Learners as Leaders: A Global Groundswell of Students Leading Choosing Wisely Initiatives in Medical Education

Medical Students' Observations of High Value and Potentially Wasteful Care Behaviors Modeled During Clinical Rotations

BACKGROUND

Medical student exposure to role-modeling of high-value care (HVC) behaviors may shape professional identity formation and future HVC practices.

OBJECTIVE

To investigate the frequency and characteristics of HVC role-modeling witnessed by medical students during core clinical rotations.

DESIGN

Cross-sectional survey study.

PARTICIPANTS

Medical students on clinical rotations at 11 US medical schools.

MAIN MEASURES

A validated 13-item survey was used to assess medical student perception of cost-conscious role-modeling behaviors or potentially wasteful role-modeling behaviors and modified to include whom demonstrated the behavior (attending vs resident/fellow) and during which clinical rotation the modeling occurred.

KEY RESULTS

Cost-conscious role-modeling behaviors were observed by medical students sometimes/often 52.9-70.5% (353/667-452/641) of the time across all clinical rotations, except for praising a student for ordering a cost-effective diagnostic work-up which was seen only 25.7% (143/556) of the time. Potentially wasteful role-modeling behaviors were observed sometimes/often 5-14.3% (26/537-87/609) of the time, except simultaneously ordering numerous tests before seeing results of initial screening tests 45.1% (273/605) and repeating tests rather than attempting to obtain recently performed test results 32.2% (194/602). HVC modeling was most often demonstrated by internal medicine attendings 67.7% (65/96) and least frequently by general surgery attendings 47.3% (17/36). Attendings were overall more likely to model HVC compared to residents/fellows.

CONCLUSION

HVC role-modeling, as observed by medical students, is not consistently demonstrated across clinical rotations. Attendings generally model more HVC than residents and general surgery models less HVC compared to other specialties. Future studies should strive to identify factors which promote or inhibit HVC modeling.

How Medical Students Benefit from Participating in a Longitudinal Resource Stewardship Medical Education Program (STARS): An International Descriptive Evaluation

BACKGROUND

STARS (Students and Trainees Advocating for Resource Stewardship) is a medical student leadership program that promotes integration of resource stewardship (RS) into medical education in at least seven countries. Little is known about how participation affects student leaders.

AIM

To understand how partaking in STARS impacted participants' knowledge, skills, and influenced career plans, and aspirations.

SETTING AND PARTICIPANTS

We conducted qualitative semi-structured interviews with STARS participants (n = 27) from seven countries.

PROGRAM DESCRIPTION

STARS was designed to facilitate grassroots efforts that embed RS principles into medical education. STARS programs globally share common features: participation from several medical schools, centralized organizing hubs and leadership summits, and support from faculty mentors. Students take lessons learnt from centralized programming to implement changes that advance RS initiatives at their schools.

PROGRAM EVALUATION

Students finished STARS with better RS knowledge, enhanced change management skills (leadership, advocacy, collaboration), and a commitment to incorporate RS into future practice. Nearly all respondents hoped to pursue leadership activities in medicine, but most were unclear if they would focus efforts to advance RS.

DISCUSSION

STARS participants gained knowledge as it relates to RS, change management skills, and catalyzed a commitment to incorporate high-value care into future practice. Medical education initiatives should be leveraged as a key strategic approach to build RS capacity.

Factors Associated with Medical Students' Attitudes About Cost-Conscious Care: A Mixed-Methods Multi-school Study

BACKGROUND

Because physician practices contribute to national healthcare expenditures, initiatives aimed at educating physicians about high-value cost-conscious care (HVCCC) are important. Prior studies suggest that the training environment influences physician attitudes and behaviors towards HVCCC.

OBJECTIVE

To explore the relationship between medical student experiences and HVCCC attitudes.

DESIGN

Quantitative and qualitative analysis of a multi-institutional survey.

PARTICIPANTS

Medical students from nine US medical schools.

APPROACH

A 44-item survey that included the Maastricht HVCCC Attitudes Questionnaire, a validated tool for assessing HVCCC attitudes, was administered electronically. Attitudinal domains of high-value care (HVC), cost incorporation (CI), and perceived drawbacks (PD) were compared using one-way ANOVA among students with a range of exposures. Open text responses inviting participants to reflect on their attitudes were analyzed using classical content analysis.

KEY RESULTS

A total of 740 students completed the survey (response rate 15%). Students pursuing a "continuity-oriented" specialty held more favorable attitudes towards HVCCC than those pursuing "technique-oriented" specialties (HVC sub-score = 3.20 vs. 3.06; p = 0.005, CI sub-score = 2.83 vs. 2.74; p < 0.001). Qualitative analyses revealed personal, educational, and professional experiences shape students' HVCCC attitudes, with similar experiences interpreted differently leading to both more and less favorable attitudes.

CONCLUSION

Students pursuing specialties with longitudinal patient contact may be more enthusiastic about practicing high-value care. Life experiences before and during medical school shape these attitudes, and complex interactions between these forces drive student perceptions of HVCCC.

Trainees as Agents of Change: A Theory-Informed Model for Trainee-Driven Curricular Advocacy in Medical Education

ABSTRACT

Trainees (medical students, residents, and fellows) are beginning to make strides in pushing for changes to their education. While there are many examples of successful trainee-led curriculum reform efforts, the path to success remains unclear. To better understand the process of trainee-driven curricular advocacy, the author analyzes this process through the lens of ecological systems theory (EST) not only to provide readers with context for the barriers and facilitators to trainee-driven curricular advocacy but also to further medical education's understanding of the sociopolitical forces influencing the process of trainee-driven curricular advocacy and reform through the lens of the trainee. EST explains how individuals are influenced by a complex web of social and environmental forces. The theory outlines 5 ecological systems of influence: the microsystem, mesosystem, exosystem, macrosystem, and chronosystem. Using EST to explore the process of trainee-driven curricular advocacy therefore clarifies the many layers of influence that trainees must navigate while advocating for curriculum change. The author then draws on this theory and their own experience as a medical student advocating for local and national curriculum reform to develop a model to facilitate trainee-driven curricular advocacy in medical education. The proposed model outlines concrete steps trainees can take while going through the process of curricular advocacy both within their own institutions and on a national level. Through developing this model, the author hopes not only to empower trainees to become agents of change in medical education but also to encourage faculty members and administrators within health professional training programs to support trainees in these efforts.

Systems-Based Practice in Graduate Medical Education: Evolving Toward an Ideal Future State

ABSTRACT

Systems-based practice (SBP) was first introduced as a core competency in graduate medical education (GME) in 2002 by the Accreditation Council for Graduate Medical Education as part of the Outcomes Project. While inclusion of SBP content in GME has become increasingly common, there have also been well-documented stumbling blocks, including perceptions that SBP has eroded the amount of curricular time available for more medically focused competencies, is not relevant for some practice contexts, and is not introduced early enough in training. As a result, SBP learning experiences often feel disconnected from medical trainees' practical reality. In this commentary, the authors provide guidance regarding potential changes that may facilitate the evolution of SBP toward an ideal future state where graduates bring a systems science mindset to all aspects of their work. Specific suggestions include the following: (1) expanding the SBP toolbox to reflect current-day health system needs, (2) evolve the teaching methodology, (3) broadening the scope of relevant SBP content areas, and (4) emphasizing SBP as an integrated responsibility for all health care team members. Levers to enact this transformation exist and must be used to influence change at the learner, faculty, program, and clinical learning environment levels.Physicians operate within an increasingly complex health care system that highlights the intersection of health care with complex social, environmental, and relational contexts. Consequently, the role of SBP in both physician work responsibilities and educational requirements continues to expand. To meet this growing demand, GME must adapt how it supports and trains the next generation of systems thinkers, ensuring they understand how levers in the health care system directly affect health outcomes for their patients, and integrate SBP into the foundation of GME curricula in an inclusive, holistic, and unrestrained way.

Integrating Choosing Wisely, Value-Based Care Principles, Into Undergraduate Medical Education: A Pilot Study

BACKGROUND

Healthcare spending represents a large portion of the GDP of the United States. Value-based care (VBC) seeks to decrease waste in health care spending, yet this concept is insufficiently taught to medical students. The Choosing Wisely Students and Trainees Advocating for Resource Stewardship (STARS) campaign promotes initiatives that integrate knowledge of VBC into undergraduate medical education (UME). This study sought to determine the most effective strategy to educate medical students on key principles of VBC as taught by the STARS campaign.

METHODS

Choosing Wisely principles were incorporated into the UME curriculum of an academic medical institution via the creation of eight new learning objectives (LOs) for case-based learning (CBL) sessions and lectures. Medical students completed an annual 10-question survey from 2019 to 2022 and 10 formal examination questions during the preclinical (years 1 and 2) curriculum after exposure to varying quantities of LOs. Pearson correlation, chi-square, and logistic regression were employed to determine the association between increased LOs in the curriculum and (1) campaign awareness and (2) knowledge of VBC principles.

RESULTS

A total of 700 survey responses over a four-year period (2019 to 2022) were analyzed. Student awareness of the campaign and knowledge of VBC principles increased year over year during the survey period (39% to 92% and 64% to 74%, respectively). There were significant associations between increased LOs in the curriculum and (1) campaign awareness (0.828, p<0.0001) and (2) knowledge of VBC principles (0.934, p<0.001). Students also performed well on formal examination questions related to VBC principles (mean: 81.5% and mean discrimination index: 0.18).

CONCLUSION

Integration of VBC-focused LOs is significantly associated with awareness of the Choosing Wisely STARS campaign and knowledge of VBC principles taught by the campaign. Collaborative initiatives to increase exposure to VBC education may improve students' knowledge of these principles during medical school.

"They were an advocate for me": A Qualitative Study Exploring Medical Student Longitudinal Relationships and Patient Well-Being

BACKGROUND

Patient navigators, community health workers, and care management teams improve patient experience and health outcomes. Medical student involvement in these roles is limited. Evaluation of these programs focuses on the student experience with less attention to patient participants.

OBJECTIVES

We sought (1) to understand the experience of being a participant in a medical education program; (2) to explore the patient-medical student relationship; and (3) to describe the impact of this relationship on patient health and well-being.

DESIGN

This was a qualitative study that utilized in-depth semi-structured interviews.

PARTICIPANTS

Participants were selected based on enrollment in a preceptorship program at an urban academic medical center between 2017 and 2020. Participants worked with a medical student during an 18-month period in which the medical student was embedded in a primary care medical home, serving as a health systems navigator for 1-2 medically and socially complex patients.

APPROACH

Nine participants completed 1-h compensated phone interviews. This study was deemed IRB exempt.

KEY RESULTS

Three themes and eight subthemes were identified, including Navigators Were Key to Accessing the System, Interpersonal Partnerships Improved Health, and Fulfillment in Teaching of Lived Experience. Navigators eased the burden of chronic illness by being a point of contact in the health system, which improved participants' overall experience. Participants also described the relationship as therapeutic, citing improvement and stability in both mental and physical health. Lastly, participants found meaning in chronic illness by teaching their students empathy.

CONCLUSIONS

Longitudinal patient-medical student relationships may provide stability and health benefits. These partnerships have the possibility of adding value to patients' healthcare experiences. This study complements current literature highlighting the value of these relationships for pre-clinical medical students. As such, additional opportunities for and additional research regarding the value of longitudinal patient connection should be incorporated in undergraduate medical education.

Leadership Training and Undergraduate Medical Education: a Scoping Review

The purpose of this scoping review is to fill the gap in understanding the current status of intervention-based studies regarding leadership training in undergraduate medical education. As of late, there is an increased focus on the role of physicians as leaders in their fields, and communities. In order to evaluate these studies, both the PubMed and ERIC databases were searched, and an ultimate total of 35 articles methodologies were evaluated for their general methodology, curricular content, specific teaching methods, and evaluation methodologies. There were a number of trends identified, as well as remaining gaps.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-021-01308-9.