August 27, 2012
AMEE Conference
Early Medical Students Can Assume
Central Roles in Patient Care
H. Carrie Chen, MD, MSEd
Leslie Sheu, MD
Patricia O’Sullivan, EdD
Olle ten Cate, PhD
Arianne Teherani, PhD
University of California San Francisco
School of Medicine
Purpose
To learn how early medical students can
legitimately participate in the clinical workplace
Learning in the Workplace
• Dependent on interactions and activities (Billet, 2004)
– Increased engagement and learning when
contributions meaningful and valued (Dornan, 2012)
– Legitimacy of work and membership (Lave & Wenger,
1991)
• Workplaces with differing characteristics/ opportunities
inviting participation (Billet, 2004)
– Rarely offer early students legitimate participation
– One exception is student-run clinics
Student-Run Clinics (SRCs)
• Widespread at US medical schools (Simpson & Long, 2007)
– Provide care for the underserved (poor, uninsured,
homeless patients)
– Generally initiated by students
– Staffed by early medical students volunteers
Study Questions
What roles do
students
assume in the
SRCs and in
what patient
care activities do
students
legitimately
participate?
What is their
level of
engagement in
these activities?
What
characteristics
of the SRCs
allow this
degree of
participation?
Single Institution Multi-Site Qualitative Study
Semi-structured interviews
• Purposive sampling
• 5 questions about
roles and activities
Data Analysis
Initial open coding
(5 random transcripts, 3 authors)
Identified themes mapped to theoretical framework
(workplace learning/ communities of practice)
Codebook for theoretical thematic analysis
All transcripts coded
(independently by 2 authors)
Discrepancies reconciled
No new codes identified
Results
• Interviewed
8
24 students
14
4 advisors
• Identified 3 major themes, 11 subthemes
Learning in
the
Workplace
Legitimate
Participation
Scope of
Practice
Study Questions
What roles do
students
assume in the
SRCs and in
what patient
care activities do
students
legitimately
participate?
What is their
level of
engagement in
these activities?
What
characteristics
of the SRCs
allow this
degree of
participation?
What roles do students assume and in what
activities do they legitimately participate?
Direct patient care
•
•
•
•
Patient
“[Intriage
the formal curriculum] we see standardized
Histories,
physicalaexams
patients…get
lot of practice on how to talk to
patients
and…go to our preceptorship to get
Patient
education
patient &
exposure…
but what
we don’t have is that,
Laboratory
immunization
procedures
knowing what you do really makes a difference or
“I don’t feel like
really matters…[in the SRC] we actually are
I’m a burden, I
these patients as if [they are] our own
Clinicseeing
management
feel like I can
and [what] we do…have real effects on the
contribute more • Patient flow, patient follow-up
patient and that’s something that we really
to the process,
• Clinicvalue.”
supplies, funding
and it’s more
• Quality improvement
rewarding.”
• Volunteer recruitment/ training, preceptor orientation
What is the students’ level of engagement?
Students empowered to take ownership of
“[The students] are much more
clinic and function
relatively autonomously
knowledgeable about the patient
“The faculty’s role is just
• Coordinators
developed/
ran training
programs
and the process
than any
of the
to keep things on
track
preceptors
so it does kind
of
• Students debriefed
clinic experiences,
generated
&
and then to be teachers
shift
bound of power
a bit.”faculty
ideas
forthe
improvement
without
and supporters at implemented
the
actual clinic sessions.”
Preceptors and advisors served as resources
to facilitate work of students
“[In the
typical clinic
setting]
primary
relationship
• Ensured
quality
of the
care
with on-site
support
[of patients] is with the preceptor and faculty that run
• Provided guidance about clinical services
the clinic, whereas in the [SRC], the primary
• Facilitated relationships with outside agencies
relationship really is with the students.”
• Often deferred to students with more knowledge
about patients and clinic
What characteristics of the SRCs allow this
degree of participation?
Limited
Scope of
Work
• Clinics with narrow scope of practice
• Patients with small range of problems
Focused
Student
Training
• Required elective course
• Just-in-time pre-clinic training
• Pairing of new with experienced volunteers
Additional
Structures
• History questionnaire, illness protocols
• Volunteer handbooks, operations manuals
• Clear sequenced roles and activities
Summary
Early medical students are able to participate in patient
care experiences reserved for more advanced students
Health Screening
Hepatitis B Vaccinations
 Depth 
Time
Potential Ideas for Transforming Curriculum
 Breadth 
Time
Acknowledgements
Co-authors
Colleagues
• Leslie Sheu, MD
• Christy Boscardin, PhD
• Patricia O’Sullivan, EdD
• Karen Hauer, MD
• Olle ten Cate, PhD
• David Irby, PhD
• Arianne Teherani, PhD
• Lauren Maggio, MLIS
• Bridget O’Brien, PhD
• John Young, MD
Questions