AAIM Perspectives|Articles in Press

System Citizenship: Re-Envisioning the Physician Role as Part of the Sixth Wave of Professionalism

      Perspective Viewpoints

      • The physician role must evolve to meet the needs of the 21st century healthcare system.
      • The physician role should embrace system citizenship, the idea that physicians diagnose and treat the system as they do individual patients.
      • In order for physicians to embrace system citizenship, healthcare systems need to be willing to support physicians in that work.


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        • Sullivan WM.
        What is left of professionalism after managed care?.
        Hastings Cent Rep. 1999; 29: 7-13
        • Hafferty FW
        • Levinson D.
        Moving beyond nostalgia and motives: towards a complexity science view of medical professionalism.
        Perspect Biol Med. 2008; 51: 599-615
        • Engel G.
        The clinical application of the biopsychosocial model.
        American Journal of Psychiatry. 1980; 137: 535-544
        • Kohn LT
        • Corrigan J
        • Donaldson MS
        • America I.
        To Err Is Human: Building a Safer Health System.
        National Academy Press, Cop, Washington2009
      1. Medical Professionalism in the New Millennium: A Physician Charter.
        European Journal of Internal Medicine. 2002; 13: 215-219
        • Lesser CS
        • Lucey CR
        • Egener B
        • Braddock 3rd, CH
        • Linas SL
        Levinson W. A behavioral and systems view of professionalism.
        JAMA. 2010; 304: 2732-2737
        • Marcotte LM
        • Moriates C
        • Wolfson DB
        • Frankel RM
        Professionalism as the Bedrock of High-Value Care.
        Academic Medicine. 2020; 95: 864-867
        • Marcotte L
        • Moriates C
        • Milstein A.
        Professional Organizations’ Role in Supporting Physicians to Improve Value in Health Care.
        JAMA. 2014; 312: 231
      2. Accreditation Council for Graduate Medical Education. Outcomes project. 1999. Accessed March 30, 2013. [No longer available.].

        • Graham MJ
        • Naqvi Z
        • Encandela J
        • Harding KJ
        • Chatterji M.
        Systems-Based Practice Defined: Taxonomy Development and Role Identification for Competency Assessment of Residents.
        Journal of Graduate Medical Education. 2009; 1: 49-60
      3. Johnson JK SM, SD Horowitz. Systems-Based Practice: Improving the Safety and Quality of Patient Care by Recognizing and Improving the Systems in Which We Work. 2008. Accessed September 22, 2020.

        • Guralnick S
        • Ludwig S
        • Englander R.
        Domain of competence: Systems-based practice.
        Acad Pediatr. 2014; 14: S70-S79
        • Gonzalo JD
        • Dekhtyar M
        • Starr SR
        • et al.
        Health Systems Science Curricula in Undergraduate Medical Education: Identifying and Defining a Potential Curricular Framework.
        Acad Med. 2017; 92: 123-131
        • Gonzalo JD
        • Haidet P
        • Papp KK
        • et al.
        Educating for the 21st-Century Health Care System: An Interdependent Framework of Basic, Clinical, and Systems Sciences.
        Acad Med. 2017; 92: 35-39
        • Skochelak S
        • Hammoud M
        • Lomis K
        • et al.
        Health Systems Science.
        Elsevier - Health Science, S.L.2020
        • Lucey C
        • Souba W.
        Perspective: the problem with the problem of professionalism.
        Acad Med. 2010; 85: 1018-1024
        • Lucey CR.
        Medical education: part of the problem and part of the solution.
        JAMA Intern Med. 2013; 173: 1639-1643
        • Swick HM.
        Toward a normative definition of medical professionalism.
        Acad Med. 2000; 75: 612-616
        • Edgar A.
        Professionalism in Health Care.
        in: Schramme T Edwards S The Handbook of the Philosophy of Medicine. Springer, The Netherlands2017
        • Brennan TA.
        Physicians' professional responsibility to improve the quality of care.
        Acad Med. 2002; 77: 973-980
        • Mall FP.
        Medical Education in the United States and Canada. By Abraham Flexner. With an Introduction by Henry S. Pritchett, Bulletin No. 4, of the Carnegie Foundation. 576 Fifth Ave., New York City. XVII. 346 pages.
        The Anatomical Record. 1910; 4: 278-280
        • Ludmerer KM.
        Instilling professionalism in medical education.
        JAMA. 1999; 282: 881-882
        • Schramme T.
        Handbook of the philosophy of medicine.
        Springer Berlin Heidelberg, New York, NY2016
        • Ginzburg C.
        • Davin A.
        Morelli, Freud and Sherlock Holmes: clues and scientific method.
        in: History workshop, Ruskin College1980: 5-36 (Editorial Collective, History Workshop)
        • Holden M
        • Buck E
        • Clark M
        • Szauter K
        • Trumble J.
        Professional Identity Formation in Medical Education: The Convergence of Multiple Domains.
        HEC Forum. 2012; 24: 245-255
      4. Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. Bulletin No. 4. Boston, Mass: Updyke; 1910.

        • Schroeder SA
        Shattuck Lecture. We can do better–improving the health of the American people.
        The New England journal of medicine. 2007; 357: 1221-1228
        • Hood CM
        • Gennuso KP
        • Swain GR
        • Catlin BB.
        County Health Rankings: Relationships Between Determinant Factors and Health Outcomes.
        Am J Prev Med. 2016; 50: 129-135
        • Godfrey MM
        • Foster T
        • Johnson JK
        • Nelson EC
        • Batalden PB.
        Quality by Design: A Clinical Microsystems Approach.
        John Wiley & Sons, Inc, Hoboken, New Jersey2017
        • Nash DB.
        Improving Health Outcomes Through Population Health Practice.
        Journal for Healthcare Quality. 2016; 38: 64-65
        • Berwick DM.
        The Moral Determinants of Health.
        JAMA. June 2020;
        • Hafferty F.W.
        • Castellani B.
        The increasing complexities of professionalism.
        Academic Medicine. 2010; 85: 288-301
        • American Board of Internal Medicine (ABIM)
        Medical professionalism in the new millennium: A physician charter.
        Ann Intern Med. 2002; 136: 243-246
        • Whitcomb ME.
        Fostering Civic Professionalism in Tomorrow??s Doctors.
        Academic Medicine. 2005; 80: 413-414
        • Mills AE.
        Professionalism in Tomorrow's Healthcare System: Towards Fulfilling the ACGME Requirements for System-Based Practice and Professionalism.
        University Publishing Group, 2005
        • Cohen JJ
        • Cruess S
        • Davidson C.
        Alliance between society and medicine: The public's stake in medical professionalism.
        JAMA. 2007; 298: 670-673
        • Cruess RL
        • Cruess SR
        • Boudreau D
        • Snell L
        • Steinert Y.
        A schematic representation of the professional identity formation and socialization of medical students and residents: A guide for medical educators.
        Acad Med. 2015; 90: 718-725
        • Keshmiri F.
        • Farahmand S.
        • NEDAEI H.H.N.
        Exploring the challenges of professional identity formation in clinical education environment: A qualitative study.
        Journal of Advances in Medical Education & Professionalism. 2020; 8: 42
        • Dyrbye LN
        • Shanafelt TD.
        Physician burnout: a potential threat to successful health care reform.
        JAMA. 2011; 305: 2009-2010
        • Salinas-Miranda AA
        • Shaffer-Hudkins EJ
        • Bradley-Klug KL
        • Monroe AD.
        Student and resident perspectives on professionalism: beliefs, challenges, and suggested teaching strategies.
        Int J Med Educ. 2014; 5: 87-94
        • Pauls MA.
        Teaching and evaluation of ethics and professionalism: in Canadian family medicine residency programs.
        Can Fam Physician. 2012; 58: e751-e756
        • Senge PM.
        The fifth discipline: the art and practice of the learning organization.
        Rev. and updated. Doubleday/Currency, New York2006
      5. Senge PM. Systems Citizenship: The Leadership Mandate for this Millennium. 2006;7. Accessed September 22, 2020.

        • Senge P.M.
        Education for an interdependent world: Developing systems citizens.
        Second international handbook of educational change. Springer, Dordrecht2010: 131-151
        • Friedman T.L.
        The world is flat [updated and expanded]: A brief history of the twenty-first century.
        Macmillan, 2006
      6. Gonzalo J.D., Singh MK. Building systems citizenship in health professions education: the continued call for health systems science curricula AHRQ PSNet [serial online]. 2019. Accessed February 5, 2019.

        • Davis CR
        • Gonzalo JD.
        How Medical Schools Can Promote Community Collaboration Through Health Systems Science Education.
        AMA J Ethics. 2019; 21: E239-E247
        • Gonzalo JD
        • Wolpaw T
        • Wolpaw D.
        Curricular Transformation in Health Systems Science.
        Academic Medicine. 2018; 93: 1431-1433
        • Colbert CY
        • Ogden PE
        • Ownby AR
        • Bowe C.
        Systems-Based Practice in Graduate Medical Education: Systems Thinking as the Missing Foundational Construct.
        Teaching and Learning in Medicine. 2011; 23: 179-185
      7. Sweeney LB, Meadows D. The systems thinking playbook: exercises to stretch and build learning and systems thinking capabilities.

        • Plack MM
        • Goldman EF
        • Scott AR
        • et al.
        Systems Thinking and Systems-Based Practice Across the Health Professions: An Inquiry Into Definitions, Teaching Practices, and Assessment.
        Teach Learn Med. 2018; 30: 242-254
        • Lucas B.
        Getting the improvement habit.
        BMJ Quality & Safety. 2015; 25: 400-403
        • Edgar L
        • Roberts S
        • Holmboe E.
        Milestones 2.0: A Step Forward.
        Journal of Graduate Medical Education. 2018; 10: 367-369
        • Graham MJ
        • Naqvi Z
        • Encandela JA
        • et al.
        What indicates competency in systems based practice? An analysis of perspective consistency among health care team members.
        Advances in Health Sciences Education. 2008; 14: 187-203
        • Holden MD
        • Buck E
        • Luk J
        • et al.
        Professional Identity Formation.
        Academic Medicine. 2015; 90: 761-767
      8. Accessed January 12, 2023.

        • Batalden PB
        • Leach DC.
        Sharpening the focus on systems-based practice.
        J Grad Med Educ. 2009; 1: 1-3
        • Billett S.
        Co-Participation: Affordance and engagement at work.
        New Directions for Adult and Continuing Education. 2001; 2001: 63
        • Irby D.M.
        Improving environments for learning in the health professions.
        in: Proceedings of a conference sponsored by Josiah Macy Jr. Foundation in April 2018, New York, NY Josiah Macy Jr. Foundation, 2018 (Accessed September 23, 2020)
        • Wenger E.
        Communities of practice: learning, meaning, and identity.
        Cambridge University Press, Cambridge, U.K.; New York, N.Y.1998
        • Wenger-Trayner E
        • Wenger-Trayner B.
        Learning in a landscape of practice A framework.
        Learning in Landscapes of Practice: Boundaries, Identity, and Knowledgeability in Practice-Based Learning. 2015; : 13-29
        • Lave J
        • Wenger E.
        Situated learning: legitimate peripheral participation.
        Cambridge University Press, Cambridge England; New York1991
        • Billett S.
        Workplace participatory practices.
        Journal of Workplace Learning. 2004; 16: 312-324
        • Baxley EG.
        The Clinic is The Curriculum: Can Attention to the Clinical Learning Environment Enhance Improvement in Health Care Delivery and Outcomes?.
        The Journal of the American Board of Family Medicine. 2020; 33: S46-S49
        • Asch DA.
        Evaluating Obstetrical Residency Programs Using Patient Outcomes.
        JAMA. 2009; 302: 1277
        • Leep Hunderfund AN
        • Dyrbye LN
        • Starr SR
        • et al.
        Role Modeling and Regional Health Care Intensity.
        Academic Medicine. 2017; 92: 694-702
        • Leep Hunderfund AN
        • Starr SR
        • Dyrbye LN
        • et al.
        Imprinting on Clinical Rotations: Multisite Survey of High- and Low-Value Medical Student Behaviors and Relationship with Healthcare Intensity.
        Journal of General Internal Medicine. 2019; 34: 1131-1138
        • Noble C
        • Billett SR
        • Phang DTY
        • Sharma S
        • Hashem F
        • Rogers GD.
        Supporting Resident Research Learning in the Workplace.
        Academic Medicine. 2018; 93: 1732-1740
        • Schumacher DJ
        • Holmboe ES
        • van der Vleuten C
        • Busari JO
        • Carraccio C.
        Developing Resident-Sensitive Quality Measures.
        Academic Medicine. 2018; 93: 1071-1078
        • Billett S.
        Learning through health care work: premises, contributions and practices.
        Medical Education. 2015; 50: 124-131
        • Batalden MK
        • Warm EJ
        • Logio LS.
        Beyond a Curricular Design of Convenience.
        Academic Medicine. 2013; 88: 644-651
        • Brown A
        • Lafreniere K
        • Freedman D
        • et al.
        A realist synthesis of quality improvement curricula in undergraduate and postgraduate medical education: what works, for whom, and in what contexts?.
        BMJ Quality & Safety. 2020; (Published online October 6bmjqs-2020-010887)
        • Gonzalo JD
        • Baxley E
        • Borkan J
        • et al.
        Priority Areas and Potential Solutions for Successful Integration and Sustainment of Health Systems Science in Undergraduate Medical Education.
        Academic Medicine. 2017; 92: 63-69
        • Olupeliyawa A
        • Balasooriya C
        • Hughes C
        • O'Sullivan A.
        Educational impact of an assessment of medical students’ collaboration in health care teams.
        Medical Education. 2014; 48: 146-156
        • Moser EM
        • Fazio SB
        • Packer CD
        • et al.
        SOAP to SOAP-V: A New Paradigm for Teaching Students High Value Care.
        The American Journal of Medicine. 2017; 130 (e2): 1331-1336
        • Gonzalo JD
        • Chang A
        • Wolpaw DR
        New Educator Roles for Health Systems Science.
        Academic Medicine. 2019; 94: 501-506
        • Gonzalo JD
        • Himes J
        • McGillen B
        • Shifflet V
        • Lehman E.
        Interprofessional collaborative care characteristics and the occurrence of bedside interprofessional rounds: a cross-sectional analysis.
        BMC Health Services Research. 2016; 16
        • Sedrak MS
        • Myers JS
        • Small DS
        • et al.
        Effect of a Price Transparency Intervention in the Electronic Health Record on Clinician Ordering of Inpatient Laboratory Tests.
        JAMA Internal Medicine. 2017; 177: 939
      9. Standards, Publications, & Notification Forms | LCME. Accessed November 17, 2020.

        • Gonzalo JD
        • Yang JJ
        • Huang GC.
        Systems-Based Content in Medical Morbidity and Mortality Conferences: A Decade of Change.
        Journal of Graduate Medical Education. 2012; 4: 438-444
        • Gonzalo JD
        • Bump GM
        • Huang GC
        • Herzig SJ.
        Implementation and Evaluation of a Multidisciplinary Systems-Focused Internal Medicine Morbidity and Mortality Conference.
        Journal of Graduate Medical Education. 2014; 6: 139-146
        • Szostek JH
        • Wieland ML
        • Loertscher LL
        • et al.
        A Systems Approach to Morbidity and Mortality Conference.
        The American Journal of Medicine. 2010; 123: 663-668
        • Satterfield JM
        • Bereknyei S
        • Hilton JF
        • et al.
        The Prevalence of Social and Behavioral Topics and Related Educational Opportunities During Attending Rounds.
        Academic Medicine. 2014; 89: 1548-1557
        • Combes John R.
        • Arespacochaga Elisa
        Physician Competencies for a 21st Century Health Care System.
        Journal of Graduate Medical Education. Sept. 2012; 4 (Accessed 28 Oct. 2022): 401-405
        • Weiss KB
        • Bagian JP
        • Wagner R.
        CLER Pathways to Excellence: Expectations for an Optimal Clinical Learning Environment (Executive Summary).
        J Grad Med Educ. 2014; 6: 610-611
      10. Clinical Learning Environment Review: National Report of Findings 2018. 2018. Accessed September 22, 2020.

      11. Governance international. Co-production. Accessed September 23, 2020.

        • Englander R
        • Holmboe E
        • Batalden P
        • et al.
        Coproducing Health Professions Education: A Prerequisite to Coproducing Health Care Services?.
        Academic Medicine. 2019; 95: 1006-1013
        • Brudney JL
        • England RE.
        Toward a Definition of the Coproduction Concept.
        Public Administration Review. 1983; 43: 59
        • Nabatchi T
        • Sancino A
        • Sicilia M.
        Varieties of Participation in Public Services: The Who, When, and What of Coproduction.
        Public Administration Review. 2017; 77: 766-776
        • Batalden M
        • Batalden P
        • Margolis P
        • et al.
        Coproduction of health care service.
        BMJ Quality & Safety. 2015; 25: 509-517
        • Holmboe ES
        • Foster TC
        • Ogrinc G.
        Co-Creating Quality in Health Care Through Learning and Dissemination.
        Journal of Continuing Education in the Health Professions. 2016; 36: S16-S18
        • Gonzalo JD
        • Dekhtyar M
        • Caverzagie KJ
        • et al.
        The triple helix of clinical, research, and education missions in academic health centers: A qualitative study of diverse stakeholder perspectives.
        Learning Health Systems. 2020; (Published online October 17)
        • Long N
        • Wolpaw DR
        • Boothe D
        • et al.
        Contributions of Health Professions Students to Health System Needs During the COVID-19 Pandemic.
        Academic Medicine. 2020; (Publish Ahead of Print)
        • Myers JS
        • Tess AV
        • McKinney K
        • et al.
        Bridging Leadership Roles in Quality and Patient Safety: Experience of 6 US Academic Medical Centers.
        Journal of Graduate Medical Education. 2017; 9: 9-13
        • Gonzalo JD
        • Ahluwalia A
        • Hamilton M
        • Wolf H
        • Wolpaw DR
        • Thompson BM.
        Aligning Education with Health Care Transformation: Identifying a Shared Mental Model of "New" Faculty Competencies for Academic Faculty.
        Acad Med. 2018; 93: 256-264
        • Prensky M.
        On the Horizon. 9. MCB University Press, 2001
        • Bodenheimer T
        • Sinsky C.
        From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider.
        The Annals of Family Medicine. 2014; 12: 573-576