Triple Challenge: How Medical Students May Solve 3 Long-Standing Problems Bedeviling Health Systems and Medical Education : Academic Medicine

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Triple Challenge: How Medical Students May Solve 3 Long-Standing Problems Bedeviling Health Systems and Medical Education

Elliott, Victoria Stagg MA1; Jackson, Jasmyne MD, MBA2; Santen, Sally A. MD, PhD3; Richardson, Judee PhD4; Heckman, Kevin MBA5; Hammoud, Maya M. MD, MBA6

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Academic Medicine 96(12):p 1643-1649, December 2021. | DOI: 10.1097/ACM.0000000000004159
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Abstract

Health systems require constant examination and improvement to ensure those working in medical education and the health system provide safe, high-quality, and equitable care. Medical educators and health care professionals spend their days and nights solving problems, both large and small, attempting to reduce the number of medical errors that impact patients, devising strategies to transform medical education from time-based to competency-based, or looking for ways to make receiving health care more culturally competent, to name just a few possibilities. They also anticipate issues that will need to be addressed, such as developing plans for the mass administration of COVID-19 vaccines, especially to uninsured and underrepresented populations. They provide care, prevention, treatment, amelioration of symptoms, and cures to patients as they learn and work with interprofessional colleagues. In so doing, they may identify and implement better ways to deliver care. Medical education and the health system, however, must address problems that, despite significant effort and medical advancement, seem unsolvable. Those newest to medicine may have fresh perspectives and can raise new questions and bring new understandings and solutions to long-standing problems. Thus, engaging medical students and residents in the improvement process is critical for the betterment of public health.

Medical education and the health system increasingly recognize health systems science (HSS)—the fundamental understanding of how care is delivered, how health professionals work together to deliver that care, and how the health system can improve patient care and health care delivery—as a potential source of solutions to the myriad problems they face and as a critical part of medical education, improving the health system, and allowing physicians to deliver better patient care. For example, medical education leaders have called HSS a mark of excellence for a medical education institution. 1 The American Medical Association’s Accelerating Change in Medical Education Consortium, which launched in 2013, has been a notable force in furthering the integration of HSS as the third pillar of medical education along with the basic and clinical sciences. 2,3 In 2018, the consortium launched the Health Systems Science Student Impact Competition (now the Health Systems Science Student, Resident and Fellow Impact Challenge) to identify medical students who had used their knowledge of HSS to improve the lives of patients, physicians, and other health professionals. 4 In the first year of this competition, students working in teams with other medical and health professions students and guided by a faculty mentor submitted 46 abstracts on completed projects; 43 of these submissions aligned with the goals of HSS and were included in the review detailed in this article. Additionally, 3 abstracts were selected through a juried process as the most impactful. The consortium gave the authors of these 3 abstracts monetary awards and invited them to present their projects at the ChangeMedEd 2019 meeting in Chicago. A list of abstracts and awardees is available online (https://www.ama-assn.org/system/files/2019-09/student-impact-competition-submissions.pdf). 4

Many of the 46 submitted abstracts detailed projects that had significant, albeit isolated effects, some of which have been the subject of other papers. 5–7 In this article, we reviewed the 43 abstracts aligned with the goals of HSS to explore whether there are larger themes medical students working in teams with other medical and health professions students and guided by a faculty mentor are helping to address.

Three Long-Standing Problems

We conducted a qualitative review of the 43 submissions to the competition that were aligned with the goals of HSS. One of us (V.S.E.) engaged with the text of the abstracts over a 1-month period, rereading them several times to identify projects addressing ongoing problems that, based on experience and intuition, would be of the most interest to academic physicians. All of us (V.S.E., J.J., S.A.S., J.R., K.H., and M.M.H.) agreed on the identification of the 3 long-standing problems in medicine and medical education that were frequently addressed by the submissions: improving care for those with mental illness (5 submissions), improving diversity in medicine (4 submissions), and improving teamwork and interprofessional education (4 submissions; Table 1). 4 We then extracted lessons from these abstracts.

T1
Table 1:
Titles, Lead Authors, and Schools of American Medical Association Accelerating Change in Medical Education 2018 Health Systems Science Student Impact Competition Projects Included in This Article’s Final Analysis, Grouped by the Long-Standing Problem They Address

The remaining projects tackled important challenges but did not align with enough of the other projects to illustrate larger themes. Additionally, the problems we chose for further analysis were selected because they are well defined. It would be possible to group abstracts in other ways. For example, 5 abstracts addressed the challenge of improving leadership skills among medical students and 5 addressed preventive care. While these themes could be considered larger buckets by which to group abstracts, we judged these problems as too broad for our purposes (Table 2).

T2
Table 2:
Problems Addressed by the American Medical Association Accelerating Change in Medical Education 2018 Health Systems Science Student Impact Competition Projects That Were Not Selected for Further Analysis in This Article

Improving care for those with mental illness

People with severe mental illness have a reduced life expectancy of an average of 10 years in comparison with those without this health challenge. 8 Mental illness and seeking help for mental illness are often stigmatized, 9 and patients with mental illness are less likely to receive routine preventive services. 10

Medical students attempted to address these issues by using the HSS domains of population health, public health, and quality improvement to improve links between those with mental illness and preventive services, outpatient mental health services, and primary care physicians. For example, a team at the University of California, San Francisco (UCSF), School of Medicine aimed to improve the availability of smoking cessation counseling for those receiving care in an inpatient psychiatry unit. This intervention involved increasing psychiatric unit team buy-in for smoking cessation, counseling through daily short presentations and emails, and training a psychiatric nurse to provide this counseling 1 day a week. After the implementation of this intervention, the percentage of patients offered smoking cessation during their inpatient psychiatry stay increased from 0–10% to 80%.

Another team of UCSF School of Medicine students attempted to strengthen the links between inpatient and outpatient care for those with mental illness. This team identified that patients discharged from the inpatient psychiatry unit who did not attend their first outpatient mental health appointment were more likely to be readmitted within 30 days. The student team worked with mental health providers and designed half-page, pink appointment reminder cards that also included a transportation plan created by the patient with a discharge social worker. After 4 months, the rate of patients attending their first postdischarge outpatient mental health appointment increased from 55% to 64%. This intervention has been permanently folded into the discharge process.

A third UCSF School of Medicine team addressed the needs of another vulnerable population—veterans seeking mental health services. This team sought to increase the proportion of veterans presenting for urgent mental health services at a drop-in clinic who then return for follow-up appointments. The team instituted a postvisit summary and informational form to give to patients at the end of their initial visit. This form explained the care process and included crisis contact information and an appointment reminder. With this initiative in place, the no-show rate decreased from 37% (29/79) in June–July 2017 to 17% (12/72) in June–July 2018.

To address disparities in cancer screening among those with mental illness, a student team at the University of North Carolina School of Medicine worked to improve cervical cancer screening rates at a primary care clinic serving this population. Over a 2-month period, the team distributed weekly Pap smear reminders to providers and placed reminder phone calls to patients. In addition, the students created a “Women’s Wellness Day” at the clinic, where women could receive Pap smears and other services. Transportation was also provided. The cervical cancer screening rate increased from 61% (119/194) before this initiative to 67% (138/206) after the implementation of this initiative.

To improve the links between pediatricians and psychological counselors, another team at the University of North Carolina School of Medicine developed a 1-page summary report for pediatricians to request information from counselors on whether initial appointments were kept, any diagnoses that were made, dates for upcoming appointments, any concerns that were noted, and any recommendations for treatment that were made. These forms were faxed to counselors following each referral. Before the intervention, 18% (30/169) of referrals were considered complete, meaning that there was communication back to the referring pediatrician from the counselor. The completed referral rate increased to 66% (103/157) after the 1-page summary reports were faxed to counselors receiving referrals. The team stated that the brevity of the form facilitated rapid incorporation into the counselors’ workflow.

These projects highlight interventions that may improve the care of those with mental illness by:

  • Expanding preventive services to settings where those with mental illness are receiving mental health services,
  • Providing clear information to patients about the care process, especially with regard to next steps,
  • Working with the patient to devise solutions to overcome structural barriers to care, such as transportation difficulties, and
  • Making it easier for mental health counselors to communicate with prescribing physicians.

Improving diversity in medicine

Despite working for years on diversifying the physician workforce, true diversity remains elusive. The number of women in medicine has increased over the past decade. 11,12 However, racial and ethnic diversity is a persistent problem, as demonstrated by the low numbers of physicians who identify as Black, Hispanic/Latino, and/or Native American. 13–16 As medicine aims to become antiracist through structural change, a more diverse physician workforce is critical to addressing significant health disparities between demographic groups. 17–20

Medical students used the HSS domain of leadership to attempt to improve the diversity of the physician workforce by strengthening the pipeline to medical school for students underrepresented in medicine (URM), which is defined by the Association of American Medical Colleges as those racial and ethnic populations underrepresented in the medical profession relative to their numbers in the general population. 21 For example, a team from the University of Michigan Medical School used a multitier peer-mentoring approach to create the Future Physician Summit. Two URM medical student coaches guided a team of 5 URM undergraduate premedical students in planning and executing a 1-day summit attended by 28 URM middle and high school students. URM undergraduate premedical students received training from 4 diverse medical student volunteers in the physical exam and related health disparity topics so that they could then lead the clinical skills session the day of the summit. During the summit, middle and high school student participants received instruction on and exposure to college readiness, clinical skills, and the premedical to medical career pipeline. Middle and high school student participants reported an increase in their confidence to pursue a career in medicine (from 4.42 to 4.77, on a 0- to 5-point Likert scale, where 0 = no confidence and 5 = very confident). Five undergraduate premedical members of the planning team published their first abstract as part of this project. The 4 medical student volunteers who assisted with this project reported increased dedication to mentorship and community outreach.

Another group from the Warren Alpert Medical School of Brown University established Health Career Opportunities Reimagined (HealthCORE), a longitudinal advising and mentorship program for URM high school students. A cohort of 23 high school students attended a 2-week summer intensive program created by medical students and focused on health topics not usually included in pipeline programs, such as global health, medical design, and narrative medicine. High school participants then spent a year volunteering in the community, shadowing physicians, and participating in research internships. High school participants reported more interest in pursuing a health career (from 4.36 to 4.59, on a 1- to 5-point Likert scale, where 1 = minimal interest/sense of capability and 5 = high interest/sense of capability) and a greater sense of capability in pursuing a health career (from 4.00 to 4.23).

Medical students at the University of California, Davis, School of Medicine helped establish the Diversity Advocacy Council, a coalition of student leaders of varying backgrounds that organizes and promotes pipeline programs and education on health disparities. Over a 2-year period, this council reached over 2,000 prehealth students through events, mentorship, and outreach; hosted over 200 prehealth students at the School of Medicine for shadowing; hosted monthly lectures and educational events focused on improving the health of marginalized communities; secured seats on several medical school committees for council members; and worked with the chancellor to develop an action plan to recruit and retain more Black, African American, and Caribbean students, residents, and faculty.

A team from Harvard Medical School developed a toolkit to deal with microaggressions and discrimination for students on the wards. There is limited research on the impact of microaggressions in medical school, 22,23 but there is evidence that microaggressions have a negative impact on a person’s health status and quality of life. 24–28 The team designed and implemented a mandatory 2-hour workshop for 163 students about strategies for identifying microaggressions and discrimination and how these can be addressed. An analysis of 81 pairs of pre- and postworkshop surveys revealed that 48% (39/81) of survey respondents were female, 36% (29/81) were from a URM group, and 56% (45/81) had experienced or witnessed microaggressions and discrimination. Attendees’ confidence in identifying and dealing with microaggressions and discrimination improved, and this workshop is being replicated by other health care institutions.

These projects highlight several interventions that may be considered to improve diversity in medicine by:

  • Implementing multitiered pipeline programs that benefit URM students at all levels of their careers,
  • Including topics in pipeline programs that are important to health care but that may not be a common focus of such programs,
  • Creating collaborations between various marginalized groups to work with the administration of a medical school at all levels, and
  • Providing training on identifying and addressing microaggressions and discrimination.

Improving teamwork and interprofessional education

Teamwork is one of the foundational domains of HSS 29 and is critical to providing good care in a modern health system. Effective teamwork, however, is challenged by problems with sharing information, occupational silos, and organizational factors. 30 Most medical schools require some form of interprofessional education, 31 although teamwork education is often lacking. 30

Medical students attempted to address this by identifying teamwork-related gaps in their medical school curricula and integrating available evidence-based education on the subject. For example, a team of medical students from Rutgers Robert Wood Johnson Medical School sought to understand student teamwork behaviors and completed the Agency for Healthcare Research and Quality’s Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) Master Training course. 32 They then led training sessions on TeamSTEPPS that reached 650 medical, nursing, and pharmacy students. There were statistically significant improvements in teamwork behaviors across all teamwork competency domains. Enthusiasm for the TeamSTEPPS Master Training course among those who took it led to an Agency for Healthcare Research and Quality–led 2-day TeamSTEPPS Master Training course attended by 80 clinical faculty and 12 medical students. This training course also will be integrated into several Rutgers Robert Wood Johnson Medical School residency programs.

Communication is a key component of improved teamwork, and a UCSF School of Medicine student team worked to improve communication among physicians and health professionals to reduce decision-to-incision (DTI) times for unplanned cesarean deliveries at a county teaching hospital. The medical student team established a grading system to standardize the urgency of unplanned cesareans and implemented a unit team huddle involving the obstetrics & gynecology chief resident, bedside registered nurse, charge registered nurse, and anesthesia resident. Unit team members were instructed to set a target incision time and discuss any delays. The intervention initially included a DTI checklist. Based on feedback, the checklist was replaced with a communication tool to facilitate discussion around urgency. The initial intervention reduced the DTI time from 97 to 93 minutes; with the change from the checklist to the communication tool, DTI time was further reduced to 82 minutes. Unit team members reported that standardized language around cesarean urgency allowed for improved situational awareness on the unit, supported good relationships between interdisciplinary team members, and increased patient trust and satisfaction.

Medical students also brought people together to work with those underserved by current health systems. A team from Harvard Medical School led a weekly student–faculty collaborative clinic that allows medical, dental, nursing, and physician assistant students to provide care and undergraduates studying any field to provide insurance enrollment, education services, and transition assistance to people incarcerated at a local jail. The clinic meets 1 evening per week and begins with a preclinic huddle. The teams of medical, dental, nursing, and physician assistant students and faculty provide direct patient care. A Medicaid enrollment team assists those nearing release with insurance paperwork and voter registration. An education team offers a teaching session on topics ranging from interviewing skills to mindfulness. The clinic holds 40 sessions per year and has involved more than 100 volunteers. Surveys of student volunteers have documented improved attitudes toward interprofessional collaboration and increased comfort caring for incarcerated patients.

At Emory University School of Medicine, a team worked to decrease emergency department visits and inpatient hospital admissions for high-utilization patients at Grady Memorial Hospital. To do this, they formed teams of 4–6 students and faculty advisers from medicine, nursing, pharmacy, social work, public health, law, and business. Each team assisted 3–5 high utilizers with navigating personal and systemic barriers to better health outcomes. Over a 6-month period, each team systematically identified high utilizers when they were admitted to the hospital, empowered these patients to identify and address the reasons behind their high utilization of health care services, and served as a reliable resource to help them navigate social services and health systems. In the program’s first year (2017), 30 students and 9 faculty advisers representing 6 disciplines participated.

These projects highlight several interventions that may improve teamwork and interprofessional education by:

  • Implementing established evidence-based education on teamwork,
  • Continually assessing and being willing to modify interventions, as appropriate,
  • Designing tools that focus communications on needed information,
  • Developing a shared understanding around critical issues, and
  • Creating teams of people with skills not traditionally associated with providing health care to address the needs of underserved patients.

Overarching Themes and Limitations

The projects detailed above all involve students addressing recognized challenges, and many continue to make an impact at multiple levels. While not all projects were scientifically rigorous enough to be published on their own and the quality of the data presented in the abstracts varied widely, many provide innovative ideas for potentially solving long-standing problems. Our ability to evaluate these projects was also limited to the information provided on the submitted abstracts. Additionally, many of the projects were submitted by a small group of students but required much broader input from students and faculty to implement and run. Some projects were implemented over a very brief time span, while others occurred over the course of a few years. Some of the lessons extracted from these projects have been highlighted by other quality improvement endeavors. We do, however, feel that these projects in their totality emphasize potential strategies for moving forward that may have been overlooked or not considered sufficiently. We also feel that they provide hope for the future of medicine because these ideas came from medical students, who will be future health care professionals.

The Future of Medical Student Involvement in HSS

We expect HSS will continue to make inroads in medical education as an increasingly important academic discipline across the education continuum. 33 To document the ongoing impact of HSS on medical students and in turn on the health system, other health professionals, and patients, the American Medical Association Accelerating Change in Medical Education Consortium has continued to hold the challenge since 2018 and expanded it to include residents and fellows. In 2020, the Health Systems Science Student, Resident, and Fellow Impact Challenge was focused on projects making an impact on the COVID-19 pandemic. This challenge will be held again in 2021. The submissions detailed above and our subsequent analysis of them demonstrate that not only do medical students make significant impacts on the health system, other health professionals, and, most critically, patients when equipped with HSS, working in teams, and advised by mentors but they may also be able to address some of medicine’s and medical education’s long-standing challenges.

The fresh perspectives and high energy of medical students are valuable and should be nurtured and encouraged. Their individual projects can be impactful and aggregated to address pervasive issues with sustainable solutions. By stimulating and empowering medical students’ innovation, HSS and medicine as a whole can be advanced.

Acknowledgments:

The authors wish to thank the students and their mentors for the work they have done in their health systems and the submissions to the American Medical Association Accelerating Change in Medical Education 2018 Health Systems Science Student Impact Competition, as well as Annalynn Skipper, PhD, RD, Health and Science, American Medical Association, for her review of the article.

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