How to Change
Medicine

“We’re trying to accelerate the adoption of evidence-based practices,” Brown says of the center’s overarching purpose. “Implementation science is a vehicle to get change to happen in a systematic way.”

Bridging the Know-Do Gap

Patients in the United States routinely go without treatments that could help them, not because the treatments don’t exist, but because the systems meant to deliver them haven’t caught up. U.S.-based organizations accounted for roughly 55% of major pharmaceutical breakthroughs worldwide between 2010 and 2019, according to a 2021 Springer Nature analysis. Yet in the Commonwealth Fund’s 2024 Mirror, Mirror report, which compared 10 high-income countries across 70 performance measures, the U.S. ranked last in access, affordability, equity, and outcomes.

“Implementation science has been a critical player in helping to bridge this dangerous know-do gap,” says Sara Becker, PhD, D ’00, inaugural director of Northwestern University’s Center for Dissemination and Implementation Science.

Even as recognition for implementation expertise has grown, dedicated master’s-level programs are still exceedingly rare. “Geisel’s MSIS program is special,” says Becker, who was the keynote speaker for the second annual Dartmouth Implementation Science Symposium in October, “because it is one of the first standalone master’s programs in implementation science in the country.”

Both Sides of the Equation

Central to DCIS’s work is adoption: getting evidence-based practices into clinical use and sustaining them. De-implementation—removing ineffective practices and substituting better ones—is also critical. Replacing an established practice often requires introducing new evidence while carefully phasing out older practices.

“This cancer protocol that you have may not be great, and there may be a new one, but nothing switches overnight,” says Gayle Cohen, MEd, director of Geisel’s MSIS program.

Whether the goal is adopting a better practice or retiring an outdated one, the real challenge is making change stick. Kelly Aschbrenner, PhD, AM, co-director of DCIS and associate professor of psychiatry at Geisel, has spent her career studying why.

Part of the story, she says, is that change is hard and people are creatures of habit. She adds, “Even when an intervention works well, there are still questions about whether organizations have the infrastructure, staffing, leadership support, and long-term resources to sustain it.”

Brown’s research illustrates what that looks like in practice: Every year, up to 14% of the more than 2 million Americans who undergo cardiac catheterization—a procedure used to diagnose and treat heart conditions—experience acute kidney injury (AKI), one of the most common and costly complications of the procedure. Evidence-based steps to prevent it exist, like administering an IV fluid bolus or limiting contrast dye. The problem, Brown found, was that only about 25% of cardiovascular teams were following those guidelines. So Brown built a $4 million national trial funded by the National Institutes of Health (NIH) including 20 VA medical centers—dubbed IMPROVE AKI—to help clinical teams put those practices into consistent use. Using team-based coaching and real-time surveillance dashboards, the IMPROVE AKI program reduced the odds of AKI following cardiac catheterization by 46%, with improvements that held long after the formal intervention ended. Brown was recently awarded a $6.6 million grant from the NIH to scale out the implementation research nationally in 30 hospitals participating in the American College of Cardiology CathPCI Registry.

Digital therapeutics can help support that effort, says Sarah Lord, PhD, who along with Aschbrenner co-directs DCIS and serves as associate professor in psychiatry and biomedical data science. “When you couple continuous symptom monitoring with usage data from digital therapeutics, researchers can better understand not only whether and how interventions work, but also when people use them, how engagement changes over time, and what supports are needed to sustain both implementation and long-term treatment effects,” Lord says.

As artificial intelligence enters clinical settings, Brown believes the demands on implementation science will only intensify. “AI is going to be predicting based on current practice patterns,” he says, “and may be slow to uptake policy changes until those changes are realized within the data.”

And the people best equipped to manage that lag are those trained to think critically about how evidence moves—or fails to move—through complex systems.

Training the Next Generation

Dartmouth’s MSIS program is both addressing the shortage of trained clinical practitioners and attracting students from beyond medicine. The current cohort includes educators across the K-12 and university spectrum and a criminal justice professional developing reentry programs to reduce recidivism, as well as medical professionals.

Capstone projects span fields and continents, too. One student is examining implementation frameworks for eating disorder interventions. Another is studying strategies for reaching Indigenous health populations in New Zealand.

For the clinicians in the program, the urgency is closer to home. Traci Kazmerski, MD, MS, an associate professor of pediatrics at the University of Pittsburgh School of Medicine who studies cystic fibrosis (CF), came to the MSIS program after years of frustration with what she calls “the how”—how to translate what she knew about her patients’ needs into care that actually reached them.

The 17 years it typically takes for evidence to change clinical practice “feels unnecessary. Clinician scientists want to do something now and want a structure to ensure that changes they trial are feasible, sustainable, and replicable.” The MSIS program, Kazmerski says, has been “invaluable in shaping the way I think about translating research into practice.”

For Brown, the goal was never simply to build a program or a center. It was to ensure that when medicine learns something new, healthcare systems can deliver those discoveries with the training to make them last.