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Medical Education
Bridges Curriculum

The Clinical Microsystems Clerkship- the Physician’s Experience

Dispatches from the Field

The Clinical Microsystems Clerkship- the Physician’s Experience by Dana Greenfield

Everyone's always worried, 'Do I know enough?' but I think that's not actually what will ultimately lead to safe patient care. It’s really about systems and communication. To ensure high quality care, I felt really drawn to improve the system. Once I saw it, it felt almost wrong not to try to fix it.

- Dr. Rachael Lucatorto, Assistant Chief, Medical Service, San Francisco VA Medical Center

Dr. Lucatorto hit on a major source of medical student angst: not knowing enough. Bridges recognizes that knowledge alone will not prepare physicians of the future to operate in complex care delivery systems. With the Clinical Microsystems Clerkship (CMC) projects, students will gain the skills to both thrive and lead in these settings.

In Summer 2014, a cohort of Curriculum Ambassadors piloted the CMC in different settings, from San Francisco General Hospital to the VA Medical Center. Building on previously reported  student experiences, this Bridges Update spotlights the pioneering faculty who worked on these summer pilots and three key value-added benefits of these student immersions.     

The Clinical Microsystems Clerkship (CMC)

The CMC introduces students to how care delivery systems impact quality, patient experience, and clinical outcomes. Beginning in their first year, students will be placed in longitudinal sites where they will participate in meaningful workplace learning. The CMC augments the practice of history-taking and physical exams by engaging students with the entire context of care. Students will work with other health care professionals--from nurses to medical assistants—contributing to the microsystem’s current operation and future optimization.

Microsystems come in all shapes and sizes: from an emergency department in a hospital to a specialty outpatient clinic. This update reviews CMC pilots on the hospitalist services at San Francisco General Hospital (SFGH) and the VA Medical Center, and a San Francisco Department of Public Health primary care clinic.

Physician, Heal Thy Systems

The physicians who piloted CMC in Summer 2014 were all thrilled with the students’ initiative and contributions to their teams.

Value-Added I: Team Integration and Collaboration
A medical and pharmacy student team navigated SFGH, a complex site, to better understand health literacy screening across the hospital. “We have to give them so much credit for being so motivated and diligent and organized. They asked, ‘how do we make this happen in the hospital? Who do we talk to?’” explained Dr. Jing-Yu Pan, a hospitalist there. Clinicians at the other sites echoed how resourceful the students were, connecting the dots across services, teams, and providers.

At the VA, one student was dubbed the “Chief Happiness Officer” for a team piloting interprofessional hospitalist rounds. Dr. Lucatorto supervised her as she observed rounds and interviewed team members to identify roadblocks to collaboration. She became an ambassador for the team, dedicated to its optimization: “At this point, they’re unencumbered by having to fix the potassium. All they have to do is focus on systems,” said Dr. Lucatorto.

Dr. Anna Chodos worked with the SF Department of Public Health (DPH), where the QI staff trained and directed the students to unmet needs.

“I’ve been floored with how committed they (staff) are to bringing students in. They think it’s really valuable to contribute to workforce development at an early stage and to meaningfully contribute to their own QI goals.”

This site, Dr. Chodos explained, “exposes the students to high performing, exciting primary care, where really high quality QI is taking off.” Aligning both clinical and systems knowledge is a major goal of the CMC course.

Value-Added II: Real Work and Grassroots QI
At the DPH, the student mapped the entire patient journey, interviewing patients and providers to understand personal and structural barriers to getting a mammogram. Her insights were used to create healthcare maintenance cards with the Medical Assistants to facilitate a more effective screening.

“It was the goal of the health department to get this issue addressed. They’re still looking at her work, using some of that information to inform the next round of projects. I was so thrilled. It was real QI. It was really useful. It’s part of the work that they’re doing in a meaningful way.”

At the VA, Dr. Lucatorto’s student conducted a revealing needs assessment: “We found that only 50-60% of the time the nurse would make it to rounds based on her baseline data. The literature suggests that when nurses are involved in real time, care is more efficient and safer, and there's increased provider satisfaction.” In partnership with the nurses and pharmacist, the student helped devise a system that improved communication and raised participation rates to 80%.

At SFGH, in addition to addressing health literacy screening, students were also the eyes and ears for hospitalists. “They actually helped us figure out which patients the transitions team captured and those they hadn’t. In a way they did a little needs assessment,” said Dr. Lawrence Haber.

Similarly, Dr. Lucatorto’s student helped the team transition to more patient-centered, bedside rounds.  “The student noticed from her conversations with team members—particularly interns and the students—that they weren’t sure what they were supposed to present in front of the patient. That was good feedback for me to hear and pass along.” These insights had impact: orientation materials were changed and team members’ needs were addressed.

Value Added III: Faculty Development
Across the board, faculty welcomed and eagerly embraced the opportunity to teach medical students. Their instruction varied: lecturing, brainstorming, developing assessment tools, and guiding data analysis.  

The CMC provided an opportunity for junior faculty to hone their teaching, mentorship and leadership skills, particularly in the growing field of QI. Dr. Pan supported the students in planning their project and understanding their data.

“It was valuable for me to go through it with them. In a way it’s me practicing doing my own QI project but through the student,” said Dr. Pan. Dr. Haber agreed and added “That’s the joie de vivre of being in academic medicine. A lot of us crave more contact with students, to gain those mentorship and leadership skills. When we are in QI groups, we are rarely a leader—this is training in how to lead, to effect change in the hospital using multiple systems.”

The students’ work facilitated mentorship and leadership development in both medical education as well as nurturing the QI workforce and community.

Envisioning and Training for the Future

Faculty who piloted the CMC are passionate about teaching and improving quality care, enabling them to align those interests and engage early learners in thinking about systems.

“If you're looking to train leaders that can meaningfully think about and change systems, I think this is an unbelievable experience," stated Dr. Chodos.

The cultivation of medical vision is an achievement of years of training. With Bridges and CMC, students are taught that to think and see like a physician now includes systems--both micro and macro. “Having that perspective shapes the way you are as a provider, physician and educator,” said Dr. Melissa Capule, a hospitalist at SFGH. The CMC makes sure they are furnished with that lens early.

Dr. Haber likened the medical system itself to a patient: "We advocate and care a lot about the patient, but we also have to think broader about the system we work in. How do we make that better for our providers, patients and staff? How do we intervene on issues of a really complex system--maybe a system that's just as complex as the human body?”  Our education should match those needs, he explained: “I think it's a similar thought process that we can teach medical students: here is how you think about physiology and pathophysiology of a human being and this is how you think about physiology and pathophysiology of a system." The CMC and Bridges will link those two realms.

Data-driven, continuous improvement is the future, explained Dr. Pan. “This is the direction health care is going and particularly important for community hospitals, low-resource patients, and how to provide care with a tight budget, ”says Dr. Capule.  Engaging students early with the CMC, prepares them to thrive in and shape the medical systems of the future.

Bridges and CMC will answer the need for a real paradigm shift in medical education to meet this future.  The faculty say that now is the time to widen and deepen the clinical gaze to place bio-metrics alongside quality metrics, because healing patients means also healing our systems.

*The CMC is being developed under the leadership of Anna Chang, MD and Cindy Lai, MD. The implemenation falls under Lee Atkinson-McEvoy and Leah Karliner, MD. Complete List of CMC Team Members
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