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Value-Added Clinical Systems Learning Roles for Medical Students That Transform Education and Health: A Guide for Building Partnerships Between Medical Schools and Health Systems

Gonzalo, Jed D. MD, MSc; Lucey, Catherine MD; Wolpaw, Terry MD, MHPE; Chang, Anna MD

doi: 10.1097/ACM.0000000000001346
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To ensure physician readiness for practice and leadership in changing health systems, an emerging three-pillar framework for undergraduate medical education integrates the biomedical and clinical sciences with health systems science, which includes population health, health care policy, and interprofessional teamwork. However, the partnerships between medical schools and health systems that are commonplace today use health systems as a substrate for learning. Educators need to transform the relationship between medical schools and health systems. One opportunity is the design of authentic workplace roles for medical students to add relevance to medical education and patient care. Based on the experiences at two U.S. medical schools, the authors describe principles and strategies for meaningful medical school–health system partnerships to engage students in value-added clinical systems learning roles. In 2013, the schools began large-scale efforts to develop novel required longitudinal, authentic health systems science curricula in classrooms and workplaces for all first-year students. In designing the new medical school–health system partnerships, the authors combined two models in an intersecting manner—Kotter’s change management and Kern’s curriculum development steps. Mapped to this framework, they recommend strategies for building mutually beneficial medical school–health system partnerships, including developing a shared vision and strategy and identifying learning goals and objectives; empowering broad-based action and overcoming barriers in implementation; and generating short-term wins in implementation. Applying this framework can lead to value-added clinical systems learning roles for students, meaningful medical school–health system partnerships, and a generation of future physicians prepared to lead health systems change.

J.D. Gonzalo is assistant professor of medicine and public health sciences and associate dean for health systems education, Penn State College of Medicine, Hershey, Pennsylvania.

C. Lucey is professor of medicine and vice dean for education, University of California, San Francisco School of Medicine, San Francisco, California.

T. Wolpaw is professor of medicine and vice dean for educational affairs, Penn State College of Medicine, Hershey, Pennsylvania.

A. Chang is professor of medicine and Gold-headed Cane Endowed Education Chair in Internal Medicine, University of California, San Francisco School of Medicine, San Francisco, California.

Funding/Support: This project was performed with financial support from the American Medical Association (AMA) as part of the Accelerating Change in Medical Education (ACE) initiative. The content of this paper reflects the views of the authors and does not necessarily represent the views of AMA or other participants in the ACE initiative.

Other disclosures: The views expressed in this paper reflect the views of the authors and do not necessarily represent the views of the AMA or other participants in this initiative.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Jed D. Gonzalo, Division of General Internal Medicine, Penn State Hershey Medical Center, HO34, 500 University Dr., Hershey, PA 17033; telephone: (717) 531-8161; e-mail: jgonzalo@hmc.psu.edu.

As U.S. health care changes rapidly to improve outcomes, health systems and medical education are evolving to provide physicians with skills to address 21st-century challenges.1–4 With 27,000 physicians graduating each year, medical schools need significant reform to advance physician readiness for practice and leadership in changing health systems to improve today’s individual and population health outcomes.5,6 To address this challenge, an emerging three-pillar framework for undergraduate medical education integrates the biomedical and clinical sciences with health systems science, which includes population health, health care policy, and interprofessional teamwork.7,8 This broader definition of clinical skills resonates with physicians whose work today includes both systems and patient skills (e.g., history taking, physical examination).7,9,10 However, the partnerships between medical schools and health systems that are commonplace today, which include preceptorship models, still use health systems as a substrate for learning through one-on-one clinician–patient encounters. These current partnerships frequently do not leverage medical education’s potential for improving health and may decrease clinical productivity and efficiency.11,12 Thus, today’s medical education efforts could evolve to include a more robust focus on health outcomes. Likewise, health system leaders have yet to embrace the novel perspective of medical students as a value added to patient care and systems improvement. New partnerships that provide authentic workplace roles for medical students could add value to health systems while transitioning medical education from a burden to an unrecognized asset.11–14 On the basis of pioneering experiences at two U.S. medical schools, we describe principles and strategies for meaningful partnerships between medical schools and health systems to engage medical students in value-added clinical systems learning roles.

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Context

In 2013, the Penn State College of Medicine (PSCOM) and University of California, San Francisco School of Medicine (UCSF SOM) began large-scale efforts to develop novel required longitudinal, authentic health systems science curricula in classrooms and workplaces for all first-year medical students (n ≈ 150).8,15 Both are state schools affiliated with multiple health systems (e.g., university hospitals, safety net hospitals, Veterans Affairs medical centers, and community-based primary care clinics). Despite independent design, disparate geography, and staggered timelines, both schools applied similar approaches, lending internal validity beyond single-institution experiences. In designing new medical school–health system partnerships, we combined two models in an intersecting manner: Kotter’s eight steps for change management16 and Kern’s six steps for curriculum development.17 Mapped to this new integrated framework (Figure 1), we recommend strategies for building mutually beneficial partnerships between education and clinical enterprises. Although we present these eight strategies (and corresponding principles) sequentially, the steps from the two models (Kotter and Kern) may occur concurrently, iteratively, or in an alternating order.

Figure 1

Figure 1

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Strategies for Building Medical School–Health System Partnerships

Initial phase: Vision and planning

Strategy 1: Establish a sense of urgency (Kotter) and identify the problem (Kern).

As productivity demands and quality expectations rise, medical education and health systems need to align toward similar goals with reciprocity. From the medical education perspective, change is necessary to sustain an adequate number of clinical learning sites for students. Although health systems topics exist in some classrooms, there are few to no experiential learning opportunities that can bring a patient’s health care experience to life for students.8,18–22 Akin to hands-on clinical skills learning experiences that help students refine techniques in physical examination and patient communication, novel systems activities for all students are now needed.21,23 Curricular time for longitudinal, meaningful clinical systems learning roles and tasks (e.g., patient navigator, health coach, panel manager, initial round of medication reconciliation, first draft of “after visit” summaries, follow-up phone calls after hospital discharges, and data collection in quality improvement projects) would allow medical students to gain a broader perspective of patients’ experiences of health, illness, and the interprofessional care delivery system.13,24,25 Limited experiential learning opportunities currently include optional community service or student-run free clinics for some, but not all, students.26–28 Medical educators are now calling for core clinical skills curricula to include systems roles in the workplace for students to help improve the health of today’s patients.23,29–33 Additionally, medical education has an opportunity to prepare physicians to be “systems ready” to function in a population-based, patient-centered environment even while serving as a workforce of residents and fellow physicians.6,7,13 Educators who perceive less urgency on the basis of the numeric success of residency matches can be encouraged to embrace a competency-based education framework that encompasses the comprehensive skills required for today’s practice as a physician.

To address the gap in both systems roles and enhanced partnerships, new education deans at the PSCOM and UCSF SOM held multiple broad-based stakeholder meetings to urge integration of the clinical and education missions to advance physicians’ systems skills. Both deans described the shared motivation for medical education to prepare physicians to effectively function and lead in future care delivery models. As clinical leaders focus on health system, organizational, and financing reform, they can appreciate the benefit of well-trained future physicians who can immediately begin working effectively with skills in multiple domains, ready to improve patient satisfaction, quality of care, patient safety, and access to care. Although the current medical education system produces skilled clinicians, policy and system leaders remain concerned that physicians are not being adequately prepared with the new systems skills needed for future medical practice.6,34

In short, the sense of urgency is already described by the problem statement that education and care delivery continuing to progress in parallel isolates these two interrelated entities. Sustainable strategies are needed now, in light of evolving funding models for academic missions. Furthermore, the current clinical workforce is overwhelmed. Thus, a mutually beneficial partnership could engage the creativity of medical students in advancing clinical aims today—a goal that we believe is feasible starting in the first year of medical school.

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Strategy 2: Create the guiding coalition (Kotter) and conduct a needs assessment (Kern).

The second strategy involves establishing initial relationships between education and health system leaders, including community partners new to academic affiliations. These links may not have been robust in the past. These leaders can assist with initiating critical conversations with new partners to offer credibility, create momentum, and provide accountability in implementing a new vision. For health systems, such leaders may be the dean, chief executive officer, chief quality officer, or chief operating officer, and for medical schools, they may be the education dean or curriculum dean. To effectively engage health system leaders, an advisory board was created at the PSCOM and UCSF SOM, consisting of members from diverse practice sites and specialties. With this type of guiding coalition, clinical leaders become consultative partners who inform the design of education programs based within health systems. This powerful coalition moves from establishing a sense of urgency and identifying the problem (strategy 1) to describing the systems’ needs (strategy 2), strengthening the partnership as team members bring goals for a shared vision (strategy 3).

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Strategy 3: Develop a shared vision and strategy (Kotter) and identify learning goals and objectives (Kern).

To partner effectively with health systems, education leaders need to articulate vision, strategy, and objectives for systems learning in medical education. The vision and design of systems curricula at the PSCOM and UCSF SOM were based on four synergistic principles (Table 1).15,35 These principles were initially based on a literature review, local needs assessments, and regulatory requirements, and were refined thematically in discussions with local and national medical education leaders. Once a vision and principles have been established, an implementation strategy can begin to take shape. An early implementation step at the PSCOM and UCSF SOM was the designation of a mobile site development work group (consisting of physician educators, curriculum coordinators, and/or program managers) to begin site visits and planning conversations. This work group establishes a relationship with each clinical site, shares the education vision, hears relevant clinical outcomes, and assesses each site’s readiness for partnership. It anticipates the complexity of individualizing implementation plans with multiple clinical sites (e.g., Department of Health tuberculosis clinic, family/community medicine patient-centered medical home clinic, surgical weight loss program, Veterans Affairs Medical Center inpatient medicine service, safety net hospital rheumatology clinic, and academic medical center surgery clinic) and serves as a champion for the new learning communities. At both the PSCOM and UCSF SOM, new positions were created to be the point of contact for clinical sites. The work group reports updates on site visits and progress, and identifies barriers to and brainstorms strategies for new systems roles and partnerships in regular meetings with education leaders. Education leaders then identify learning goals for students, and the group uses these to design new systems roles for students in collaboration with clinical partners. In this manner, the partnership advances from problem identification (strategy 1), to needs assessment (strategy 2), to the development of a shared vision and strategy, as well as goals and objectives (strategy 3).

Table 1

Table 1

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Maintenance phase: Sustaining and growing

Strategy 4: Communicate the change vision (Kotter) with organizational and educational strategies (Kern).

Initial meetings with clinical sites should focus on respectful listening for alignment, feasibility, and understanding of shared goals. The concept of students in systems roles is likely new for both educators and clinicians. A final partnership model is unlikely to emerge after one meeting. In the case of the PSCOM and UCSF SOM, a series of meetings began to allow both parties to build a new model together. This included an acknowledgment that implementation details were awaiting collaborative development. An infrastructure to support effective feedback loops to address issues as they arose was critical. For busy clinical teams, the workload of education could become a barrier. We recommend reiterating both the value added and learning, as well as describing differences between this model and the traditional clinical preceptorship model (Table 2), to address this barrier. For example, students can be integrated into a hospital’s transitions program to anticipate barriers, facilitate communication between patients and providers in inpatient and outpatient settings, and reinforce patient education for safe discharges. Model building for these student roles can begin with those patients most in need, followed by broadening the value-added nature to other patient groups. Although resources and creativity are required at initiation, returns should increase with time.

Table 2

Table 2

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Strategy 5: Empower broad-based action and overcome barriers (Kotter) in implementation (Kern).

Applying our design principles to create large-scale curricular reform at the PSCOM and UCSF SOM, we identified criteria for longitudinal partnerships with clinical sites (Table 3). In one example, medical students provide continuity of care from the preoperative clinic, to the home, to the operating room, and to the postoperative inpatient setting. Students coach vulnerable patients to use interprofessional care plans to optimize function and nutrition prior to high-risk surgery and to improve the patients’ experiences of health care settings that would otherwise be disconnected during a serious illness. In another example, medical students are matched with patients in a state-operated tuberculosis clinic to identify adherence barriers during the months-long treatment for latent tuberculosis. Through clinic visits, regular phone calls, and periodic home visits, students facilitate communication between patients and providers and identify strategies to improve the patient experience.

Table 3

Table 3

For effective implementation of systems roles, several potential barriers should be addressed. First, longitudinal exposure is necessary for student roles to result in meaningful contributions.36 At the PSCOM and UCSF SOM, dedicated curricular time for systems workplace learning ranges from two to four half-days per month for preclerkship medical students. Creating space in the curriculum required an open dialogue with all education stakeholders to review the shared vision and identify opportunities to remove existing redundancy or outdated content. Second, coordinating student activities requires a champion at each clinical site. Although leaders may make the introductions, frontline clinical staff guide students daily. A site champion has a sense of ownership for student activities. This can be a care coordinator, patient navigator, or nurse practitioner; the champion can, but need not be, a physician. The champion helps students achieve educational objectives and contribute to health system goals, while maintaining staff and patient satisfaction. Finally, using multiple clinical sites with a diversity of characteristics for a whole class of medical students brings variability. The large-scale networks of the PSCOM and UCSF SOM include sites with broad clinical focus areas rather than a system with a single goal (e.g., high utilization) or patient population (e.g., breast cancer survivors). This means that a number of systems activities at different sites can map to a single learning objective; for example, a surgical weight loss clinic is different from a family medicine clinic, but both include opportunities for students to be embedded within interprofessional care teams to measure and improve patient experience and disease outcomes. Such an inclusive approach allows for a number and variety of sites that can all facilitate student education through authentic work. As care delivery systems continue to be optimized for chronic care and high utilization, existing medical school–health system partnerships would stand ready to co-create new educational opportunities within innovative care models.

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Strategy 6: Generate short-term wins (Kotter) in implementation (Kern).

Stories of early successes help both education and health systems leaders gain confidence about innovations. A habit of disseminating stories about successful pilots advances the effort and celebrates accomplishments. A task force, point person, or administrative infrastructure as the champion for clinical site network activities is critical for success. In addition, all representatives of the education enterprise should be facile with concrete success stories of medical students making a difference. For example, at the UCSF SOM students helped design a sustainable process integrated into the electronic health record that led to improved osteoporosis screening rates for patients at high risk of fractures at one clinic. Sharing such success stories on the school’s Web site and during meetings helped other sites brainstorm opportunities for engaging students in improving care.

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Strategy 7: Consolidate gains (Kotter) while beginning evaluation and feedback (Kern).

Partnerships between medical schools and health systems require relationship-building “marathons” rather than “sprints.” The process involves multiple conversations to build a collective vision, generate ideas, solve problems, share goals, and identify an implementation model. Developing long-term partnerships involves scheduling periodic in-person meetings and follow-up phone calls. The PSCOM and UCSF SOM are planning intentional performance improvement cycles in the coming years to address unanticipated issues at each clinical site over time. Staff may need reminders of programmatic goals, and student systems roles may need to be renegotiated. Additionally, unexpected personnel turnover can occur with little notice. Our site-based implementation teams are ready for just-in-time support of students and sites for immediate response to such unanticipated changes. If particular partnerships prove ineffective, backup clinical sites may be necessary. In short, a new partnership will include challenges, and so requires a process for continuous improvement.

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Strategy 8: Anchor new approaches in the culture (Kotter) while continuing evaluation and feedback (Kern).

At both the PSCOM and UCSF SOM, and increasingly across the country, a mounting body of work is helping to establish health systems science as a priority area in the education and clinical missions.7 Our approach is a practical one for integrating what some have referred to as an emerging “third science” of medical education—which complements the basic and clinical sciences and includes course work and application of various systems-related topics, including the evidence underlying interprofessional teamwork, population health, patient safety, and quality improvement.10 Furthermore, with this work, students contributing as professionals-in-training may eventually become a welcome norm for health systems, as from day one, they would learn an integrated triad of biomedical, clinical, and systems topics, simulating the work of physicians today. For academic institutions, the quality of the medical school has implications for the success of the health system, and vice versa. Value-added clinical systems roles for students allow medical education to help advance the health system, creating synergy for long-term success.

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Conclusion

Medical education and health systems have traditionally operated in silos. Clinical systems prioritize efficiency and quality, while medical education emphasizes knowledge and apprenticeships. These different mental models can be transformed to build effective collaborations. As care delivery and medical education undergo reform, medical students can learn and contribute to health systems. Applying Kern’s steps for curriculum development and Kotter’s steps for change management as an integrated framework can lead to value-added clinical systems learning roles for medical students, meaningful partnerships between education and clinical enterprises, and a generation of future physicians prepared to lead health systems change.

Acknowledgments: The authors would like to acknowledge the clinicians in collaborating health systems who hosted students for systems educational experiences.

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