Addition to Value-Added Roles for Medical Students
Written by Victoria Stagg Elliott, MA; Jed D. Gonzalo, MD, MSc; Maya M. Hammoud, MD, MBA; Gregory W. Schneider, MD
The ongoing COVID-19 pandemic and the increased focus on racial justice brought on by the murder of George Floyd in May 2020 and numerous other incidents of excessive force on the part of police officers against people of color without accountability have highlighted the importance of health equity and the critical role of physicians and other health professionals in reducing inequities.1 Creating value-added roles, as explored and explained in our book Value-Added Roles for Medical Students, is a strategy for integrating medical students in this important work that is at the core of medical practice. These roles can lay the groundwork and help encourage medical students to become physicians dedicated to fostering health equity throughout their careers.2
What is a Value-Added Role?
We define a value-added role for a medical student as one that involves patient care tasks—inside or outside a clinical workplace environment—that add value to care delivery processes. These tasks also allow the student to learn clinical and systems-based competencies. These roles are starting to become more common, reversing the trend of declining medical student involvement in patient care activities.3,4
To best illustrate how value-added roles for medical students can improve health care delivery processes and health equity, we present several programs that do it well.
Helping patients navigate the health system
Penn State College of Medicine pioneered a patient navigator program for first-year medical students. This program is part of the health systems science curriculum and involves assigning first-year students to a clinical site with an interprofessional mentor. Students receive training in history taking, communication, and identifying and understanding social determinants of health. They then begin working at various clinical sites, which include skilled nursing facilities, acute and subacute rehabilitation facilities, primary care clinics, and subspecialty clinics. They are assigned to work with patients who clinicians have identified as in need of navigation services. Medical student navigators provide patients with education, support, and care coordination. From 2014-2020, approximately 800 medical students provided navigation services to more than 5,000 patients. For students, this is an early—and in some cases first—clinical experience that improves the health care experience for the patients served. The program also improves medical students’ understanding of social determinants of health and several other health systems science domains.
Case Western Reserve University School of Medicine modified Penn State’s navigator model to serve veterans and newly arrived refugee families.5 Medical students become members of an interprofessional team within a patient-centered medical home and help patients navigate the health system and address social service needs. They accompany patients to primary and specialty care appointments and coordinate with case managers, social service agencies, pharmacies, and community-based organizations, in order to promote optimal health outcomes for diverse populations.6
The value-added roles program at Florida International University (FIU) Herbert Wertheim College of Medicine, NeighborhoodHELP, is focused on household-centered service-learning and emphasizes ethics, social accountability, interprofessional teamwork, and the social determinants of health. All medical students at FIU become part of teams that also include students from the nursing, social work, and physician assistant schools. These teams visit designated underserved households throughout Miami-Dade County and connect household members to needed services and service providers in order to address complex medical, behavioral, social, environmental, ethical, and legal issues. Services can include health education and coaching, facilitating food stamp applications, and linkages to immigration assistance. Connections can be made to job training programs, food banks, and rental assistance.
Always improving quality
The University of North Carolina at Chapel Hill created a quality improvement curriculum that facilitates medical students identifying potential system improvements at the practices where they rotate. They are then supported to create quality improvement projects at these practices that benefit patients and the practices themselves. Many of these projects make the practices more equitable by, for example, increasing hepatitis C screening rates, improving the process for getting diabetic eye exams, or addressing other health and health care inequities.
At the University of California, San Francisco, Medical School, preclinical medical students are embedded in clinical microsystems as team members and change agents. These microsystems are based at affiliated academic, county, and veterans’ health systems, and, in conjunction with a coach, students identify important health system improvement projects that they would like to implement in these settings. These projects have worked toward reducing inequities in hypertension care, improving the management of opioid prescriptions, and bettering the quality of sleep of hospitalized patients, as well as addressing many other challenges for patients, physicians, and other health care professionals within local health systems.
The value-added roles program at Vanderbilt University School of Medicine is also focused on quality improvement within microsystems. In the first year of medical school, students are embedded into a clinical microsystem for one afternoon a week at a single clinic. There they learn the structure and function of an interprofessional health care team. Second-year medical students move on to learn more about the meso- and macro-systems of care. In the third year, students focus on quality improvement and identify ways to change and improve the clinic where they are based. Students completed 187 projects from 2014 to 2019. About a third were focused on system redesign to improve patient flow and timeliness, and another third focused on improving patient care. The remainder addressed patient or physician education. Most projects are small in scope, but in the aggregate improve the health system overall.
Medical students at A.T. Still University’s School of Osteopathic Medicine in Arizona spend most of their time at community-based health centers focused on learning community-oriented primary care. These health centers serve people who are underserved or historically excluded from the health system, and in the second year of medical school, students implement projects that add value for patients, the health center, and the community. These projects have included creating education around oral health or mindfulness meditation, identifying EHR issues that are barrier to colorectal cancer screening, or developing community-based training for responding to opioid overdoses. The latter project led to at least 10 overdose reversals in its first year, and in the aggregate these projects improve the overall health care for marginalized populations.
Improving health equity is increasingly viewed as an core part of a physician’s scope of practice.2 Initiating recognition of this expanded scope early in medical training has the potential to affect the ways that future physicians develop their professional identity and practice throughout their lifetimes. Implementing value-added roles for medical students, whether providing health-related services directly to patients or identifying ways—both large and small—to improve the health system and patient care, is an important strategy for making health and health care more equitable.