Exposure of college (i.e., baccalaureate) students to clinical practice is often minimal, which may make it difficult for them to make an informed decision about pursuing medicine as a career.1,2 This limited exposure constitutes a shortcoming of premedical education, especially given the large personal and financial commitment required to complete medical education and training.3 The need for clinical role modeling may be particularly important for students from nonmedical families and/or students with economically disadvantaged backgrounds.4 Some students’ understanding of a physician’s role in health care may be based on the perspective gained from being a patient or from watching highly romanticized television shows, such as Grey’s Anatomy, House, or ER.
Through shadowing, premedical students have the opportunity to learn about a physician’s daily responsibilities and challenges, as well as the nature of physician–patient interactions.2 Many students also develop meaningful relationships with their physician mentors, who provide valuable guidance in navigating the challenges of a medical career.5
However, physician shadowing opportunities can be difficult to secure because, in part, identifying a physician in the community willing to host a student can be challenging.6 Furthermore, the growing regulatory environment surrounding patient privacy and information security creates another barrier for premedical students who may not be permitted to shadow in hospitals and clinics without first overcoming legal restrictions.
In their recent review, Kitsis and Goldsammler7 reported a scarcity of data about physician shadowing programs. Most of the programs they identified were outside of the United States, and of the four U.S. programs they included, only two were at the college student level. The authors also noted the organizational variability among programs, which leaves them especially vulnerable to the same problems affecting other physician shadowing experiences (e.g., maintaining patient confidentiality, enforcing infection control standards, defining the role/duties of the student).7
Herein, we describe a model for a formal undergraduate physician shadowing program that addresses these shortcomings and has been successfully implemented at Stanford University. The Stanford Immersion in Medicine Series (SIMS) offers physician shadowing within the structure of an academic course and delineates standards for patient privacy, infection control, and professionalism. In addition, we describe how we have evaluated the SIMS shadowing program in an effort to understand whether it promotes participants’ understanding of the role of the physician and whether it influences participants’ decisions to pursue medicine as a profession.
The SIMS program
Stanford University has offered SIMS through the School of Medicine’s Department of Medicine each academic quarter (except for the summer quarter) since 2007. The Undergraduate Advising and Research Center administers the program in collaboration with three Stanford-affiliated sites: Stanford Healthcare, Lucille Packard Children’s Hospital, and the Veterans Affairs Palo Alto Health Care System (Figure 1). Stanford-affiliated physicians practicing at these sites are invited through e-mail to volunteer as mentors. Interested physicians upload basic information about their practices, including their weekly schedule, to an online database that displays each physician’s profile under an anonymous identification number. SIMS participants review this database to find a physician whose schedule and interests align with theirs, and they indicate their preferences to the program coordinators using the physician identification numbers.
Stanford sophomores, juniors, and seniors are eligible to apply to SIMS. On the application, students provide short-answer (paragraph-length) responses to prompts that explore their interest in SIMS as well as mock e-mail messages to physician mentors that demonstrate their professionalism. Applicants are accepted on the basis of their suitability for the program, seniority, and previous participation, plus the availability of physician mentors and other logistical factors. SIMS coordinators pair accepted students one-on-one with a physician mentor, based (as mentioned) on physician specialty preferences and schedule compatibility. Prior to shadowing, students attend an orientation covering professionalism, clinic etiquette, and Health Insurance Portability and Accountability Act regulations. Participating students obtain hospital clearance, complete code of conduct forms, and receive a hospital photo ID badge. Additionally, they must complete the immunizations and other health requirements of Stanford first-year medical students.
SIMS students must attend a minimum of four shadowing sessions in a 10-week period, and they must submit a 250- to 500-word reflective essay at the end of the program. Shadowing sessions (the recommended length for each is a minimum of two hours) may consist of observing the physician in outpatient clinics, in the operating room, or during inpatient rounds; accompanying the physician to departmental grand rounds; or holding mentoring meetings outside of the clinical setting. Students who complete the requirements earn undergraduate course credit.
Evaluating the SIMS program
SIMS coordinators presented a 15-question online survey to students via e-mail both before the shadowing experience began and again after it had ended. The findings presented below result from the questionnaires completed by students participating in SIMS from March to June of 2010.
The 2010 survey included questions about student demographics, prior shadowing experiences, and other premedical experiences. Students also rated on a nine-point scale their agreement with statements concerning their attitudes about a medical career (Figure 2). The postshadowing survey was identical to the preshadowing one, except for the addition of a comments section in which students could report the best and worst parts of their shadowing experience. Surveys were deidentified and assigned anonymous, random numbers. We analyzed data either in aggregate or by matching pre–post survey numbers. We offered no incentives to students for completing the questionnaires. Our study was formally reviewed by Stanford’s institutional review board and was determined not to meet the federal definition of human research.
We categorized student ratings of the survey statements as follows: we considered a rating of 7, 8, or 9 to be agreement; a 4, 5, or 6, neither agreement nor disagreement; and a 1, 2, or 3, disagreement. Using the paired-proportion t test, we analyzed each statement’s ratings for statistically significant (P ≤ .05) changes in the percentage of students in each agreement category from pre- to post shadowing. We excluded from analysis the responses of students who did not submit both pre- and postshadowing surveys (as determined by assigned anonymous numbers).
Study participants consisted of all SIMS students participating in the March–June 2010 academic quarter who completed both the preshadowing and postshadowing surveys (Table 1). Of the 75 students who were enrolled at the beginning of the quarter and submitted preshadowing surveys, 61 (81%) remained enrolled and completed the postshadowing survey. Of the 14 students excluded from the study, the majority did not complete the course, and several did not provide postshadowing surveys.
To determine whether shadowing through SIMS affected student attitudes toward a career in medicine, we analyzed student agreement with nine statements that addressed the students’ familiarity with the medical profession, their commitment to pursuing a career in medicine, and their perception of the utility of physician shadowing.
Significant increases in student familiarity with medicine were detected (Figure 2, top third). Before the shadowing experience, 28 of the students (46%) agreed with the statement “I understand how physicians interact with patients in clinical settings,” whereas 52 (85%) agreed post shadowing (P < .01). Similarly, before participating in SIMS, only 20 of the students (33%) agreed with the statement “I am familiar with what a physician does to fulfill his/her responsibilities,” whereas 42 (69%) agreed post shadowing (P < .01). Finally, only 14 students (23%) agreed with the statement “I understand what a physician does in an academic environment” before the shadowing experience, whereas 28 (46%) agreed post shadowing (P < .05). These increases in familiarity occurred even for students who reported prior shadowing experience through SIMS or another venue (not shown).
We observed no significant changes in student commitment to pursuing a medical career (Figure 2, middle). We detected modest nonstatistically significant increases in students’ reported desire to be clinical practitioners, anticipated enjoyment in performing the duties of a physician, and interest in being a medical researcher. There was no difference in students’ reported desire to pursue a career in medicine after shadowing compared with before; however, notably, 52 of the 61 students (85%) had already reported agreement with the statement “I want to pursue a career in medicine” before shadowing.
Finally, we observed no differences in student agreement with statements describing their perceptions of the utility of shadowing; perceptions were high both pre- and post shadowing (Figure 2, bottom).
To gain insight into the features of shadowing that were most impactful, we asked students to identify on the postshadowing survey “the best [and worst] parts of the physician shadowing experience.” We analyzed students’ responses to these questions, as well as the assigned reflective essays they wrote about their shadowing experiences.
The most common positive features of the shadowing experience that students reported were related to observing physician–patient interactions and becoming familiar with daily physician activities. To illustrate, one student commented,
After watching TV shows like ER and Medical Mystery Diagnosis, where things are highly dramatized, it was nice to see the real-life pace and approach that a medical professional takes in working with patients and carrying out surgery.
Other “best” experiences identified by students on the survey included the following: “getting to sit in on patient visits in the clinic,” “understanding how the physician reasons and comes to conclusions,” “being on rounds,” and “being in the [operating room].”
For a few participants, the shadowing experience provided insight that a nonphysician role in health care might be more suitable. For example, one student commented:
Throughout the quarter, I had been struggling to decide whether I wanted to pursue becoming a [physician assistant] or a physician. Ultimately, I decided to work towards a PA license. My shadowing experience showed me the roles of nurses, nurse practitioners, medical students, residents, fellows, and attending physicians in a teaching clinic, and I got to see that there are more options for medical careers than medical school.
Likewise, another student wrote, “I saw this quarter some of the things that influenced me to decide as a sophomore that I didn’t think medicine was the right profession for me.” This same student also commented that “being reminded of this firsthand confirmed my doubts.”
Another benefit of the SIMS program that students often identified was the opportunity to build a mentoring relationship with a physician. One student noted that she enjoyed “so much personal attention from a busy physician–scientist.” Many others appreciated the openness with which their physician mentor addressed questions about work–life balance or their kindness in alleviating anxieties about applying to medical school or being in a medical environment.
Our introduction of the SIMS program, which incorporates many of the general principles proposed by Kitsis and Goldsammler,7 demonstrated that the implementation of a successful physician shadowing program is possible in a university setting by following a series of well-organized steps (Figure 1). Our experience has been that by investing two to three hours of time for training and administrative preparation, most students are able to begin shadowing their physician mentors within two to three weeks of the orientation session.
The results of our evaluation of SIMS suggest that shadowing is valuable in providing greater insight into the roles and responsibilities that physicians assume. Interestingly, our results indicate little change in students’ desire to pursue a career in medicine after shadowing, possibly because most students entering our program had already committed to a career in medicine. Thus, the experience for many of our students was confirmatory rather than revelatory. For some students, however, the shadowing experience became a pivotal point in their career decision-making process. SIMS exposed them to the day-to-day realities of clinical practice that made medicine less appealing. Likewise, some SIMS participants gained exposure to other, alternative career paths within health care that were, for them, more attractive than medicine. By increasing student knowledge about the profession and by demystifying and deromanticizing the roles that physicians assume in medical practice, shadowing can help inform students’ decisions about pursuing—or not pursuing—a career in medicine. Further, the opportunity to develop mentor–mentee relationships with physicians was another notable outcome that our students reported valuing highly. As mentioned, these relationships could be particularly important for students from groups traditionally underrepresented in medicine, who may not have family members or other adult role models to advise them about a medical career.8
Future research may reveal whether such baccalaureate programs increase the likelihood that college students, especially those from groups often underrepresented in medicine, pursue medical education and eventually a career in medicine.
Our small sample from a single, private West Coast university may not accurately reflect the premedical student population at other institutions; thus, developing similar structured programs elsewhere will help determine the generalizability and potential benefit of formal baccalaureate physician shadowing programs. Furthermore, the apparently minimal impact of shadowing on career decision making that we observed may have been biased by our particular study cohort, composed of college sophomores, juniors, and seniors who may have already committed to applying to medical school. Given that over 80% of our group indicated an interest in pursuing a medical career before shadowing, students with more ambivalence toward a medical career may not have been well represented. A future study could assess whether undergraduate freshmen with less certain career goals would be more influenced by early exposures to the clinical setting through shadowing. It will also be important to identify the amount of shadowing that is needed to confer benefit in terms of increasing student familiarity with the medical profession. Finally, future research may also help define the ideal structure of a baccalaureate shadowing program—that is, which elements (observation, discussion, written reflection) are most beneficial.
Although SIMS has been successful at our institution, it is important to recognize that establishing and sustaining a physician shadowing program can be challenging. Physician mentor recruitment and program oversight to ensure regulatory compliance and student satisfaction are critical. Undergraduate institutions may vary in their hospital affiliations, risk management policies, or availability of administrative support, all of which may affect the feasibility of our model elsewhere. Nonetheless, we hope that the SIMS program serves as one example of a means for creating a formalized opportunity for premedical undergraduates to shadow physicians and better inform their decision to pursue a career in medicine.