Advances in Health Sciences Education

, Volume 23, Issue 4, pp 699–720 | Cite as

A practical guide for implementing and maintaining value-added clinical systems learning roles for medical students using a diffusion of innovations framework

  • Jed D. Gonzalo
  • Deanna Graaf
  • Amarpreet Ahluwalia
  • Dan R. Wolpaw
  • Britta M. Thompson


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.


Undergraduate medical education Implementation science Curricular development Value-added medical education 



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.

Compliance with ethical standards

Conflicts of interest

Dr. Gonzalo is co-editor of a textbook on Health Systems Science (Elsevier, 2016). There are no other conflicts of interest to report.


  1. American Medical Association: Accelerating Change in Medical Education Initiative. (2013).
  2. Association, A. M. (2014). How two schools are embracing a new science in medical education. Retrieved from AMA Wire website:
  3. Bernard, H. R., & Ryan, G. W. (2010). Analyzing qualitative data: Systematic approaches. Los Angeles, CA: SAGE.Google Scholar
  4. Berwick, D. M., & Finkelstein, J. A. (2010). Preparing medical students for the continual improvement of health and health care: Abraham Flexner and the new “public interest”. Academic Medicine, 85(9 Suppl), S56–S65. Scholar
  5. Boyatzis, R. E. (1998). Transforming qualitative information: Thematic analysis and code development. Thousand Oaks, CA: Sage Publications.Google Scholar
  6. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101.CrossRefGoogle Scholar
  7. Chen, H. C., Sheu, L., O’Sullivan, P., Ten Cate, O., & Teherani, A. (2014). Legitimate workplace roles and activities for early learners. Medical Education, 48(2), 136–145. Scholar
  8. Combes, J. R., & Arespacochaga, E. (2012). Physician competencies for a 21st century health care system. The Journal of Graduate Medical Education, 4(3), 401–405. Scholar
  9. Cooke, M., Irby, D. M., O’Brien, B. C., & Carnegie Foundation for the Advancement of Teaching. (2010). Educating physicians: A call for reform of medical school and residency (1st ed.). San Francisco, CA: Jossey-Bass.Google Scholar
  10. Cordasco, K. M., Horta, M., Lurie, N., Bird, C. E., & Wynn, B. O. (2009). How are residency programs preparing our 21st century internists? A study conducted by staff from rand health for the Medicare Payment Advisory Commission.
  11. Crosson, F. J., Leu, J., Roemer, B. M., & Ross, M. N. (2011). Gaps in residency training should be addressed to better prepare doctors for a twenty-first-century delivery system. Health Affairs (Millwood), 30(11), 2142–2148. Scholar
  12. Curry, R. H. (2014). Meaningful roles for medical students in the provision of longitudinal patient care. JAMA, 312(22), 2335–2336. Scholar
  13. Elo, S., & Kyngas, H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62(1), 107–115. Scholar
  14. Freeman, H. P., & Rodriguez, R. L. (2011). History and principles of patient navigation. Cancer, 117(15 Suppl), 3539–3542. Scholar
  15. Gonzalo, J. D., Dekhtyar, M., Hawkins, R. E., & Wolpaw, D. R. (2017). How can medical students add value? Identifying roles, barriers, and strategies to advance the value of undergraduate medical education to patient care and the health system. Academic Medicine, 92(9), 1294–1301.Google Scholar
  16. Gonzalo, J. D., Dekhtyar, M., Starr, S. R., Borkan, J., Brunett, P., Fancher, T., et al. (2017a). Health systems science curricula in undergraduate medical education: Identifying and defining a potential curricular framework. Academic Medicine, 92(1), 123–131. Scholar
  17. Gonzalo, J. D., Haidet, P., Blatt, B., & Wolpaw, D. R. (2016b). Exploring challenges in implementing a health systems science curriculum: A qualitative analysis of student perceptions. Medical Education, 50(5), 523–531. Scholar
  18. Gonzalo, J. D., Haidet, P., Papp, K. K., Wolpaw, D. R., Moser, E., Wittenstein, R. D., et al. (2017b). Educating for the 21st-century health care system: An interdependent framework of basic, clinical, and systems sciences. Academic Medicine, 92(1), 35–39. Scholar
  19. Gonzalo, J. D., Haidet, P., & Wolpaw, D. R. (2014). Authentic clinical experiences and depth in systems: Toward a 21st century curriculum. Medical Education, 48(2), 104–105. Scholar
  20. Gonzalo, J. D., Lucey, C., Wolpaw, T., & Chang, A. (2017c). 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. Academic Medicine, 92(5), 602–607. Scholar
  21. Gonzalo, J. D., Thompson, B. M., Haidet, P., Mann, K., & Wolpaw, D. R. (2017d). A constructive reframing of student roles and systems learning in medical education using a communities of practice lens. Academic Medicine, 92(12), 1687–1694. Scholar
  22. Gough, H. G. (1978). Some predictive implications of premedical scientific competence and preferences. Journal of Medical Education, 53(4), 291–300.Google Scholar
  23. Grumbach, K., Lucey, C. R., & Johnston, S. C. (2014). Transforming from centers of learning to learning health systems: The challenge for academic health centers. JAMA, 311(11), 1109–1110. Scholar
  24. Harting, J., Rutten, G. M., Rutten, S. T., & Kremers, S. P. (2009). A qualitative application of the diffusion of innovations theory to examine determinants of guideline adherence among physical therapists. Physical Therapy, 89(3), 221–232. Scholar
  25. Irby, D. (2011). Educating physicians for the future: Carnegie’s calls for reform. Medical Teacher, 33(7), 547–550. Scholar
  26. Jones, R. F., & Korn, D. (1997). On the cost of educating a medical student. Academic Medicine, 72(3), 200–210.CrossRefGoogle Scholar
  27. Lin, S. Y., Schillinger, E., & Irby, D. M. (2015). Value-added medical education: engaging future doctors to transform health care delivery today. Journal of General Internal Medicine, 30(2), 150–151. Scholar
  28. Lucey, C. R. (2013). Medical education: Part of the problem and part of the solution. JAMA Internal Medicine, 173(17), 1639–1643. Scholar
  29. Mauthner, N. S., & Doucet, A. (2003). Reflexive accounts and accounts of reflexivity in qualitative data analysis. Sociology-the Journal of the British Sociological Association, 37(3), 413–431. Scholar
  30. Miles, J., & Gilbert, P. (2005). A handbook of research methods for clinical and health psychology. New York: Oxford University Press.CrossRefGoogle Scholar
  31. Murray, D. M. (1986). Dissemination of community health promotion programs: The Fargo-Moorhead Heart Health Program. Journal of School Health, 56(9), 375–381.CrossRefGoogle Scholar
  32. Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York: Free Press.Google Scholar
  33. Rohrbach, L. A., Graham, J. W., & Hansen, W. B. (1993). Diffusion of a school-based substance abuse prevention program: Predictors of program implementation. Preventive Medicine, 22(2), 237–260. Scholar
  34. Shea, S., Nickerson, K. G., Tenenbaum, J., Morris, T. Q., Rabinowitz, D., O’Donnell, K., et al. (1996). Compensation to a department of medicine and its faculty members for the teaching of medical students and house staff. The New England Journal of Medicine, 334(3), 162–167. Scholar
  35. Shenton, A. (2004). Strategies for ensuring trustworthiness in qualitative research projects. Education for Information, 22(2), 63–75.CrossRefGoogle Scholar
  36. Skochelak, S. E. (2010). A decade of reports calling for change in medical education: What do they say? Academic Medicine, 85(9 Suppl), S26–S33. Scholar
  37. Skochelak, S. E., Hawkins, R. E., & AMA Education Consortium. (2016). Health systems science. St. Louis, MO: Elsevier.Google Scholar
  38. Thibault, G. E. (2013). Reforming health professions education will require culture change and closer ties between classroom and practice. Health Affair (Millwood), 32(11), 1928–1932. Scholar
  39. Witzburg, R. A., & Sondheimer, H. M. (2013). Holistic review—Shaping the medical profession one applicant at a time. The New England Journal of Medicine, 368(17), 1565–1567. Scholar

Copyright information

© Springer Science+Business Media B.V., part of Springer Nature 2018

Authors and Affiliations

  • Jed D. Gonzalo
    • 1
    • 6
  • Deanna Graaf
    • 2
  • Amarpreet Ahluwalia
    • 3
  • Dan R. Wolpaw
    • 4
  • Britta M. Thompson
    • 5
  1. 1.Medicine and Public Health Sciences, Health Systems EducationPenn State College of MedicineHersheyUSA
  2. 2.Office of Medical EducationPenn State College of MedicineHersheyUSA
  3. 3.Penn State College of MedicineHersheyUSA
  4. 4.Medicine and HumanitiesPenn State College of MedicineHersheyUSA
  5. 5.MedicinePenn State College of MedicineHersheyUSA
  6. 6.Division of General Internal MedicinePenn State Hershey Medical Center – HO34HersheyUSA

Personalised recommendations