SPECIAL COMMENTARY
Reinventing the Health Services Researcher Rebecca Russ-Sellers, PhD,* Jerry R. Youkey, MD,w and Ronnie D. Horner, PhDz
H
ealth services research has yet to deliver on its full promise of identifying effective or efficient approaches to the provision of health care. In preceding commentaries we have outlined considerations for conducting clinically relevant and patient-focused research.1–3 Such research addresses questions relevant and critical to health care delivery, uses methodological approaches that consider realities of the practice setting, and assesses interventions compatible with the health care delivery organizational and regulatory environment. We have also highlighted the necessity of integrating the respective strengths and research goals of all stakeholders, including clinical practitioners, academic researchers, corporate interests, and patients. We believe that at the heart of the current underachievement is the pervasive lack of clinical awareness of the prototypical health services researcher. Although the majority of health services researchers do not possess the medical doctorate, the issue is not so much lack of medical credentials as it is that the perspicacious health services researcher needs an understanding of the full context in which medicine is practiced. This context includes not only the physical setting of the clinic, but the fiscal and policy pressures and, most of all, the patient-provider covenant that is at the center of medical practice. If lack of knowledge of clinical practice has resulted in underachievement of change in health care practices and policies, then the solution lies in acquisition and utilization of that knowledge in the conduct of health services research. To achieve such enhanced and sustained insight, we suggest 2 experiential pathways to educating health services researchers in the realities of health care delivery now and into the foreseeable future.
GAINING A CLINICAL PERSPECTIVE THROUGH A CLINICALLY BASED PRACTICUM Training programs for health services research are, by and large, effective in developing the researcher’s competencies in scientific methodology underlying the discipline. What is typically lacking is training in the application of these scientific methods in the real-world of health care delivery. This deficiency can be rectified by a practicum within the health system that is the focus of the research effort. This would entail immersion into the clinical environment so that the health services researcher experiences first-hand the organization, management and operation of, say, a general practice clinic or an operating room. The intensity of the practicum can be tailored to the individual health services researcher based on his or her desires, training, and prior experiences. Although the practicum could be a passive observational exercise, we advocate a more active experience. One type of practicum is the embedded health scientist approach that involves a short-term, intense experience. Embedded health scientists function as members of health care delivery workforce teams, serving as research experts in the investigation and solving of critical health care delivery issues faced by the health care units in which they are embedded. As one version, these embedded researchers may have From the *Care Coordination Institute, Greenville Health System; wUniversity of South Carolina School of Medicine, Greenville; and zDepartment of Health Services Policy and Management, University of South Carolina, Columbia, SC. The authors declare no conflict of interest. Reprints: Ronnie D. Horner, PhD, Department of Health Services Policy and Management, Arnold School of Public Health, Discovery I Building, Suite 303, 915 Greene Street, Columbia, SC 29208. E-mail: [email protected]. Copyright r 2014 by Lippincott Williams & Wilkins ISSN: 0025-7079/14/5207-0573
Medical Care
Volume 52, Number 7, July 2014
www.lww-medicalcare.com |
573
Russ-Sellers et al
Medical Care
Volume 52, Number 7, July 2014
a short-term, project-focused placement through academic and clinical partnerships, again to solve a current, clinically identified problem. Another type of practicum is a fellowship formatted similar to graduate medical education residencies. It involves a much longer defined-length program, involving a structured experiential curriculum designed to develop additional competencies through numerous varied experiences in mentoring and being mentored. It should be noted that these practicums represent an applied, collaborative, mutual-learning opportunity for the clinician (as supervisor of the experience) and the researcher (as researcher-in-residence) with the goal of developing several competencies in each. For the health services researcher, these competencies include the following.
appreciate the perspectives of others involved in the effort, as well as the strengths and weaknesses of themselves and each of their collaborators. Perhaps more importantly, effective collaboration involves interweaving individual strengths to offset shortcomings among the partners to achieve an agreed upon goal—the collaborative whole should become more than the sum of the parts. Through the day-to-day interactions involved in the practicum, the health services researcher will learn how to bring his or her skill set into the clinical environment in a complementary manner to address clinically driven issues in the delivery of health care. Needless to say, such collaboration is more effective when the clinician and the health services researcher check their egos at the proverbial door.
Understanding of the Complexity of the Clinical Environment
REPRIORITIZING HEALTH SERVICES RESEARCH OUTCOMES ACCORDING TO CLINICAL EFFECTS
Real time experience in the world of medical practice will provide awareness of the full array of “moving parts” and insight into how to investigate intervention that meshes with this “machinery.” These “moving parts” include clinical workflow, such as the flexibility of patient scheduling, clinical work intensity, physician and extender staffing, seasonal cycles in clinical activity, fiscal pressures in the generation of revenue, policy pressures determining quality measures that can enhance reimbursement or levy penalties, and regulatory requirements unique to the patient-provider setting. The health services researcher will also gain a critical understanding of the patients served by the medical unit and the roles of structural, social, economic, and disease orientations that facilitate and impede care.
Refining the health services researcher into a more effective change agent for the health care delivery system also requires a rethinking of the metrics by which we assign value to this research. Historically, research has been assigned value based on 2 major outcomes. The first is contribution to scientific knowledge as evidenced by scientific publications that arise from the work. The metrics used for this criterion include number of publications, the reputation of the journals in which the articles appear, and the number of times a publication is cited by one’s peers. The second outcome is the scientific merit of the work as indicated by award of funding for its conduct. The metrics for this criterion include size and source of the award. Scientific merit is typically determined by one’s colleagues through peer review. Having been involved in peer review panels as members, as funding agency program officials, and as applicants for grants, we contend that the peer review process is, shall we say, highly subjective. Although perceived scientific rigor of the methods weighs heavily in determining merit, so do a number of other factors. The perceived reputation of the investigator’s institution and the investigator’s own reputation for contributing to scientific knowledge often seem to carry considerable weight in the decision process. In contrast, a clear-eyed assessment of the potential of the project to yield sustainable change in practice or policy does not seem to exert much influence at all. We offer as supporting evidence for this latter conclusion our observation that many health services researchers cannot convincingly articulate where their research topic fits in the overall scheme of health care delivery, nor can they provide an accurate assessment of the potential for their work to effect meaningful change. An exercise that we have performed repeatedly is further evidence. If you ask a room full of health services researchers for a show of hands as to who among them has conducted a study that identifiably changed policy or practice, there will be few, if any, hands raised. It is our contention that the better metric for measuring health services research value is by actual impact on health care delivery, and particularly if that impact is of direct and identifiable benefit to patients. The first tenet of medicine is “Do no harm.” This is the fundamental principal of the covenant between the provider
Understanding That the “Bottom Line” in Health Care Delivery is the Needs of the Patient For health care delivery research, the old adage that “Time is money” can be recharacterized as “Time is life.” Delay in meeting health care needs may have profound implications for the lives of patients. Without denigrating the importance of longitudinal studies and necessity of confirming findings through follow-up investigation, a patient-centered focus should generate a sense of urgency for making health care delivery changes. This understanding shifts emphasis from scientific certitude in identifying the perfect intervention to the need for identification and rapid translation of interventions that will have an impact for patients now. Admittedly, this change in emphasis will likely result in the necessity of fine-tuning the implemented intervention over time but, then, most health care delivery interventions require ongoing process improvement. Moreover, the health care environment is dynamic both at the macro policy level and the micro practice level such that even effective interventions can quickly become suboptimal and require modification or even replacement.
Understanding Effective Collaboration A third competency for the health services researcher to gain from the clinical practicum is knowledge of how to function effectively as a researcher—an effective collaborator—within a clinical environment. Effective collaborators understand and
574 | www.lww-medicalcare.com
r
2014 Lippincott Williams & Wilkins
Medical Care
Volume 52, Number 7, July 2014
and patient. The provider is to be the patient’s advocate who seeks to do what is best for the patient. We suggest that the first tenant of health services research become “Do good.” The health services researcher, then, becomes advocate for identifying and implementing changes in practice or policy that will benefit the patient. There is nothing inherently wrong with the traditional research evaluation measures of merit: presentations, publications, and research support. However, the valuation of clinically driven health services research should, first and foremost, be based on the direct and beneficial outcomes of the intervention derived from the research.
Reinventing the Health Services Researcher
will require enhancement of their education opportunities to provide them with an understanding of real-world clinical challenges and awareness of the health care environment in which they must generate actionable research findings. Postdoctorate delivery system practicums like embedded scientists experiences or fellowship programs can provide such opportunities. For this to be attractive to health services researchers, the reinvented health services researcher must be supported by a scientific community that advocates for, and uses, a set of metrics that reward investigation designed to effect change that is rapidly beneficial to patients.
CONCLUDING THOUGHTS
REFERENCES
The initial commentaries in this series posited that change in the direction and conduct of health services research is necessary to expand research capacity to generate findings relevant to, and adoptable by, clinicians and patients. For health services researchers to lead such change
1. Horner RD, Russ-Sellers R, Youkey JR. Rethinking health services research. Med Care. 2013;51:1031–1033. 2. Sinopoli A, Russ-Sellers R, Horner RD. Clinically-driven health services research. Med Care. 2014;52:183–184. 3. Russ-Sellers R, Hudson M, Youkey JR, et al. Achieving effective health service research partnerships. Med Care. 2014;52:289–290.
r
2014 Lippincott Williams & Wilkins
www.lww-medicalcare.com |
575
Reinventing the Health Services Researcher Rebecca Russ-Sellers, PhD,* Jerry R. Youkey, MD,w and Ronnie D. Horner, PhDz
H
ealth services research has yet to deliver on its full promise of identifying effective or efficient approaches to the provision of health care. In preceding commentaries we have outlined considerations for conducting clinically relevant and patient-focused research.1–3 Such research addresses questions relevant and critical to health care delivery, uses methodological approaches that consider realities of the practice setting, and assesses interventions compatible with the health care delivery organizational and regulatory environment. We have also highlighted the necessity of integrating the respective strengths and research goals of all stakeholders, including clinical practitioners, academic researchers, corporate interests, and patients. We believe that at the heart of the current underachievement is the pervasive lack of clinical awareness of the prototypical health services researcher. Although the majority of health services researchers do not possess the medical doctorate, the issue is not so much lack of medical credentials as it is that the perspicacious health services researcher needs an understanding of the full context in which medicine is practiced. This context includes not only the physical setting of the clinic, but the fiscal and policy pressures and, most of all, the patient-provider covenant that is at the center of medical practice. If lack of knowledge of clinical practice has resulted in underachievement of change in health care practices and policies, then the solution lies in acquisition and utilization of that knowledge in the conduct of health services research. To achieve such enhanced and sustained insight, we suggest 2 experiential pathways to educating health services researchers in the realities of health care delivery now and into the foreseeable future.
GAINING A CLINICAL PERSPECTIVE THROUGH A CLINICALLY BASED PRACTICUM Training programs for health services research are, by and large, effective in developing the researcher’s competencies in scientific methodology underlying the discipline. What is typically lacking is training in the application of these scientific methods in the real-world of health care delivery. This deficiency can be rectified by a practicum within the health system that is the focus of the research effort. This would entail immersion into the clinical environment so that the health services researcher experiences first-hand the organization, management and operation of, say, a general practice clinic or an operating room. The intensity of the practicum can be tailored to the individual health services researcher based on his or her desires, training, and prior experiences. Although the practicum could be a passive observational exercise, we advocate a more active experience. One type of practicum is the embedded health scientist approach that involves a short-term, intense experience. Embedded health scientists function as members of health care delivery workforce teams, serving as research experts in the investigation and solving of critical health care delivery issues faced by the health care units in which they are embedded. As one version, these embedded researchers may have From the *Care Coordination Institute, Greenville Health System; wUniversity of South Carolina School of Medicine, Greenville; and zDepartment of Health Services Policy and Management, University of South Carolina, Columbia, SC. The authors declare no conflict of interest. Reprints: Ronnie D. Horner, PhD, Department of Health Services Policy and Management, Arnold School of Public Health, Discovery I Building, Suite 303, 915 Greene Street, Columbia, SC 29208. E-mail: [email protected]. Copyright r 2014 by Lippincott Williams & Wilkins ISSN: 0025-7079/14/5207-0573
Medical Care
Volume 52, Number 7, July 2014
www.lww-medicalcare.com |
573
Russ-Sellers et al
Medical Care
Volume 52, Number 7, July 2014
a short-term, project-focused placement through academic and clinical partnerships, again to solve a current, clinically identified problem. Another type of practicum is a fellowship formatted similar to graduate medical education residencies. It involves a much longer defined-length program, involving a structured experiential curriculum designed to develop additional competencies through numerous varied experiences in mentoring and being mentored. It should be noted that these practicums represent an applied, collaborative, mutual-learning opportunity for the clinician (as supervisor of the experience) and the researcher (as researcher-in-residence) with the goal of developing several competencies in each. For the health services researcher, these competencies include the following.
appreciate the perspectives of others involved in the effort, as well as the strengths and weaknesses of themselves and each of their collaborators. Perhaps more importantly, effective collaboration involves interweaving individual strengths to offset shortcomings among the partners to achieve an agreed upon goal—the collaborative whole should become more than the sum of the parts. Through the day-to-day interactions involved in the practicum, the health services researcher will learn how to bring his or her skill set into the clinical environment in a complementary manner to address clinically driven issues in the delivery of health care. Needless to say, such collaboration is more effective when the clinician and the health services researcher check their egos at the proverbial door.
Understanding of the Complexity of the Clinical Environment
REPRIORITIZING HEALTH SERVICES RESEARCH OUTCOMES ACCORDING TO CLINICAL EFFECTS
Real time experience in the world of medical practice will provide awareness of the full array of “moving parts” and insight into how to investigate intervention that meshes with this “machinery.” These “moving parts” include clinical workflow, such as the flexibility of patient scheduling, clinical work intensity, physician and extender staffing, seasonal cycles in clinical activity, fiscal pressures in the generation of revenue, policy pressures determining quality measures that can enhance reimbursement or levy penalties, and regulatory requirements unique to the patient-provider setting. The health services researcher will also gain a critical understanding of the patients served by the medical unit and the roles of structural, social, economic, and disease orientations that facilitate and impede care.
Refining the health services researcher into a more effective change agent for the health care delivery system also requires a rethinking of the metrics by which we assign value to this research. Historically, research has been assigned value based on 2 major outcomes. The first is contribution to scientific knowledge as evidenced by scientific publications that arise from the work. The metrics used for this criterion include number of publications, the reputation of the journals in which the articles appear, and the number of times a publication is cited by one’s peers. The second outcome is the scientific merit of the work as indicated by award of funding for its conduct. The metrics for this criterion include size and source of the award. Scientific merit is typically determined by one’s colleagues through peer review. Having been involved in peer review panels as members, as funding agency program officials, and as applicants for grants, we contend that the peer review process is, shall we say, highly subjective. Although perceived scientific rigor of the methods weighs heavily in determining merit, so do a number of other factors. The perceived reputation of the investigator’s institution and the investigator’s own reputation for contributing to scientific knowledge often seem to carry considerable weight in the decision process. In contrast, a clear-eyed assessment of the potential of the project to yield sustainable change in practice or policy does not seem to exert much influence at all. We offer as supporting evidence for this latter conclusion our observation that many health services researchers cannot convincingly articulate where their research topic fits in the overall scheme of health care delivery, nor can they provide an accurate assessment of the potential for their work to effect meaningful change. An exercise that we have performed repeatedly is further evidence. If you ask a room full of health services researchers for a show of hands as to who among them has conducted a study that identifiably changed policy or practice, there will be few, if any, hands raised. It is our contention that the better metric for measuring health services research value is by actual impact on health care delivery, and particularly if that impact is of direct and identifiable benefit to patients. The first tenet of medicine is “Do no harm.” This is the fundamental principal of the covenant between the provider
Understanding That the “Bottom Line” in Health Care Delivery is the Needs of the Patient For health care delivery research, the old adage that “Time is money” can be recharacterized as “Time is life.” Delay in meeting health care needs may have profound implications for the lives of patients. Without denigrating the importance of longitudinal studies and necessity of confirming findings through follow-up investigation, a patient-centered focus should generate a sense of urgency for making health care delivery changes. This understanding shifts emphasis from scientific certitude in identifying the perfect intervention to the need for identification and rapid translation of interventions that will have an impact for patients now. Admittedly, this change in emphasis will likely result in the necessity of fine-tuning the implemented intervention over time but, then, most health care delivery interventions require ongoing process improvement. Moreover, the health care environment is dynamic both at the macro policy level and the micro practice level such that even effective interventions can quickly become suboptimal and require modification or even replacement.
Understanding Effective Collaboration A third competency for the health services researcher to gain from the clinical practicum is knowledge of how to function effectively as a researcher—an effective collaborator—within a clinical environment. Effective collaborators understand and
574 | www.lww-medicalcare.com
r
2014 Lippincott Williams & Wilkins
Medical Care
Volume 52, Number 7, July 2014
and patient. The provider is to be the patient’s advocate who seeks to do what is best for the patient. We suggest that the first tenant of health services research become “Do good.” The health services researcher, then, becomes advocate for identifying and implementing changes in practice or policy that will benefit the patient. There is nothing inherently wrong with the traditional research evaluation measures of merit: presentations, publications, and research support. However, the valuation of clinically driven health services research should, first and foremost, be based on the direct and beneficial outcomes of the intervention derived from the research.
Reinventing the Health Services Researcher
will require enhancement of their education opportunities to provide them with an understanding of real-world clinical challenges and awareness of the health care environment in which they must generate actionable research findings. Postdoctorate delivery system practicums like embedded scientists experiences or fellowship programs can provide such opportunities. For this to be attractive to health services researchers, the reinvented health services researcher must be supported by a scientific community that advocates for, and uses, a set of metrics that reward investigation designed to effect change that is rapidly beneficial to patients.
CONCLUDING THOUGHTS
REFERENCES
The initial commentaries in this series posited that change in the direction and conduct of health services research is necessary to expand research capacity to generate findings relevant to, and adoptable by, clinicians and patients. For health services researchers to lead such change
1. Horner RD, Russ-Sellers R, Youkey JR. Rethinking health services research. Med Care. 2013;51:1031–1033. 2. Sinopoli A, Russ-Sellers R, Horner RD. Clinically-driven health services research. Med Care. 2014;52:183–184. 3. Russ-Sellers R, Hudson M, Youkey JR, et al. Achieving effective health service research partnerships. Med Care. 2014;52:289–290.
r
2014 Lippincott Williams & Wilkins
www.lww-medicalcare.com |
575
