Early Medical Students’ Experiences as System Navigators: Results of a Qualitative Study

Abstract

Purpose

To explore how early meaningful experiential learning in community settings impacted medical students’ application of systems thinking, their perceptions of systems navigation, and their professional identity as health system change agents.

Methods

Following an immersive Health Systems Science course, first-year medical students partnered with veterans or newly arrived refugee families and served as health system patient navigators embedded within primary care teams for a year. Across two cohorts, fifty-six students participated in the elective. Three voluntary focus groups were conducted each year for a total of six groups with 50 patient navigator students. Inductive content analysis of focus group transcripts was conducted.

Results

Qualitative analysis produced three major themes: program impact on students, student impact on patients, and student perceptions of the role of healthcare providers. Students reported a rich understanding of social determinants of health. By improving patient awareness of health and well-being, building capacity to understand medical issues, and increasing medication adherence through teaching, students recognized their impact on patient care. The importance of interprofessional collaboration with social workers also emerged and helped shape students’ understanding of how they as physicians are part of a coordinated team working toward better patient care.

Conclusion

The Case Western Reserve University WR2 curriculum teaches students how to address complex determinants of health and how to consider their role in dynamic health systems. This study highlights rich themes that emerged from students as they recognized the context that creates health for both individuals and communities. It underscores the role of such experiences in reinforcing systems thinking and development of change agency, both contributing to their professional identity formation as physicians.

INTRODUCTION

Health Systems Science (HSS), emerging as critical content in medical education, is defined as the fundamental understanding of how care is delivered, how healthcare professionals work together to deliver care, and how the health system can improve healthcare delivery, in addition to patient and community health outcomes.^1,2 HSS enables clinicians to incorporate “systems thinking” in their clinical problem-solving, with a deeper understanding of the context of a patient’s illness and empowers them to advocate for systems change.¹ Systems thinking and advocacy are critical to addressing the inequities in health outcomes currently evident in the USA .³

HSS curricula enable students to broaden the view of their work through a systems’ lens and develop their professional identity as health care leaders and advocates committed to improving individual, community, and population health.^4–6 Most educators believe that this learning should begin with early exposure to the health system while doing meaningful work in community-based settings.^6–8 Additionally, when introduced to community health systems in a learning context, students should bring value to that system in the form of additional expertise, meaningful patient care coordination, and/or patient advocacy.^9–11 Adding value to the system heightens student engagement and fosters the relationship between the medical school and the health system, rather than burdening over extended healthcare providers in clinical sites.^12–14

One pragmatic approach to adding value is to incorporate medical students as patient navigators (PNs).¹⁵ PNs partner with patients and families to assist in navigating health systems. Since this work is directly related to the functions of health systems, PN experiences engage students in learning about health system challenges through the eyes of the patient while adding value to the clinical learning environment.^16–18 Previous reports have explored what constitutes a successful student PN program, in terms of student engagement, mentor time, site capacity, and educational benefit.¹⁹ However, there is a paucity of research on how the PN experience impacts systems thinking of students or professional identity formation. Limited case reports suggest that such learning has allowed students to see themselves as change agents; however, the generalizability and durability of these findings is unknown.^4,15

Further research is needed to understand student perception of learning about structural determinants of health (SDH), to recognize how such student experiences shape professional identity formation, and identify curricular design elements that reinforce achievement of professional identity as health system change agents. The Association of American Medical Colleges (AAMC) and the Accreditation Council on Graduate Medical Education’s (ACGME) core competencies in professionalism and systems-based practice require physicians to recognize the larger context of care and its impact on health.^20,21 As medical schools develop longitudinal HSS or socially accountable curricula, it is important for educators to recognize the impact of such learning on physician identity formation.^4,22,23

In this study, we use a qualitative analysis of focus group (FG) results with students in two successive PN cohorts to explore their application of systems thinking, their perceptions of system navigation, and how it impacted their professional identity formation.

METHODS

Context

In 2016, the Case Western Reserve University (CWRU) School of Medicine (SOM) was awarded funding to join the American Medical Association’s (AMA) Accelerating Change in Medical Education (ACE) Consortium. The goals of our participation in the consortium were to expand the role of Health Systems Science (HSS) training across the medical education continuum, with an initial emphasis on students in the preclinical years. In 2006, CWRU implemented as the first block of medical education, Block 1: Becoming A Doctor, which focuses on population health, determinants of health, health systems, and quality improvement.²⁴ As part of the AMA initiative, we built on this decade of experience in teaching HSS in the first year to integrate a multi-faceted HSS curriculum into the first eighteen months of preclinical foundational coursework.²⁵

One component of the HSS curriculum developed in the ACE project is the patient navigator (PN) program. The PN program is a year-long immersive experience where first- and early-second-year students gain first-hand experience within a local health system.²⁶ Participation in this program is optional and available to students upon completion of Block 1. A total of 56 students elected to do the PN program over 2 years. In the PN program, medical students work as members of interprofessional primary care patient-centered medical home teams to optimize care for vulnerable patients and families.²⁶ Students are matched with a patient and/or family in the greater Cleveland area and accompany them on primary and specialty care visits, help with communication challenges, and other identified needs. The two PN clinical sites in this study are the Louis Stokes Cleveland Veterans Affairs Medical Center where students partner with veterans and Neighborhood Family Practice, a federally qualified community health center, where students partner with newly arrived refugee families. Monthly, 2-h debrief sessions complement these clinical encounters where students reflect on their experiences and learn about HSS concepts. The goal and learning objectives for this experience are listed in Table 1.

Table 1.

Patient Navigator Program Goal and Learning Objectives

Goal: To reinforce multiple Health Systems Science content areas through community patient navigation experiences and monthly workshops. Learning objectives: By the end of the Patient Navigator Program, students will:  1. Engage in systems thinking and systems analysis to identify advocacy opportunities for different levels of patient and health care team needs.  2. Identify health care needs of patients, develop coordination of care plans, and implement the plans using quality improvement methods.  3. Integrate effectively into interprofessional teams  4. Demonstrate skills necessary for clinical systems navigation, including electronic health record and interpreter training.  5. Reflect on the role of medical students and physicians in health systems change to positively impact individual and community health outcomes.

Data Sources

The study period was September 2016–November 2018. After completion of the PN program, students were asked to participate in a focus group. Three voluntary focus groups were conducted per year in November of 2017 and 2018 with a total of 50 out of a possible 56 students from participating sites. Verbal consent was collected from all participants prior to the start of each focus group. Focus groups were conducted by a trained moderator (SKG) with an average duration of 60 min each and were held in the early afternoon on different days to accommodate students’ schedules. Students were recruited through email by the moderator and were asked to sign up for a specific date and time. Faculty were not present during the focus groups and the moderator was not involved in the PN curriculum development. Students met the moderator for the first time during the focus group. No identifying information such as demographic characteristics was collected to ensure anonymity and protect study participants.

A semi-structured interview guide was used to facilitate conversation. Probing questions were used to encourage elaboration of student comments. Focus group recordings were transcribed and redacted by an external research consultant who also participated in coding (BD). The redaction protocol removed identifiable references to students, clinical sites, and patients. These research activities were approved by the CWRU Institutional Review Board (#IRB-2015-1389).

Data Analysis

The research team employed inductive content analysis (i.e., concepts are derived from the data).²⁷ For example, inductive codes used to categorize data included those that reflected the topics of our focus group questions (e.g., experience working with an interprofessional team, program structure, patient experience) and more specific themes that emerged in the focus groups (e.g., the role of providers, the impact of SDH, HSS communication). Data analysis was guided by the Standards for Reporting Qualitative Research.²⁸ The unit of analysis was at the focus-group level as transcripts were developed without tracking individual student responses.

Multiple researchers engaged in data collection, data analysis, and interpretation, which Lincoln and Guba consider a form of triangulation.²⁹ Five members of the research team were involved in the iterative refinement of the codebook (KQ, MS, KP, YZ, BD). One faculty member (MS) had direct involvement with the creation and implementation of the program. Three members (KQ, KP, YZ) served as evaluation and educational researchers and were not directly involved with any specific programs. BD was hired as an external research consultant with no affiliation to CWRU.

Independently, all members of the research team read the same transcript. The team was encouraged to write memos and notes to discuss major themes during team meetings. A draft of a codebook was developed through the initial review of the transcript, memos, and team discussions. The same transcript was then re-read and independently coded using NVivo12 software by three team members (KQ, YZ, BD). One team member (KQ) conducted a coding analysis for reliability. The team met to discuss the findings of the coding analysis and adjusted the codebook as needed. KQ, YZ, and BD then re-coded the same transcript. Once reliability was reached with one transcript, the same process was repeated for a second transcript with all team members reading the same transcript, developing memos and notes, meeting to discuss revisions to the coded book, and independently coding the transcript. Initial co-coding of two transcripts led to further refinement of the codebook and an increased inter-rater reliability. After the second co-coded transcript, all team members read a third transcript and met to discuss the final refinement of the codebook. The remaining four transcripts were coded independently (KQ, YZ, BD). The team met bi-weekly to discuss progress and review coding reliability findings. The researchers reached a Kappa of .60, which provides evidence of acceptable reliability.³⁰

RESULTS

Thematic analysis of the focus group transcripts produced three major themes (Table 2). We present insights on the program’s impact on students, followed by student reflections on their level of impact on patients, along with reflections on healthcare provider roles.

Table 2.

Summary of Patient Navigator Student Focus Group Findings

Theme	# of focus groups	# of references	Illustrative quotation
Program impact on students	6	132	“There’s no quick fix to this. There’s this super deep complicated problem and I felt kind of hopeless, but it also gave me an understanding that these people are dealing with such bigger complex issues than anybody probably understands.”
Student impact on patients	6	122
Increased importance of healthcare	6	92	“Being there through the whole ultrasound experience and afterward helping the patient figure out what the next steps was a really impactful experience because I was able to provide comfort. There was all these things going on that the patient didn’t fully understand. I was able to tell them that it’s going to be okay and help figure out what was next.”
Building capacity	6	12	“When we went to her home, I was able to describe everything to her more in depth again and use the teach-back method and have her repeat back to me. I felt that was one experience where I was able to help her understand some of the things that she heard from the primary care physician.”
Medication adherence	5	18	“Following the prescription was a challenge. I feel like there’s some misunderstanding with how to use certain medications, especially if they’re not a pill, they’re a drop.”
Role of healthcare providers	6	102
Social workers	6	53	“We worked really close with the social worker and the interpreter for the family to help with our family, so I think in regards to working with social work that really helped me a lot to gain insight of what they do.”
Physicians	4	49	“I grew in compassion for people…and it made me reflect on one of the things we said when we took our oath. We said we take care of each other and we don’t often talk about how we need to be doing that, even now as medical students.”

Program Impact on Students

Students reported that the PN program provided them with rich, first-hand opportunities where they witnessed patients’ experiences with the health system inside and outside of the hospital. Students felt that this experience created more impactful learning compared to the traditional classroom setting. One student characterized this as, “Rather than practicing in a hypothetical environment, [you were] actually throwing yourself into real life patient interaction.” Another reflected on how the experience brought to life content learned in a traditional setting during their first block on medical school. “This elective encouraged us to still keep [SDH] and health systems in mind and helped us see through firsthand experience at least in some small degree that it is important.” These comments provide evidence that the PN program impacted students understanding of Health Systems Science by providing an opportunity to build from prior knowledge and gain exposure to the content in the real world.

The direct observation of SDH in the field facilitated student understanding of the scope of SDH, which cannot be fully experienced in the classroom. One student mentioned the “size” of the problem as “larger and more complex” than any student understands. Several students commented on being “overwhelmed,” “lost,” or “hopeless” when reflecting on their first-hand experiences with the barriers their patients were facing. For these students, it was not until they worked with patients in the PN program that they developed a deeper awareness of the scope of patient barriers. “The crazy thing is you get trapped in a black hole. Keep going and you don’t know where to start. It’s not a band aid, there’s no band aid you can put on.”

Student Impact on Patients

Increased Importance of Healthcare

Students mentioned that patients seemed to be more invested in their health and seeking care due to their interactions together. One student mentioned that their patient did not understand the severity of their health issues at the beginning of this program. However, as the program progressed, they “built this trust and by the end of it, the patient was willing to do more to address her health because of it.” At least one student from every focus group mentioned their “presence” helped the patient understand the importance of receiving care. Having a familiar face to help guide them through the system was encouraging to patients. “If patients see, somebody cares about me, somebody’s taking care of me, their overall attitude toward healthcare or barriers to getting something done is lower in a sense.” Students spent a considerable amount of time with their patients inside and outside of office visits and built relationships which increased patients’ awareness of the importance of seeking care.

Building Capacity

Several students noted that they taught the patient a skill or necessary behavior. One student taught their patient to “raise the alarm” during their visit if something did not seem correct. This patient was seeing practitioners in two different hospital systems. The patient was overprescribed some medications and noticed the prescription did not match the doctor’s instructions. When none of the staff noticed the mistake, the student “brought it up with the patient and showed him how to bring it to the attention of the nurse and it went up the chain.” Several students had to teach their patients to call and reschedule or move appointments to other locations. Patients without their own transportation were made to attend visits at various sites across the city, often at times, they could not attend due to childcare issues or work commitments. “I taught my patient to do a lot of calling different offices and speaking to administrative folks because they visited multiple offices in different geographical locations” which was extremely difficult for them to manage. Lastly, a pair of students helped teach a new mom how to arrange for same-day care. After the mother expressed concern over the baby’s temperature, the students prompted the mother to use a thermometer. However, she did not have one and grew increasingly concerned. The students taught the mother to call and arrange a same-day appointment, where the physician taught the mother to take the baby’s temperature.

Medication Adherence

Several students experienced instances of patients not adhering to their medication guidelines either due to lack of sufficient physician explanation or patient ability to understand the medication instructions. One pair of students brought all the patient’s medications to an appointment and asked the doctor to discuss each medication again with the patient. The patient was supplied with a medication organizer. The students then marked the bottles with symbols for when to take each dose and had a second conversation with the patient about the medication instructions. Two students mentioned they helped patients obtain medications from the pharmacy. “These patients have a ton of barriers, so even picking up meds, fighting for the pharmacist to even give you the meds, was something we did a lot.” These instances highlight that in some cases the students’ presence directly impacted the patient’s health by ensuring they obtained needed medications and followed medication instructions.

Role of Healthcare Providers

Social Workers

Students recognized the expertise that social workers bring to each patient’s case and the critical role they play in identifying resources for patients. A pair of students noted the only time they could reach their patient was when the social worker was involved. Others mentioned that “the social worker is especially valuable to understand what difficulties the patient will encounter in terms of helping find care,” as the social workers “definitely have the fullest picture of what was happening with the patient.” Students also made comments that the social worker had “a wealth of information” about local resources. “I’ve come to value the role of social work more as I had to interact with those individuals…. trying to navigate coordinating care would have been impossible if it hadn’t been for them.” Students learned, however, that “social workers can be so overtaxed.” Physicians should “take some initiative to learn what you can do yourselves and not make the patient go to another appointment or wait longer if they know how to sign a form for a patient that takes five minutes.”

Physicians

Students vocalized their perceptions of their role in addressing patient barriers to care. One student felt it was “part of my job to figure out why and understand what barriers prevent [patients from receiving care].” However, most student perceptions culminated with developing an understanding of barriers, as students felt that “doctors are limited in how much they can do for the patients.” Most students did not feel they were responsible for addressing barriers. “I think it’s been useful for me to be overwhelmed at times by the complexity of problems and the amount that I can’t fix or help. I think going into medicine, I’ve been constantly and repeatedly faced with the ideal of doctors being able to almost have magical powers and fix and cure everything. For me, it’s useful to be aware of my own expectations and have a better sense of the things I can and cannot help.” Most students felt they were not able to directly address patient barriers and even felt “disheartened” by this realization.

Despite grappling with the gravity of these issues, some students mentioned ways in which the PN experience will shape them as physicians. One student was able to apply some perspective in understanding prioritization. This student mentioned that a value of the PN experience was “…realizing that patients are going to deal with the order of problems in a different way than our profession thinks that they should because they have so many other things to worry about.” Two focus groups discussed the role of empathy and compassion through the PN program, with one student noting: “I don’t think you can learn empathy. I think it’s something that’s naturally innate to you. But I think this experience pushes you to get there because you see stuff that you’ve never seen coming from a more privileged background.” Students also mentioned how they would consider communicating with patients during office visits and history taking.

DISCUSSION

The CWRU HSS curriculum and the PN program aim to ensure medical students learn to address complex determinants of health while considering how to impact systems change. The integrated HSS curriculum is designed to challenge students to apply systems thinking to unravel the many layers of context involved in caring for individuals, families, and populations Prior work has identified the roles of HSS experiences in providing value to patients, but little is described on how HSS defines students’ change agency in professional identity formation.^31–33 This study not only highlights rich themes that emerged through students’ PN experiences but also identifies how such experiences reinforce systems thinking, followed by development of change agency, both contributing to their professional identity formation.

Through the PN program, students were exposed to frequent barriers patients encounter when trying to access care, an experience not afforded in a traditional classroom. Students repeatedly identified emotions when facing a fragmented healthcare system that did not address patient needs. In many instances, students identified pragmatic ways in which they provided value-added roles for patients. However, the study findings suggest that students did not often recognize themselves as change agents or appreciate the impact of the encounter on their own professional identity formation.

Based on the three identified themes, exposure to longitudinal, immersive HSS experiences is transformative on many levels. However, providing such experiences without formal training on systems thinking and HSS tools is insufficient. The findings of this study highlight the critical importance of balancing mastery of HSS content with intentional processing and reflection that engenders a deep understanding of the change agency role of physicians.²⁸ Change agency is an effective attribute that becomes part of a physician’s professional identity. The cognitive skill of systems thinking, coupled with knowledge of HSS, are necessary foundational elements for change agency. Students’ ability to see themselves as change agents within a dynamic system may be influenced by self-efficacy, an evolving knowledge as training progresses, along with an expanding sphere of influence as learners progress through training. Future studies in medical education should evaluate the impact of HSS experience on the concept of change agency and professional identity formation along the medical education continuum.

Participation in this study was voluntary and limited to students who completed the PN elective. Students who volunteered for the PN program may have been personally motivated to learn about HSS and PN. Nevertheless, this self-selected group of students did not recognize their change agency role, despite motivation and interest. This study is unable to draw conclusions comparing its findings to students who did not participate in the PN or to students who participated in other community engagement programs at the same institution. To determine the added value of the PN program for patients, the health system, and their own sense of change agency and professional identity formation, a comparison group is necessary. The qualitative methods used in this study were selected to provide an evaluation of the benefits and student perceptions of the PN program with the intention of disseminating its impact to other institutions creating similar programs.

Professional identity of the future physician has expanded beyond the provision of person-centered humanistic care to include roles as agents of change. The AAMC and the ACGME core competencies recognize physicians’ need to understand the larger context of care and identify the many determinants of care. However, for physicians to internalize such learning and integrate it as part of their role as physicians, they will need strategies such as systems thinking so that the fragmented healthcare system does not appear to be too overwhelming. Medical education must incorporate systems thinking early in training, so the next generation of clinicians recognize and are equipped to function in their role as systems change agents, who provide care for patients and communities. It is not enough to simply provide HSS experiences, but they must be coupled with mentored reflection so students can develop a deeper understanding of their role and how physicians foster change. Longitudinal, mentored HSS programs, such as the PN program, coupled with systems thinking strategies will guide the professional identity formation of early medical students as they recognize the physician’s role in addressing the structural determinants of health.

Funding

This work was funded by the American Medical Association’s (AMA) Accelerating Change in Medical Education (ACE) Consortium.