#KeyLIMEpodcast 131: Integrating Medical Students into the Health Care System

The Key Literature in Medical Education podcast tackles curriculum design this week.  In the past we discussed  a longitudinal integrated curriculum design.  (See Episode 66)  This week it’s a curriculum that organizes learning by integrating medical students into a spectrum of health care system roles.

There is a growing emphasis on health care systems in the clinical, education and administration literature.  Designing health professions education without integration into the larger context (i.e. health care system) has consequences for our learners… and our patients.

So, what do you think?  Does the approach these authors describe resonate with you?  Do you need to re-examine how your training programs incorporate the perspective of the health care system?

The abstract is below.  The podcast is here.

– Jonathan


KeyLIME Session 131 – Article under review:

Listen to the podcast

View/download the abstract here.


Gonzalo JD, Graaf D, Johannes B, Blatt B, Wolpaw DR. Adding Value to the Health Care System: Identifying Value-Added Systems Roles for Medical Students. American Journal of Medical Quality. 2016 Apr 26. [Epub ahead of print]

Reviewer: Jason Frank (@drjfrank)


For nearly 100 years, there have been calls from experts and other stakeholders to change medical education to incorporate “health systems science” (HSS). This catchphrase has various synonyms in the literature, including “population health science”, systems-based practice (ACGME), quality and safety, and “demand-side education” (EFPO), no name a few. My fresh copy of the AMA’s Health Systems Science text (Skochelak, et al) includes an enormous list of domains that are part of HSS:

  • Health care delivery systems
  • Value
  • Patient safety
  • Quality improvement
  • Teamwork
  • Leadership
  • Clinical informatics
  • Populations health & outcomes of care
  • Social determinants of health
  • Health policy, and
  • Health economics

This push for HSS in health professions education is heating up, as multiple countries seek physicians who have new sets of skills and behaviours to improve the performance of health care systems and improve patient outcomes. (See ACGME work, CanMEDS 2015, Frenk’s paper in the Lancet, etc).

However, while there are many calls to train health professionals differently, there is almost nothing in the literature about what could be incorporated into UGME to provide hands-on roles for med students to learn HSS.


The authors set out to identify “value-added roles for medical students within the health care delivery system” in Pennsylvania, USA.

Type of Paper

Research: Qualitative study

Key Points on Methods

In the context of a curriculum renewal, the authors describe a qualitative approach to identifying roles for pre-clerkship students to spend a year learning HSS in 30 varied clinical settings. They used two data collection methods:

  1. Field notes and reflections from site visits
  2. Structured interviews with a single clinical leader from each site.

The data were recorded verbatim, transcribed, and the authors nicely describe a constant comparative analysis with iterative coding by the author group.

In essence, they are using methods to describe social construct of value-add student placements.

Key Outcomes

The authors describe 2 main themes in the data about systems roles for med students:

  1. Direct patient benefit activities
  2. Direct clinic benefit activities.

The former included such things as: monitoring care plans, helping patients access services, patient coaching, and identification of care barriers.

On the local clinical setting side, participants described roles for students as a “bridge” between patients and providers, and care coordinators, and there was a small mention of identifying potential issues for CQI.

Participants described the experience as improving their understanding of clinical missions, and improved learning.

Overall, the list of subthemes unfortunately reads like the students took on the role of amateur social workers.

Key Conclusions

The authors conclude…that their unique, qualitative rich data elaborate on the roles pre-clinical med students can play in clinical settings while learning HSS.

However, I found it concerning that so many other aspects of HSS were simply missing in action…Where was patient safety?? As a reader, I felt the desired HSS content from the Intro was simply not a construct shared by participants in these 30 clinical settings.

Spare Keys – other take home points for clinician educators

  1. Kudos to the authors for making scholarship out of their curricular innovation
  2. This is an interesting approach to elaborating potential needs, opportunities, and constructs around an emerging meded topic
  3. The methods section description detailing the constant comparative analysis procedure is a valuable template
  4. For other prominent authors who are writing about how to really implement HSS in meded, check out: Brian M Wong (Toronto) and Eric Holmboe (ACGME Chicago).

Shout out

Shout out to listener Miguel Galán de Juana who suggested this article as a worthy innovation. Miguel listens to KeyLIME on his way into clinical in the mornings.

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