The problems in the American health care system are complex. By embedding first-year medical students within the system as health navigators for high-utilization patients, a program at Case Western Reserve University School of Medicine (CWRU) is turning to the next generation of physicians to help solve them.
Looking at medicine from a health systems perspective
The AMA Accelerating Change in Medical Education Consortium got its start in 2013 when the AMA provided five-year grants of $1 million each to 11 medical schools. The initiative was expanded in 2016, with three-year grants of $75,000 apiece to 21 medical schools.
CWRU joined the Consortium with the second group of schools, looking to grow its HSS curriculum. Based on a program at fellow Consortium school Penn State College of Medicine, CWRU’s Patient Navigator program is among the key initiatives in integrating HSS components, such as population health and the social determinants of health, into its pre-clerkship teachings.
In CWRU’s program, now in its second year, roughly 40 first-year medical students work as members of interprofessional patient-centered medical home teams to optimize care for vulnerable, high-utilization patients (veterans and refugees).
Heidi Gullett, MD, MPH, is an assistant professor of family medicine and community health at CWRU who helped develop the Patient Navigator program. In the program’s first year, 19 students devoted 375 work hours to helping newly arrived refugee families who were patients at the Neighborhood Family Practice, where Dr. Gullett practices.
“One of the hallmarks across all the patients that were part of this program was that the social determinants of health were a big impact on their health status, so our students were really learning about not just how to navigate the health care system but also how to navigate all these ancillary things that are impacting their social determinants,” Dr. Gullet said.
Those ancillary factors could be as simple as getting a patient to an appointment or as complex as getting a primary care physician to communicate with a specialist on a treatment plan.
Adding value, gaining knowledge
Students participating in the program are coming off their first block of medical training. That block focuses on some of the broader concepts of HSS, such as patient-centered care. It also includes lessons on the societal factors that adversely impact many of the patients whom students will encounter.
Typically, navigators will join patients on their visits and help with any communication barriers—students working with refugees have specific training on how to work with an interpreter in a clinical setting. The barriers go beyond language, however.
“I do a Bridges Out of Poverty training, so they understand the different elements of partnering with people living in generational poverty,” Dr. Gullett said. “How our hospital systems operate may be a very different set of rules than our patients are used to.”
The Patient Navigator program offers students the opportunity to gain knowledge from the other members of their interprofessional team. It also offers them a chance to contribute to the well-being of a patient.
“Medical students often feel like they are added on and they don’t bring added value to [patients], they are just there to learn,” Dr. Gullett said. “And, really, it’s not true. They have so much to offer.”
In the short-term, Dr. Gullett hopes the program helps create more well-rounded physicians who approach their practice with a health systems science bent. Longer term, she has higher hopes.
Dr. Gullett tells the story of a time when a student navigator working with a refugee patient discovered the patient’s chemotherapy treatments were unnecessarily delayed because two physicians had a miscommunication. The root cause of that error—the two physicians were unable to correspond over electronic medical records—was systemic.
The student saw that error as unjust and preventable. Even after he completed his rotation in the patient navigator program, he has remained in contact with the patient.
“We want our students to understand health systems so much that they see themselves as agents of change in our broken health care systems and they use their brilliance and creativity to think about how we can do better in the future for both individuals and populations of patients,” she said.
