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Engaging Learners to Advance Medical Education

Burk-Rafel, Jesse MRes; Jones, R. Logan; Farlow, Janice L. PhD

doi: 10.1097/ACM.0000000000001602
Invited Commentaries

Learners are a pillar of academic medicine, yet their voice is seldom heard in national and international scholarly conversations on medical education. However, learners are eager to contribute: in response to a recent open call from Academic Medicine, medical students and residents representing 98 institutions across 11 countries submitted 224 Letters to the Editor on wide-ranging topics. In this Invited Commentary, the authors—three medical students serving in national leadership roles—contextualize several themes discussed in these learner-authored letters.

The authors first explore the unique voice learners contribute to educational innovation, highlighting the value learners add to curricular and systemic educational reform efforts. They then turn to the broader implications of the many submitted letters addressing the culture and humanism of medicine, proposing that learners can be powerful catalysts and partners in cultural change. Despite these benefits, the authors note that learners are largely untapped change agents who are particularly underrepresented in medical education scholarship, finding that students were just 2.8% (39/1,396) of authors and 3.5% (12/340) of first authors among all print publications in Academic Medicine in 2016. The authors conclude by offering tangible steps for the academic medical community to engage learners in leadership, advocacy, and scholarship.

J. Burk-Rafel is a fourth-year medical student, University of Michigan Medical School, Ann Arbor, Michigan, and is primary representative, Association of American Medical Colleges Organization of Student Representatives.

R.L. Jones is a fourth-year medical student, University of Nebraska College of Medicine, Omaha, Nebraska; is chair, American Medical Association (AMA) Medical Student Section Committee on Medical Education; and serves on the National Advisory Panel to the AMA Accelerating Change in Medical Education Consortium.

J.L. Farlow is an eighth-year MD–PhD student, Indiana University School of Medicine, Indianapolis, Indiana, and serves on the Association of American Medical Colleges Board of Directors.

An Academic Medicine Podcast episode featuring this article is available through iTunes.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Disclaimer: The authors’ views are their own and do not necessarily reflect the views of their institutions or the organizations they serve.

Correspondence should be addressed to Jesse Burk-Rafel, University of Michigan Medical School, 1301 Catherine St., Ann Arbor, MI 48109; telephone: (206) 334-2187; e-mail:; Twitter: @jbrafel.

Learners are critical stakeholders in academic medicine, yet their voice is seldom heard in national and international scholarly conversations about medical education. When given the opportunity, however, learners are eager to contribute. In August 2016, Academic Medicine issued a call for medical-student- and resident-authored Letter to the Editor submissions on topics ranging from curricular changes to the learning environment. Over a 10-week period, students and residents from 98 institutions across 11 countries (Australia, Austria, Canada, Iran, Jordan, the Netherlands, Norway, Poland, Singapore, United Kingdom, and the United States) submitted 224 letters.

As student leaders who have represented our peers by serving on Association of American Medical Colleges (AAMC) and American Medical Association (AMA) groups and committees, we were thrilled but unsurprised to learn of this remarkable response. We have spoken with many passionate students who want to engage in scholarly forums, who crave moving beyond passive educational participation to become active coinvestigators, advocates, and change agents. The tremendous response to Academic Medicine’s call for submissions would support this sentiment, and we applaud the journal for proactively engaging the learner voice.

In this Invited Commentary, we draw on our own experiences as student leaders to contextualize several themes of the submitted letters: curricular improvement, admissions, and the learning environment. We will discuss the unique voice learners bring to educational innovation, and the broader implications of the many letters addressing the culture and humanism of medicine. Finally, we will highlight the need to engage learners as change agents in leadership, advocacy, and scholarship, and provide recommendations for tangible steps the academic medical community can take to achieve this aim.

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Learners’ Unique Perspective in Educational Innovation

Among all submitted letters, learners most frequently discussed curricular improvements, including learner-led innovations and curricular reform. The letters on this topic that were ultimately accepted are published in this issue of the journal. We believe learner-led medical education innovation has distinct benefits. Learners offer a unique firsthand perspective on curricular issues, perceiving hidden curricula and intangibles of the learning environment that may be opaque to educators. The purposeful engagement of learners can provide critical context during design, implementation, and assessment of educational initiatives and can drive the educational agenda toward practical interventions. Moreover, students increasingly enter medical school with expertise from undergraduate, graduate, or workplace experiences in nonmedical disciplines such as sociology, economics, and general education—expertise which enables them to lead interdisciplinary approaches to medical education. Finally, our generation is accustomed to the ever-changing technological landscape and is thus poised to integrate emerging technologies with medical education.

Assuming a dual role of learner and educational innovator also brings tremendous value to curricular reform efforts. Drawing from Kotter’s1 “Leading Change” framework, learners can help establish urgency while contributing credibility and energy to guiding coalitions. Learners’ unique perspective leads to a more learner-centered change vision, never shying away from disruptive innovations and complete paradigm shifts in medical education. Learners can communicate this vision to peers organically with pride of ownership, empower broad-based action through social media and learner-led town halls, and generate short-term wins through pilots and speaking authentically to what has been accomplished. Case studies like the one from Loeser and colleagues2 highlight the value of learner leadership in curricular transformation, but more work is warranted to better understand approaches to and the value of engaging learners as partners in curricular innovation.

The learner perspective has also been instrumental in guiding changes to systemic educational issues, most notably in admissions. Students’ proximity to the medical school admissions process lends them insights and powerful narratives that have promoted community pipeline programs, holistic review, and diversity and inclusion.3,4 Similarly, the residency selection process has elicited calls for change,5 and learner-authored perspective pieces have validated our experiences and offered compelling alternatives.6 We are hopeful that the learner perspectives shared in these letters will similarly help frame local and global discussions, thereby shaping the future of medical education.

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Concern With the Culture and Humanism of Medicine

In addition to letters focused on curricular issues and admissions, this call prompted numerous submissions on wellness and burnout, diversity and inclusion, empathy, and the learning environment. Collectively, we feel these letters represent a broader critique of the culture and humanism of medicine. Data showing tremendous burnout,7 erosion of empathy,8 and depression and suicidality9,10 among medical trainees—transcending institutional and geographic boundaries, and exceeding rates seen in the general population—speak to underlying challenges in the culture and humanism of medicine. Many trainees at some point find their profession is changing them, often in unanticipated ways. In response, trainees seek to constructively combat the emotional and moral distress that occurs during training. These letters are one manifestation of that resilient response.

However, while resilience may temper the hardships of medical training and practice, it does little to address the underlying cultural challenges that repeatedly cause these hardships. As we increasingly recognize that our health and wellness as providers is intertwined with that of our patients,11,12 it becomes even more essential that we not only foster trainees’ resilience and self-care but also address the root causes driving our dysfunctional medical culture. To this end, we are encouraged by efforts to overhaul curricula through the lens of trainee wellness13 and recent calls for broader actions as a matter of “environmental health.”14

Culture change is difficult, but we posit that learners can be powerful catalysts and partners in this effort. Their engagement—exemplified by the letters submitted in response to the call—serves as a powerful antidote to the conditions that produce “symptoms” like burnout.15 Powers and Jain16 call learners “youthful critics—committed and interested, but not full members of the profession,” combining insider credibility with outsider idealism and values. Addressing medicine’s cultural challenges will undoubtedly take engagement from all members of our profession, yet learners’ idealism and vision will be invaluable to this effort, and their courage and resilience can lead by example. Our partial outsider position, however, can make voicing concerns difficult. Internally, we may face self-doubt and disempowerment, while externally we may face skepticism regarding the wisdom of our nascent views and lack the “social capital” to speak out in a hierarchical system—all while trying to find our place within the profession and develop as clinicians.17 We thus are humbled by the many courageous learners willing to speak out so publicly through these letters on such sensitive and complex issues.

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Learners Are Largely Untapped Educational Change Agents

Empowering the learner voice—whether in discussions about curricular reform, admissions, or the learning environment—is a crucial first step toward advancing medical education. However, as several submitted letters attest, learners must go beyond voicing opinions to actively engaging in leadership, advocacy, and scholarly work as educational change agents. Our firsthand experience in the AMA Medical Student Section (AMA-MSS) and AAMC Organization of Student Representatives (AAMC-OSR) has shown us the impact students can have on the medical education landscape—all while honing systems-thinking, communication, and leadership skills. Although the achievements of these groups have been impressive, they engage just a small fraction of all U.S. medical students.

One area with arguably the greatest unexplored potential for engaging learners is educational scholarship. We analyzed medical student and resident authorship in all 12 print issues of Academic Medicine in 2016 (Table 1). Students were authors on 7.9% (27/340) of analyzed publications, first authors on 3.5% (12/340) of publications, and represented 2.8% (39/1396) of all authors. Students first-authored Perspective articles more frequently than other article types (Fisher exact two-tailed P < .05). Resident authorship rates—while eclipsing student authorship rates across most publication types—were also modest. We were unable to conduct similar analyses in other leading medical education journals, as they do not unambiguously indicate authors as trainees. We applaud Academic Medicine for publishing many student and resident authors and suspect that such authorship rates have never been higher. Yet, U.S. medical students are proportionally one-tenth the size of the total U.S. physician workforce,18,19 and a larger proportion still of U.S. academic physicians, highlighting a gap in student authorship.

Table 1

Table 1

We can attest to several barriers to student involvement in medical education scholarship. Most medical students are minimally aware of the field of educational scholarship. Thus, although many students engage in curricular development and program improvement, few apply a scholarly framework to their innovations. Additionally, students often lack mentors who can socialize them to the field of medical education and offer guidance for transforming their ideas into scholarly products. Those students who do find mentorship often work without funding for conducting and disseminating their work. The resultant paucity of students involved in medical education scholarship is a missed opportunity for academic medicine. Scholarship not only fosters habits of inquiry and critical thinking applicable to broader issues in medicine but is also a chance to galvanize and shape the careers of future physician–educators.

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Empowering Students as Change Agents

The robust response to Academic Medicine’s call for Letters to the Editor demonstrates that learners are eager to engage actively in medical education. As students ourselves, we see numerous ways in which faculty, institutions, medical education journals, and organized medicine can further empower our student voice to lead change in medicine.

To faculty and institutional leaders: We hope that you will reach out to the authors of these letters to offer additional mentorship and collaborate on multi-institutional scholarly projects. Analogous to community-based participatory research, if students are subjects in your leadership, advocacy, or scholarly work, bring student leaders aboard your team as partners. Consider developing scholarly concentration programs in medical education and health policy, as many leading U.S. medical schools have done.20 Encourage your students to engage in organizations that elevate the student voice in medical education, such as the AMA-MSS and AAMC-OSR. Finally, consider institutional initiatives to incentivize and reward students’ efforts in leadership, advocacy, and scholarship, such as funding for conference attendance and certificates of distinction.

To medical education journals: We are eager to see further initiatives directly engaging the student voice, such as additional calls for student-authored opinion pieces and original research, recurring sections or theme issues dedicated to learner viewpoints, and article types geared toward smaller-scale innovations. We again applaud Academic Medicine for this call and hope that the data we have collected regarding student and resident authorship rates can benchmark progress in the coming years. Ideally, other medical education journals will join Academic Medicine’s example and begin indicating and tracking learner authorship.

To our leaders in the AAMC, AMA, and respective international counterparts: We hope to see student-directed medical education abstract competitions and additional innovation challenges. Concerted efforts should be made to address the financial barriers to conducting and disseminating student-led educational innovation. For example, a competitive small-grants program could help seed small-scale innovations, while a need-based travel awards program could help students disseminate their work at conferences. Earmarking funding for trainees, even if in small amounts, demonstrates that learner engagement is valued while stimulating student work and potentially shaping careers.

The medical education community has a collective responsibility—imperative to the vitality of academic medicine—to empower learner-centered leadership, advocacy, and scholarship. By purposefully engaging learners in national and international dialogue, you will help learners develop a scholarly “academic” mindset that will pay dividends in how we care for our patients, educate future trainees, serve our communities, and tackle emerging health care challenges.

Acknowledgments: Special thanks to Rajesh Mangrulkar, MD, Michelle Daniel, MD, Sally Santen, MD, PhD, and Kelly Caverzagie, MD, for their support, guidance, and review of this Invited Commentary.

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