Broadening the Lens of System-Based Practice: From Micro to Macro and Basic to Complex in Residency Training

Objective: This paper aimed to develop a model for understanding the various dimensions of system-based practice (SBP) and determine the extent to which psychiatry residents perform behaviors along these dimensions. Methods: Sixty-one supervisors from seven psychiatry programs rated resident performance of SBP behaviors using a 60-item instrument. Multi-dimensional scaling and cluster analysis were conducted to determine how the instrument items related to one another and the larger concept of SBP. Average supervisor ratings between clusters were compared to determine resident performance along the identified SBP dimensions. Results: The data supports a model of SBP defined along two dimensions: (1) from micro (patient) to macro (population-based) interventions and (2) from low to high system complexity. Residents were more likely to perform behaviors at the patient level compared to those at the population-based level. Conclusions: Training in SBP remains predominately focused on the doctor-patient level and not the greater system of health-care delivery.