The perspicacious health services researcher

by The Incidental Economist on July 15, 2014 · 11 comments

In a series of special commentaries published in the journal Medical Care [1-4], Rebecca Russ-Sellers, Jerry Youkey, Ronnie Horner, and Matthew Hudson raised some provocative ideas about how health services research ought to be reoriented. I found myself agreeing with some of their suggestions and in strong disagreement with others. In this post, I’ll cover some of their ideas I think make sense. In a subsequent post, I’ll push back against a few that I think do not.

I read their most recent commentary [4] first, so I’ll begin there. (For the reader’s convenience, full references and links to all their commentaries to date are at the end of this post.) The premise, established in the first three commentaries [1-3] is that health services research (HSR) has underachieved, failing to identify “effective or efficient approaches to the provision of health care.” I don’t fully agree with that premise, but it’s important not to be too defensive. Some valuable things can be learned by withstanding a bit of critique.

Indeed, I think the authors are on to something in writing,

[A]t 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.

I cannot think of a good reason why greater understanding of the practice of medicine would not improve the work of a health services researcher. I don’t mean (and neither do the authors) that every HSR practitioner need to be able to perform open heart surgery. Heavens no! But knowing just enough to be able to make one’s way through at least some of the clinical studies one encounters in, say, the New England Journal of Medicine or the Journal of the American Medical Association is important.

Why? Because we’re supposed to be in an age of ascendance of evidence-based medicine. HSR practitioners should be participants in this enterprise, if not at or near the center of it. And at the center, it is about medicine and how it’s delivered.

For this reason, I encouraged the community to beef up its understanding of medical science in a 2013 post on this blog. I still have not come across a course in any HSR-relevant program that teaches basic concepts of medicine for social scientists. (If you’re aware of one, let me know.) I wrote,

Does it strike you as odd that we are training students to be experts in health care delivery, organization, and policy without at least offering the opportunity for them to learn some details about medical science? It’s a bit like an engineer not knowing Newton’s laws. Maybe this made sense some time in the past, but given the current emphasis on evidence-based care and comparative effectiveness research, I think it is time that even health services researchers, health economists, and anybody who claims to be a health policy expert knew more about medical science. [...]

We all, as health services researchers, need to get up to speed. If we’re going to talk the “evidence-based medicine” talk, we’ve got to walk the walk.

In that post, I went on to suggest ways you can get yourself up to speed, even without a course, though that would be better. Likewise, Russ-Sellers and colleagues [4] argue that students and practitioners of HSR should participate in a practicum in which they are immersed in the clinical environment, experiencing “first-hand the organization, management and operation of, say, a general practice clinic or an operating room.”

This sounds great to me. Sign me up. (But also pay my salary during my immersion please!)

References

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.

4. Russ-Sellers R, Youkey JR, Horner RD. Reinventing the health services researcher. Med Care. 2014;52:573-575.

Austin B. Frakt, PhD, is a health economist with the Department of Veterans Affairs and an associate professor at Boston University’s School of Medicine and School of Public Health. He blogs about health economics and policy at The Incidental Economist and tweets at @afrakt. The views expressed in this post are that of the author and do not necessarily reflect the position of the Department of Veterans Affairs or Boston University.

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{ 9 comments }

Zackary Berger July 15, 2014 at 9:24 am

drop by my clinic anytime.

Lisa Simpson July 15, 2014 at 12:02 pm

I think this is a time of tremendous potential and change for our field of HSR, as I have noted before in various talks, posts and articles (e.g. Learning How to Learn (http://tiny.cc/l4o1ix); so I agree with the authors that we are seeing an evolution in our field – maybe not a “re-orientation.” I also agree that we have much more work to do to realize the full impact of HSR on health and care improvement.

As a field we must do a better job at answering the tough questions, not just the easy ones, the ones that are driven by what data we have, or the ones that the vagaries of funding agencies drive us to. To that end, I think the authors’ view of the field of HSR is far too limiting. While the care process is often the central focus of our work, it goes far beyond that. The work of our colleagues in the social sciences develops the theories that ground our study designs, advances the methods we use and provide critical evaluations of new policies and regulations. The breadth and complexity of our field must both include – and expand beyond – the clinical perspective.

And yet, here is where I agree with the authors’ comments about the “pervasive lack of clinical awareness of the prototypical health services researcher.” As a pediatrician by training, I still find myself surprised – sometimes even stunned – at the comments of some colleagues in various social sciences about the motivations and processes inherent in clinical care delivery. Patients and their care are often messy, unpredictable, and inefficient. Understanding those nuances better and using our rigorous HSR methods to tease out patient, provider, and contextual dimensions will only improve our work. So I endorse the authors’ call for more engagement and awareness by health services researchers in the clinical enterprise. The challenge is how to achieve that awareness and engagement! We have launched the Delivery System Science Fellowship as one approach – to embed superbly prepared researchers in clinical systems. I welcome suggestions on how AcademyHealth might do even more to facilitate greater “clinical awareness” across our field. What else could or should we do?

However, if there is any “underachievement” by our field (as the authors assert), I think it is that once we have relevant and “dissemination ready” findings, we are not getting those into the hands of the right decisionmakers, at the right time, in the right way.

AcademyHealth works hard to bridge that divide. We work as disseminators and knowledge brokers for the field. And, we are building on our traditional dissemination mechanisms (conferences, technical assistance, etc…) through our Translation and Dissemination institute to identify innovations and approaches from other fields to help push ourselves and our field to improve in this challenge. Here too research can help us learn how to do this better! That is why I am so excited to be co-hosting with NIH the 7th Annual Conference on Research on Dissemination and Implementation (http://tiny.cc/f1o1ix).

What else could or should we do? Let me know!!

Lisa

Will Fleischman July 15, 2014 at 11:03 pm

I agree on the importance of health services researchers understanding the nuances of the practice of medicine; and including more on this in their training curriculum will make some difference as long as it is structured around clinical ‘immersion’, not abstract classroom discussions. Still, I’m skeptical any of this would do justice in conveying the “patient-provider covenant”. Real appreciation of the practice of medicine comes with practicing medicine. We need to train and support more clinicians as health services researchers.

Will Fleischman July 15, 2014 at 11:09 pm

…and since I’m advocating I should add in full disclosure: I have myself just begun such a training program.

Michelle Moniz July 16, 2014 at 8:05 am

I am an obstetrician-gynecologist and currently pursuing a fellowship in HSR. In reading this piece and the comments here, I can’t help but think that clinicians are an important, but sometimes underutilized resource in the HSR space. In my field, I commonly interact with clinicians who haven’t heard of HSR. Better involving practitioners with a wealth of clinical knowledge into health services research activities is, in my view, a critically important way to use an existing resource in our healthcare system and ensure that HSR questions are grounded in the context of the provider-patient relationship and day to day healthcare delivery. Importantly, clinicians with an HSR perspective may also be better prepared to influence our medical system at levels other than the doctor-patient level.

lisa Simpson July 22, 2014 at 8:06 pm

Thanks for all the comments! These as well as comments on the RWJF Learning Network on Linked In on this topic have really underscored the importance of cross-fertilization and more of it earlier in careers. Not only do HSR’s need to better understand different context and the core transactions/work of those environments to study them (be they a clinical encounter, a community program, etc…), clinicians need to be exposed to what HSR is earlier. Maybe we need an HSR 101 curriculum for medical, nursing, and other health professional schools? Maybe we need more rotations for social scientists to engage with communities and clinics? We at AcademyHealth will be noodling on this… If folks have additional thoughts – we are always listening!!

Margaret July 16, 2014 at 10:52 am

The Tulane MPH program requires a course called “The Biological Basis of Disease” which may fit what you’re looking for. The course objectives are here: http://www.sph.tulane.edu/publichealth/tropmed/upload/TRMD-6010-Biological-Basis-of-Diseases.pdf

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