Abstract
After emphasizing biomedical and clinical sciences for over a century, US medical schools are expanding experiential roles that allow students to learn about health care delivery while also adding value to patient care. After developing a program where all 1st-year medical students are integrated into interprofessional care teams to contribute to patient care, authors use a diffusion of innovations framework to explore and identify barriers, facilitators, and best practices for implementing value-added clinical systems learning roles. In 2016, authors conducted 32 clinical-site observations, 29 1:1 interviews with mentors, and four student focus-group interviews. Data were transcribed verbatim, and a thematic analysis was used to identify themes. Authors discussed drafts of the categorization scheme, and agreed upon results and quotations. Of 36 sites implementing the program, 17 (47%) remained, 8 (22%) significantly modified, and 11 (31%) withdrew from the program. Identified strategies for implementing value-added roles included: student education, patient characteristics, patient selection methods, activities performed, and resources. Six themes influencing program implementation and maintenance included: (1) educational benefit, (2) value added to patient care from student work, (3) mentor time and site capacity, (4) student engagement, (5) working relationship between school, site, and students, and, (6) students’ continuity at the site. Health systems science is an emerging focus for medical schools, and educators are challenged to design practice-based roles that enhance education and add value to patient care. Health professions’ schools implementing value-added roles will need to invest resources and strategize about best-practice strategies to guide efforts.
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Acknowledgements
The project was performed with financial support from the American Medical Association (AMA) as part of the Accelerating Change in Medical Education Initiative and the Josiah Macy Jr. Foundation. The content of this paper reflects the views of the authors and does not necessarily represent the views of AMA, the Josiah Macy Jr. Foundation, or other participants in this Initiative. We acknowledge the clinicians in collaborating health systems for piloting educational experiences.
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Dr. Gonzalo is co-editor of a textbook on Health Systems Science (Elsevier, 2016). There are no other conflicts of interest to report.
Appendices
Appendix 1: representative field site questions and prompts
Questions for medical students during visit:
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1.
What is your typical schedule?
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a.
Arrival time/leave time
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b.
Home visits, phone calls
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a.
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2.
How long do you work with patients?
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3.
Do you document in the EHR?
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4.
What did you learn during patient navigation?
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5.
Do you complete any additional activities during navigation days?
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6.
Do you have any suggestions on improvements in regards to navigation?
Questions for site mentors during visit:
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1.
Do you have any questions in regards to program expectations?
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2.
Should we provide any additional training or resources to the students?
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a.
Resource lists, guidelines, etc.
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a.
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3.
What were the barriers you experienced in developing or implementing this program at your site?
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b.
Schedule, engagement
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b.
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4.
How long did it take to orient the students?
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5.
How has patient navigation affected your work?
Appendix 2: student patient navigator focus-group interview guide
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1.
Implementation stage questions:
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a.
What are your experiences so far with the student PN program?
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1.
Probe: How would you describe your experience?
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2.
Probe: (If they did not indicate any positive aspects), what was the most positive aspects of PN?
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3.
Probe: What factors facilitated those positive aspects?
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4.
Probe: (If they did not indicate any barriers or negative aspects), what were factors specific to your site that may have negatively impacted your learning as a PN?
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5.
Probe: What are the features of the student patient navigator program in your site that make it successful?
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6.
Probe: In thinking of your class as a whole—based on what you heard and your own experiences, what are barriers that may have negatively impacted the program as a whole?
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7.
Probe: For those barriers that you described, how were these addressed?
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1.
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b.
Tell me about expectations of your role.
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1.
Probe: What were the expectations of you? Were they clear?
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2.
Probe: What was a typical day/experience?
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1.
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c.
What about the patients at your PN site?
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1.
Probe: Which patients did you work with?
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1.
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d.
Describe the mentoring at your site.
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1.
Probe: Who were the mentors at your site?
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2.
Probe: How did this mentoring relationship work best?
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3.
Probe: How were the mentors influential to your experience in patient navigation?
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1.
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e.
Think about things you needed to know to do your job as a patient navigator.
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1.
Probe: Thinking about your few first experiences in patient navigation, what knowledge/skills do you think helped you navigate your patient?
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2.
Probe: What kind of knowledge/skills would have facilitated even more?
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3.
Probe: What resources did you use during your navigation experience?
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How did you access them?
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What resources would you have found useful?
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4.
Probe: How long was the time frame for working with any one individual patient? What is optimal?
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1.
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f.
What barriers did you experience in the implementation of the patient navigation program?
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a.
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2.
Value From the Student Patient Navigator Program (to the site, to the stakeholders, to education)
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a.
What value did you bring to your clinical site or program during the navigation program?
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Probe: How were you able to extend the work of the clinic?
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2.
Probe: Tell me about how you helped to improve patient outcomes?
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3.
Probe: Please describe the learning that occurred through the patient navigator program (either for the students, patients, or the clinic).
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4.
Probe: If you were to put a value on the job you performed, how would you describe that value?
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1.
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b.
Which patients in the clinic benefitted most from having a student assigned to them in the role of patient navigators?
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1.
Probe: Which patients? Why do you think those patients benefitted?
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1.
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a.
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3.
Closing
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a.
Please add any additional comments about the patient navigator program or the best practices that other programs should use to build their program.
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a.
Appendix 3: representative site mentor interview questions and guide
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1.
Implementation stage questions
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a.
How would you describe your experiences so far with the student PN program?
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b.
When you reflect on your implementation of the patient navigator program at your site, what were the barriers when you were implementing the program?
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a.
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2.
Maintenance stage
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a.
Is your clinical site/program continuing in the student patient navigator program? What, if any, factors/issues were involved with the decision to continue or not continue the program?
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b.
Are there any rewards or positive responses that have been realized through the program?
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c.
Any negative outcomes from the program?
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d.
Thinking about your original implementation of the PN program, I’m interested in how you have modified the program to work optimally at your site.
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1.
Probe: Were there tasks/activities that you anticipated students could do at the start of the program that they ended up not being able to?
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a.
If so, tell me about those tasks and reasons you think they were unable to do them.
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a.
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ii.
Probe: Likewise, were there tasks/activities students that you did not anticipate student being able to do that they could do? How did the students advance from the beginning of the year?
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a.
If so, tell me about those tasks and reasons you think they were unable to do them.
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a.
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1.
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a.
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3.
Value from the student patient navigator program (to the site, to the stakeholders, to education)
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a.
During an average session where medical students were serving in a patient navigator role in your clinic/program, how much time did it take to work with the students: ________
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b.
What value did the students bring to your clinical site or program during the navigation program, if any?
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1.
Probe: How did students extend the work of the clinic, if any?
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2.
Probe: How did they help to improve patient outcomes, if any?
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3.
Probe: If you were to put a value on the job performed by students, how would you describe that value?
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a.
Dollar value? Other value?
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a.
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4.
Probe: As you think about the patients in your clinic that were part of the student patient navigator program, what types of patients benefitted most from having a student assigned to them as a patient navigator? What challenges were these patients experiencing?
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1.
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a.
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4.
Closing
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a.
Do you have any advice or comments for us as we develop our program of systems-based practice for medical students?
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a.
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Gonzalo, J.D., Graaf, D., Ahluwalia, A. et al. A practical guide for implementing and maintaining value-added clinical systems learning roles for medical students using a diffusion of innovations framework. Adv in Health Sci Educ 23, 699–720 (2018). https://doi.org/10.1007/s10459-018-9822-5
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DOI: https://doi.org/10.1007/s10459-018-9822-5