John Wiley & Sons; 1974.
3. Ackoff R. The Democratic Corporation. New York, NY: Oxford University Press; 1994.
4. Johnson J, Miller S, Horowitz S. Systems-Based Practice: Improving the Safety and Quality of Patient Care by Recognizing and Improving the Systems in Which We Work. AHRQ.gov. Accessed October 31, 2015.
5. Graham M, Naqvi Z, Encandela J, et al. Journal of Graduate Medical Education. 2009;(1):49-60.