Innovation Report
Patient Shadowing: A Useful Research Method,
Teaching Tool, and Approach to Student Professional
Development for Premedical Undergraduates
Jason W. Wilson, MD, MA, Roberta D. Baer, PhD, and Seiichi Villalona, MA
Abstract
Downloaded from https://journals.lww.com/academicmedicine by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 10/31/2020
Problem
Questions have been raised about
whether undergraduate institutions are
effectively preparing premedical students
in the sociobehavioral and cognitive
reasoning content found on the revised
Medical College Admission Test,
providing opportunities to understand
and apply these sociobehavioral and
cognitive reasoning concepts in realworld scenarios, and offering career
exploration opportunities.
emergency medicine physician and an
applied medical anthropologist. As of
January 2016, the course is offered each
spring at the University of South Florida,
Tampa, Florida. The course provides
opportunities for patient and physician
shadowing within the anthropological
methodological framework of participant
observation. Other qualitative research
methods are also taught, and students
complete a group patient experience
quality improvement project.
Approach
The Research in Physician–Patient
Interactions course is a 15-week course
designed for premedical students and
taught through the collaboration of an
Outcomes
Thematic analysis of students’ field
notes and reflection essays and followup communications with course alumni
revealed 3 salient themes regarding the
Problem
mechanically applied in standardized
patient encounters. Simulation of the
complex social determinants that shape
the patient experience of health care
delivery is difficult to achieve in a way
that adequately prepares physiciansin-training for practice, frustrating
physicians and potentially contributing to
future burnout.2 The move to standardize
how physicians-in-training learn clinical
communication skills raises the question
of how this aspect of medical education
can be improved.
There is increasing recognition of the
importance of quality-based health
care and the role of the social sciences
in the training of physicians. Improved
interdisciplinary health care team and
provider–patient communication
are recognized to be cornerstones
of improving quality care. In 2004,
the United States Medical Licensing
Examination Step 2 Clinical Skills
assessment was added to the series of
licensing exams to evaluate medical
student competency in patient
interactions, and recent advances in
simulation-based training have improved
clinical communication education.1
However, the assessment of social
interactions is often transformed into
checklists that, for testing purposes, are
Please see the end of this article for information
about the authors.
Correspondence should be addressed to Jason W.
Wilson, 1 Tampa General Cir., Tampa, FL 33606;
telephone: (813) 843-2110; email: tampaERdoc@
gmail.com.
Acad Med. 2019;94:1722–1727.
First published online July 16, 2019
doi: 10.1097/ACM.0000000000002882
Copyright © 2019 by the Association of American
Medical Colleges
1722
The Medical College Admission Test
(MCAT) was revised in 2015 to maintain
science content and to add material that
assesses sociobehavioral knowledge and
cognitive reasoning to screen for more
well-rounded applicants.3 While there is
understanding that medical education
should provide opportunities for students
to incorporate patient experiences into
practice, especially given the increased
emphasis on patient-centered value
and the increase in reimbursement
models related to health outcomes,4 the
clinical applicability of such education
opportunities has, so far, been limited.3
This further raises questions about
whether undergraduate institutions are
utility of patient shadowing as a research
method that provides unique types
of qualitative data, as a teaching tool
for premedical students to understand
the perspectives of patients, and as an
approach to developing the professional
skills necessary in health care, such
as effective communication styles,
establishment of rapport, and empathy.
Next Steps
Similar courses should be offered at
other universities to premedical students.
While it appears that patient shadowing
experiences have a great impact during
premedical education, there may also be
value in integrating a similar experience
into medical school and residency training.
effectively (1) preparing premedical
students in the sociobehavioral and
cognitive reasoning content found on the
revised MCAT, (2) providing students
with opportunities to understand
and apply these sociobehavioral and
cognitive reasoning concepts in realworld scenarios, and (3) offering career
exploration opportunities.5
Premedical students could benefit from
completing a course that allows them
access to hospitals, physicians, and
patients while also providing them with
research opportunities. The premedical
time frame represents the earliest stage
of biomedical enculturation, which takes
place over a decade of medical training.
A nascent student adopts the biomedical
worldview as they move from premedical
education to medical school, to residency
training, and ultimately to becoming
an attending physician, fully engrained
in the symbols and language of the
biomedical model.6 Traditionally, this
model has emphasized understanding the
pathophysiological models of disease and
technological approaches to therapy at
the expense of communication skills and
other explanatory models of illness and
approaches to relieving human suffering.
Academic Medicine, Vol. 94, No. 11 / November 2019
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Innovation Report
One pathway to improving patient
experiences with the health care system
is to integrate patient-centered training
into early medical education. Medical
school curricula may include some work
on patient experiences; however, work in
this area can also be done in premedical
education.
The course discussed in this Innovation
Report is taught to premedical students
and uses formal training in qualitative
research methods to increase student
engagement in learning about the
patient experience, with a focus on the
utility of the anthropological method
of participant observation and patient
shadowing as a research methodology,
a teaching tool, and an approach to
professional development.
Approach
First taught in January 2016, the Research
in Physician–Patient Interactions
course is a 15-week course designed for
premedical students and taught each
spring through the collaboration of an
emergency medicine physician (J.W.W.)
and an applied medical anthropologist
(R.D.B.) at the University of South
Florida, Tampa, Florida. The goal of the
class is to address the deficit of training in
patient-centric approaches to health care
by using directed participant observation
in the emergency department (ED) as
well as self-directed shadowing activities.
Participant observation involves observing
an unfamiliar setting while participating
in it. This allows the researcher to
discover aspects of the setting that may
be important to investigate; for example,
students observed that ED patients
often nodded that they understood the
physician’s explanations but quickly turned
to Google once the physician left the room.
Objectives of the course include the
following:
1. establishing an understanding of the
social determinants of health (SDH)
framework,
2. exploring how qualitative research
methods from medical anthropology,
such as participant observation,
can be applied in clinical settings to
study physician–patient encounters
to improve patient experiences
and enhance required shadowing
opportunities, and
3. providing premedical students
with opportunities to learn and use
qualitative research methods, conduct
career exploration, and develop
the professional skills necessary for
working in health care settings.
Each cohort of students (defined by the
year students were enrolled in the course)
is responsible for working on a patient
experience quality improvement project
in the ED using field notes and data
collected during participant observation
in the waiting room and shadowing
of emergency medicine physicians
and patients. To this end, students are
taught methods in qualitative data
analysis, and at the end of the course,
they give a presentation on their project
to the administrative leadership of the
university and partnering hospital. The
projects of the 3 cohorts to date (2016–
2018) have been on the following topics:
physician–patient communication,
patient education interventions in EDs,
and patient experiences of nonfatal
firearm trauma. The first 2 projects were
submitted for institutional review board
(IRB) approval. The last project was
carried out only for the purposes of the
course and training in research methods,
and the IRB determined that this did not
require further human subjects approval.
Figure 1 provides a schematic timeline of
the course, illustrating how the content
is introduced and reinforced throughout
the 15 class sessions (i.e., there is 1 class
session per week of the course). In each
class session, the instructors (J.W.W. and
R.D.B.) guide discussions of assigned
readings and documentaries.
The SDH framework and unique
history of emergency medicine serve as
introductory content areas, complemented
with an orientation at the partnering
hospital’s ED (class sessions 1 and 2).
The third class session is dedicated to the
exploration of a specialized research topic
that serves as the central theme of that
semester’s project. The third class is also
used to introduce students to qualitative
research methods, including participant
observation and qualitative interviewing,
as well as how to write field notes so as to
carefully document their observations.
Class sessions 4 to 6 introduce key
concepts in medical anthropology
(see Figure 1 for examples) and review
Academic Medicine, Vol. 94, No. 11 / November 2019
qualitative studies previously conducted
in emergency medicine. Students practice
participant observation by shadowing
physicians and other hospital staff in
different areas of the ED (e.g., behind
security desks, in triage rooms, and
waiting areas) and completing two
4-hour patient shadowing assignments
during these class sessions. These
experiences are different from traditional
shadowing as the student has been
trained in participation observation
methods.
Half of the time during class sessions 7
to 10 is dedicated to understanding the
concept of culture in clinical settings;
to this end, guest speakers who discuss
topics such as bloodless medicine and
emergency medicine abroad complement
the instructor-guided discussions (see
above). The other half of the time during
these class sessions is dedicated to the
development, testing, and revision of
a qualitative research tool based on
the students’ participant observation
experiences that the cohort will use for
data collection in the ED.
Class sessions 11 to 15 are dedicated
to the collection and analysis of data
and the preparation of results for
presentation to university and hospital
administrative leadership. At the end of
the semester, each student is required
to write reflective essays on their
accomplishments and major lessons
learned during the course.
As an example of how a project progresses
over the course of a semester, the second
(2017) student cohort explored patient
education interventions in EDs by
developing a patient education leaflet for
their class project. The students spent
the first weeks of the semester, after basic
training in participation observation,
conducting fieldwork in the ED to identify
the type of information a patient would
like to see in a leaflet, addressing gaps
between the patient expectations and the
reality of the ED encounter (weeks 1–6).
Over the next few weeks (weeks 7–10), the
students developed a leaflet based on their
observations. Later, students distributed
the leaflet and spent more time with
patients evaluating their response to it
(weeks 11–15). Finally, students analyzed
these responses, synthesized their findings,
and gave a professional presentation to
the university and hospital administrative
leadership (weeks 11–15).
1723
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Innovation Report
Figure 1 Schematic timeline of the Research in Physician–Patient Interactions course, University of South Florida, Tampa, Florida, 2016–2018.
Outcomes
Enrollment and student characteristics
The course has now been offered 3 times
(2016–2018), and each year, the number of
students requesting entry into the course
has increased (with an average of 100
applicants per year). Students are eligible
to apply for a seat in the course if they have
taken an introductory-level anthropology
course. A formal application process was
created in 2017 with preference given to
sophomores or juniors, students in the
7-year BS/MD program, students with
scholastic achievements (e.g., high GPA)
who are likely to matriculate into medical
school, and students with additional
background coursework in anthropology.
Table 1 outlines the demographics of
the 51 students who have completed the
course as of 2018. Eight (16%) students
have continued related work with a
follow-up thesis, focusing on topics such
as a patient concierge project, physician–
patient communication, patient education
leaflets, patient experiences with sickle cell
disease, and provider assessments of a new
analgesia pathway. One (2%) student has
been accepted into a graduate program
in medical anthropology, 9 (18%) have
been accepted into medical school, and
14 (27%) are in the process of applying
1724
to medical school. Students have also
presented their course experiences and
details of their cohort’s patient experience
quality improvement projects at local
(USF Health Research Day) and national
(e.g., Society for Academic Emergency
Medicine Scientific Assembly) academic
conferences.
Thematic analysis of students’ field notes
and reflection essays and follow-up
communications with course alumni
revealed 3 salient themes regarding the
utility of patient shadowing as follows:
1. a research method that provides
unique types of qualitative data,
Participant observation and patient
shadowing
2. a teaching tool for premedical students
to understand the perspectives of
patients, and
As a way of methodologically
triangulating how patients experience
health care services in ED settings from
different vantage points, 3 types of
participant observation are incorporated
into the course:
3. an approach to developing the
professional skills necessary in health
care, such as effective communication
styles, establishment of rapport, and
empathy.
1. observations with ED staff in different
clinical spaces, including security
desks, triage rooms, and inpatient
waiting areas (one 3-hour block),
2. physician shadowing (one 3-hour
block), and
3. patient shadowing (two 4-hour
blocks).
To our knowledge, patient shadowing
has only been employed in 2 studies
measuring patient satisfaction.7–9 Over
300 hours of shadowing 89 patients was
conducted by the 3 student cohorts.
Table 2 presents some illustrative quotes
that show how students found patient
shadowing to be a useful research
method, teaching tool, and approach to
professional development.
Research method. As a distinct
qualitative research method, patient
shadowing provides the researcher
with a completely different perspective
when studying how patients experience
receiving health care services in ED
settings—the perspective of the actual
patient. This perspective is important to
consider when conducting ethnographic
Academic Medicine, Vol. 94, No. 11 / November 2019
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Innovation Report
Table 1
Demographics of Students Enrolled in the Research in Physician–Patient
Interactions Course, University of South Florida, 2016–2018
Characteristic
Year enrolled in the course
2016
No. of
students
% of
students
14
27
2017
16
31
2018
21
41
Year of study while enrolled in the course
Freshman
1
2
Sophomore
16
31
Junior
15
29
Senior
18
35
1
2
Male
14
27
Female
37
73
Asian
5
10
African American or black
7
14
Hispanic/Latino
11
22
White
22
43
Indian
2
4
Mixed
4
8
Graduatea
Self-identified gender
Self-identified race/ethnicityb
Undergraduate major/minor
Biology/Biomedical sciences
34
67
Anthropology
5
10
Science and anthropology double major
4
8
Biology/Biomedical science with anthropology minor
6
12
Biology/Biomedical science with other minor
2
4
51
100
Total
a
Although the course is designed for premedical students, there are a few medical anthropology graduate
students in the course who are interested in this type of research/work.
Percentages in this section may not add up to 100% because of rounding.
b
research in clinical settings, as it offers
insights into aspects of the clinical
encounter that patients consider
important, which can differ vastly from
those the physician considers important.
Across the 3 cohorts, students noted that
this method was useful in identifying
communication gaps that occur over
the course of a patient’s entire ED visit.
These gaps include misunderstandings
of medical jargon, ED procedures, and
follow-up care instructions.
Teaching tool. Students’ reflection essays
revealed the utility of patient shadowing
as an exercise and a teaching tool.
From an academic standpoint, students
indicated that the course challenged
them to consider influential sociocultural
factors (e.g., level of education, race,
country of origin, gender, income) that
contribute to biological diseases and the
experience of illness. Students observed
that explanatory models of illness are
not universally shared; patients have
a number of ethnomedical (i.e., lay,
nonbiomedical) perspectives, while
physicians have a biomedical model
with its own understanding of health,
disease, and illness. The tensions that
emerge between the physician and
patient during the clinical encounter
are due to a miscommunication or
lack of understanding of one another’s
worldview, which influences each party’s
understanding of the experienced
symptoms and courses of action for
treating or managing the condition.
Student reflections highlighted how the
clinical encounter is a negotiation of
Academic Medicine, Vol. 94, No. 11 / November 2019
care between the explanatory cultural
models of both patients and providers,
an idea introduced by Kleinman and
colleagues.6 Lastly, student reflections
also indicated that the theoretical and
conceptual aspects of class discussions
facilitated their ethnographic work by
providing a useful methodology, a guide
for interpreting their observations, and a
theoretical frame for reflection.
From a pedagogic standpoint, patient
shadowing served as a useful exercise
for students in terms of immersing
themselves in how patients experience
health care services and medical
evaluation in the ED. Students were
challenged to establish and build rapport
with patients who consented to be
shadowed, while using effective eliciting
techniques to interview these patients
throughout their visit and taking accurate
field notes. Many students indicated that
conducting anthropological research
challenged their ideas of what constituted
research, as most had understood
research to be using the traditional
scientific method within controlled
settings. This experience broadened
their perspective by demonstrating how
qualitative research methods offer unique
types of data that are useful in improving
physician–patient interactions.
Approach to professional development.
Patient shadowing also appeared to serve
as a useful approach to professional
development. Many students expressed
appreciation for how the course
provided them with a career exploration
opportunity that allowed them to learn
about emergency medicine, research,
and medical anthropology. General
communication, rapport building, and
elicitation techniques are some of the
skills that students indicated developing
and refining via being participant
observers in the ED, interviewing
patients, and shadowing patients for
extended periods of time.
Next Steps
Patient shadowing and participant
observation are novel activities
included in this course that represent
anthropologically based methodological
approaches to medical training and that
could easily be scaled up and replicated to
better understand the patient experience.
As a methodological approach, patient
shadowing has not been widely used
1725
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Innovation Report
Table 2
Illustrative Quotes From Students Who Completed the Research in Physician–Patient
Interactions Course, University of South Florida, 2016–2018
Patient
shadowing
as a/an …
Research method
Illustrative quotes
One issue that can be difficult to notice is how cold the medical-technical caring can be for the patient and how much time
is spent being left alone and waiting. People come to the ER perceiving that their life is in danger, and they are often feeling
pain. However, to the people working, this is just another shift. This is essentially a cross-cultural experience, and the readings
and class discussions made it apparent that biomedicine is in fact its own cultural system.
In reality, the majority of people who come to the ER do have fascinating, rare, or life-threatening problems. People come
with chest pain, back pain, and social pain. They come just in case or because nowhere else will take them. This causes the
true gap in models: expectations. Physicians simply want to make sure someone is healthy enough to leave. Patients want to
find out what is wrong with them and fix it.
Shadowing the patients opened my eyes to issues that I hadn’t even noticed while shadowing the physician.
The patient asked what her diagnosis was, and he [the nurse] told her that she can read her diagnosis in the discharge
paperwork.
The patient stated, “I thought talking to the physician would give me some clarity, but it just made me more confused.”
When patients complain that doctors are “sitting around,” the doctors are always busy checking other patients and putting
information into the computer. However, physicians often forget just how … [it] feels to be a patient under stress and in pain
and waiting hours to see you.
It comes down to the perspective of the patient and not just viewing them as a disease state. Communicating with the patient
as a person and caring for them as such is the best way to make sure they have the best understanding of their treatment.
Teaching tool
The course exposed me to the very visceral and at times emotional lived experience of patients that go to the emergency
room. What this course has provided me is a deep understanding of how different patients make sense of their condition
and experience illness in emergency settings.
Before I would, like many physicians do, ignore the ethnomedical part of the interaction and focus more on the symptoms
that could “actually happen” and that have an “actual cause and effect.” Before this class, I truly did not know the
importance of certain people’s cultural medical needs, and I was also not aware of how often that happens to people that
come to the ER.
I learned not to lose sight of how much of an impact you can have as a physician on a patient’s life, both for the good and
the bad. For the doctor, curing the disease is the goal, while for the patient it isn’t just the biological side that matters to their
health. It’s how their disease will affect their daily life and whether they can afford to be sick.
The readings and class discussions went hand in hand with our work in the ED. For example, at the beginning of the class,
we read many articles about how to perform interviews and about participant observations, and I could use this information
when I was at the hospital. There were also a lot of articles about observations in the field, and I would use these ideas when
I shadowed in triage, the waiting room, and at the security desk.
The idea of being a participant observer is a very useful way of initial information gathering. The participant observation
reading taught me to avoid being a scientific stranger, which goes against all my research training but is essential to being
able to blend into the culture and reduce the observer effect.
Never could I have imagined what this class would teach me about medicine and myself. Despite dreading the 4-hour patient
shadowing assignment since syllabus day, looking back, it was probably my favorite assignment of the class. Mainly, the
patients taught me that their health wasn’t something separate from their lives. Their health was something that affected
them every day and really influenced the person they had come to be, and how the interactions they would have in the ER
would impact their coming days and weeks.
Approach to
professional
development
Building rapport is one of the most important factors while doing interviews because it allows you to get the most accurate
answers. Not only that, but it makes the interview less awkward.
The other important lesson learned was that of how to start a conversation with a stranger and establish rapport. The course
taught research in a hands-on way, which I found much easier than learning it from a textbook.
I don’t think I have ever cried more in a class from the readings, discussions, and films we watched. These were some of the
best literature works I could ever have been given to read, talk about, and watch. They taught me that we are all humans,
we all have our own worldviews of what we think is great care.
No matter what specialty I might choose in the future, what I have learned from this class will undoubtfully be helpful. When
a doctor sees so many patients during each shift, it may be easy to forget that they are people, with real lives, feelings, and
concerns. The insight into patient experience that I gained was extremely unique and not something that I will be exposed to
in medical school, and I am eager to apply these experiences in the future.
I think what makes this class so unique compared to all other classes on campus is that it also integrates a hands-on
experience where students are able to really take what they learn in the classroom and apply it in a real medical setting. I
believe that this class has helped expose me early to the problems that reside within medicine, and hopefully, I can be part of
the next generation of doctors who implement change, ultimately benefiting the health and overall well-being of the patient.
Since I took the course in my last semester, I graduated and started medical school immediately in August. I am doing
exceptionally well in my clinical practice course, which I think, in part, is due to the extensive patient interaction I had while
taking this class. Having to talk to so many patients in the ER helped me become comfortable with speaking to patients and
has helped me identify ways we can improve communication with patients in any clinical environment.
Abbreviations: ER indicates emergency room; ED, emergency department.
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Academic Medicine, Vol. 94, No. 11 / November 2019
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Innovation Report
in health services research despite its
potential for providing unique types of
qualitative data.9,10
As demonstrated by student reflections
from each cohort, patient shadowing
can provide an uncomfortable but lifealtering experience and may solidify the
importance of understanding the patient
perspective early in the training of future
physicians. These reflections reinforce the
notion that incorporating such patient
encounters into training early may add
more value in terms of improved patient
satisfaction than current efforts to alter
the behavior of adult learners who have
already been enculturated into modern
biomedicine. Establishing a patientcentered perspective through patient
shadowing may allow future physicians to
develop more empathic frameworks for
managing patient encounters.
This course has been taught at our
institution for 3 consecutive years, but
our findings are limited in that we have
used the same pair of instructors, the
same hospital, and the same university
setting each time. While it appears
that patient shadowing experiences are
impactful during premedical education,
there may also be value in integrating a
similar experience into medical school
and residency training. Similar courses
should be offered at other universities
to premedical students, medical
students, and residents to explore the
generalizability of this method.
Although some medical schools do offer
a humanities course, we believe that this
educational time might be enhanced if a
medical anthropology course of the type
described here were offered. Humanities
education is important for creating wellrounded physicians; however, we believe
that this should occur as part of a general
liberal arts education and be assessed on
the revised MCAT.
Medical anthropology and qualitative
research training in medical education
presents an important strategy for
improving patient experiences, while
offering a unique approach to the
challenging issue of developing the next
generation of well-rounded physicians.
Acknowledgments: The authors would like to
acknowledge Tampa General Hospital, the
University of South Florida (USF) Honors
College, the USF Department of Anthropology,
and Charles Adams, PhD, dean of the College of
Arts and Sciences, USF.
Funding/Support: Funding for this course was
provided by the USF Honors College.
Other disclosures: None reported.
Ethical approval: The USF institutional review
board reviewed this study and determined that it
is not human subjects research and so is exempt.
Previous presentations: Data from this manuscript
were presented at the Association of American
Medical Colleges Western Group on Educational
Affairs (WGEA) Regional Meeting in Denver,
Colorado, March 24–27, 2018.
J.W. Wilson is associate professor, Division of
Internal Medicine, Department of Internal Medicine,
Morsani College of Medicine, University of South
Florida, Tampa General Hospital, Tampa, Florida;
ORCID: https://orcid.org/0000-0002-4291-5802.
R.D. Baer is professor, Department of
Anthropology, University of South Florida, Tampa,
Florida.
S. Villalona is a first-year medical student, Rutgers
Robert Wood Johnson Medical School, Piscataway,
New Jersey.
Academic Medicine, Vol. 94, No. 11 / November 2019
References
1 Institute of Medicine. Health Professions
Education: A Bridge to Quality. Washington,
DC: National Academies Press; 2003.
2 Rosenstein AH. Physician dissatisfaction,
stress, and burnout, and their impact on
patient care. In: Papadakos PJ, Bertman S,
eds. Distracted Doctoring: Returning to
Patient-Centered Care in the Digital Age.
Cham, Switzerland: Springer; 2017:121–142.
3 Schwartzstein RM, Rosenfeld GC, Hilborn
R, Oyewole SH, Mitchell K. Redesigning
the MCAT exam: Balancing multiple
perspectives. Acad Med. 2013;88:560–567.
4 Association of American Medical Colleges.
MR5: 5th comprehensive review of the
Medical College Admission Test (MCAT):
Final MCAT recommendations. https://
www.aamc.org/download/273766/data/
finalmr5recommendations.pdf. Accessed
June 24, 2019.
5 Wang JY, Lin H, Lewis PY, Fetterman DM,
Gesundheit N. Is a career in medicine the
right choice? The impact of a physician
shadowing program on undergraduate
premedical students. Acad Med. 2015;90:629–
633.
6 Kleinman A, Eisenberg L, Good B. Culture,
illness, and care: Clinical lessons from
anthropologic and cross-cultural research.
Ann Intern Med. 1978;88:251–258.
7 DiGioia A III, Lorenz H, Greenhouse PK,
Bertoty DA, Rocks SD. A patient-centered
model to improve metrics without cost
increase: Viewing all care through the
eyes of patients and families. J Nurs Adm.
2010;40:540–546.
8 Digioia T. Patient shadowing: How to
reduce costs while improving the patient
experience and outcomes. IHI Improvement
Blog. http://www.ihi.org/communities/
blogs/_layouts/15/ihi/community/blog/
itemview.aspx?List=7d1126ec-8f63-4a3b9926-c44ea3036813&ID=172. Published
November 11, 2015. Accessed June 24, 2019.
9 Kitsis EA, Goldsammler M. Physician
shadowing: A review of the literature
and proposal for guidelines. Acad Med.
2013;88:102–110.
10 Kleinman A. Concepts and a model for the
comparison of medical systems as cultural
systems. Soc Sci Med. 1978;12:85–95.
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