A Different Differential: Using Consultation to Teach and Evaluate Systems-Based Practice

Abstract: As growing demand for psychiatric care outstrips workforce capacity and the successful provision of psychiatric care depends increasingly on systems-level knowledge, it becomes all the more critical for consultation-liaison fellowships and psychiatry residency programs to educate their graduates around systemic factors that impact patient care. Recognizing this, the Accreditation Council of Graduate Medical Education (ACGME) developed competencies around systems-based practice (SBP) in 2009, as well as observable milestones (Graham 2009; Martinez J et al 2014; ACGME 2020). Both psychiatry residency programs and consultation-liaison fellowships must teach and assess trainees in three competencies: SBP 1 - Patient Safety and Quality Improvement, SBP 2 - System Navigation for Patient-Centered Care and SBP 3 - Physician Role in Health Care Systems (ACGME 2020). These competencies are a meaningful construct towards contributing to graduating a cohort of psychiatrists ready to assess and address systems-level impacts on individual patient care and have become increasingly valued trainees in recent years (Ranz J et al 2014, Fried J et al 2014). However, the SBP competencies remain challenging to teach and evaluate, especially those outside patient safety and quality improvement; their broad nature and complexities in local health care delivery that make large-scale SBP curricula elusive (Fried J et al 2014).

This workshop will present an instructional approach utilizing consultation service settings to deliver SBP education. This technique uses an expanded differential diagnosing technique called the “different differential”, which is a systematic approach to identifying and addressing barriers to patients' clinical progress at the patient, provider, team and broader systems levels. In this interactive workshop, we will briefly introduce the "different differential" framework and how to apply it in practice as well as teach this framework to trainees at various levels. After the overview of the framework's structure, principles and an associated decision-making algorithm, we will spend the majority of the session practicing the application of this framework in small group discussions of three case examples. Participants will leave prepare to use this approach in both hospital consultation service and outpatient integrated care settings.

Fried JL, et al. Psychiatry residents' experiences with systems-based practice: a qualitative survey. Acad Psychiatry. 2014 Aug;38(4):414-9.

Graham, M. J et al. (2009). Systems-based practice defined: taxonomy development and role identification for competency assessment of residents. Journal of graduate medical education, 1(1), 49–60.

Martinez, J., Phillips, E., & Harris, C. (2014). Where do we go from here? Moving from systems-based practice process measures to true competency via developmental milestones. Medical education online, 19, 24441.

Ranz JM et al. A four factor model of systems-based practices in psychiatry. Acad Psychiatry. 2012 Nov 1;36(6):473-8.