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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. 1726 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 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. 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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. 1727 Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.