Reshaping Medical Education with Innovative, Early Clinical Experiences

University of South Carolina School of Medicine Greenville

Within a few months of arriving at the University of South Carolina School of Medicine Greenville, a medical student may have already saved someone’s life.

That’s because Greenville medical students spend their first seven weeks training to become certified emergency medical technicians (EMTs). After receiving EMT certification, students work one 12-hour shift with the county’s ambulance service each month during their first and second years. From day one, medical students are introduced to the diversity of patients and populations they’ll be caring for, according to Tom Blackwell, MD, a clinical professor at Greenville and director of the school’s EMT Training Program.

“We’re teaching [students] how to do a history, take vital signs, how to critically think and problem solve in the first six weeks. It really builds their confidence,” Blackwell said.

The experience is one of many ways medical schools are giving students direct clinical and patient care experiences early in their educations, long before they begin clerkships. Experiences range from EMT training to serving as health system navigators to working alongside community health workers. In addition to enhancing medical education, students who have the opportunity to get early clinical experiences also add value to local health care systems.

A focus on social determinants

At Penn State College of Medicine, first-year students are immersed in a required Systems Navigation curriculum, initially launched as a pilot in 2014. As part of the new curriculum, students spend a few weeks learning how health systems function and about the many social determinants of health that patients face. Then they begin work as health system navigators in one of dozens of local clinics, where they help real patients overcome social challenges to accessing care and staying healthy.

The curriculum better prepares students to practice in an increasingly patient-centric field, said Jed Gonzalo, MD, MSc, associate dean for health systems education at Penn State College of Medicine. First-year students also receive a richer contextual framework for taking in the reams of scientific information taught in the classroom, he noted.

“We’re not asking them to make diagnostic or therapeutic plans; we’re asking them to be human beings,” Gonzalo said of the students’ roles as health system navigators. “They get to learn about health care systems through a patient’s eyes.”

Penn’s student navigators may help patients shop for insurance coverage, find public transportation services, connect with social service assistance, or learn how to have a wheelchair ramp installed at home. While many student navigators are paired with a physician mentor at the clinics, Gonzalo noted that about half are paired with other members of a health care team to emphasize the importance of being an “interdependent team player.”

During the first year the curriculum was offered, 85 students served as health system navigators. Now in its third year, the number is up to 136.

“Over the past decades, the value that students bring to clinical operations has been somewhat low—they don’t necessarily add value to care delivery,” Gonzalo said. “But having students do this work extends the work of the system itself. Students are doing work that might not otherwise get done. That’s a paradigm shift.”

“Having students do this work extends the work of the system itself. Students are doing work that might not otherwise get done. That’s a paradigm shift.”

Jed Gonzalo, MD, MSc
Penn State College of Medicine

Offering early clinical experiences was also part of a recent curriculum overhaul at Wright State University Boonshoft School of Medicine in Dayton, Ohio. The curriculum, required for all first-year students beginning the summer of 2017, includes a course called Upstream Medicine, in which students learn about the social determinants of health, health care delivery, and population health. They also prepare for their first clinical experiences as community health advocates, noted Sabrina Neeley, PhD, MPH, professor in the Department of Population and Public Health Sciences and director of the Population Health curriculum in the Office of Medical Education.

Students prepare for their advocacy roles by taking a slightly modified community health worker (CHW) training offered by the university’s Center for Healthy Communities, though they do not become certified CHWs. After finishing the training, students are assigned to a local primary care clinic. Students work in groups of four at the clinics, taking referrals from the physicians and working directly with patients on issues ranging from housing to food access to finding insurance or enrolling in Medicaid.

Among the goals, Neeley said, is to help medical students understand the value of CHWs and their role in improving health outcomes in vulnerable populations.

“As physicians, maybe you’ll get 10 minutes with a patient, so [students] need to understand that most of what impacts that patient’s health isn’t the time they spend with you in your office,” Neeley said.

Gaining perspective

At the University at Buffalo Jacobs School of Medicine and Biomedical Sciences, students are assigned to a local clinician within a month of starting school. The experience is part of the Clinical Practice of Medicine course, which has been offered since the 1990s, said Andrew Symons, MD, MS, a clinical associate professor and vice chair for medical student education in the Department of Family Medicine. In fact, Symons took the course himself when he was a medical student at Buffalo.

The course is a mix of classroom learning and clinical experience, with students participating in about a dozen preceptor sessions in their first year. Initially, Symons said, students simply observe the preceptor. But as students move through the semester, they have more direct patient contact, such as taking a history or doing a basic physical exam, while observed by their preceptor.

For Buffalo’s medical students, the course is typically their only longitudinal experience in which they have the opportunity to see the same patient multiple times and work as part of a medical office team for an entire year.

“Students often comment on how the [course] helps them understand why they’re spending so much time learning the basic sciences because they can see right away how it applies to practice,” Symons said. “This puts everything else into perspective and gives it purpose.”

Back in South Carolina, Blackwell said the school’s EMT training helps students reaffirm why they came to medical school in the first place. “The first time you perform CPR and save someone’s life, it’s pretty extraordinary,” Blackwell said. “It’s quite the motivator.”