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Interviewer: Learn how other institutions are supporting students, empowering faculty, and connecting with patients for healthier communities. This is Pathways in Academic Medicine from the Scope Radio Live at Learn, Serve, Lead. Join us as we learn about the pathways academic medical centers are building to impact education, research, and patient care. Today we're joined by Dr. Jed Gonzalo. He is the Senior Associate Dean for medical education at Virginia Tech Carilion and also Dr. Sara Lamb, Vice Dean of Education at Ï㽶ÊÓƵ of Utah Health. We're talking about pathways, developing ways to make academic medical centers better. There's a problem, there's a pathway that helps fix that. What is the topic that we wanted to talk today about Dr. Lamb?

Sara Lamb: Well, I think Dr. Gonzalo, my friend Jed, is a leader in developing and thinking about the problems that we face in healthcare and bringing those problems to students early in their education, so that they too can start thinking about how we train the next generation of physicians to solve those problems and understand exactly what they are so we don't keep making the same mistakes over and over and over again. But that's hard and he's been a leader and has really worked on this for a long time.

Interviewer: Great. Medical students go to medical school to learn about medicine, but they don't necessarily learn about how can I approach a problem that I see, that I know, oh, if we could just solve this problem, medicine would be so much better. So let's go ahead and jump into this challenge. How would you define the problem Dr. Gonzalo and what can be done to address it?

Jed Gonzalo: When a student's coming into medical school starting next summer, they will matriculate through medical school, go through residency. They'll be practicing in 2031 or 2032. And I think it's our job in academic medicine to think about what's needed for the patient populations in the communities in which we serve, whether it be Utah or Virginia Tech Carilion in Southwest Virginia, and how do we help them develop the skills that they need to meet the patient's needs? And that's where some of the systems-based practice and health system science learning really comes into play. All the social determinants of health. There's 23 plus social determinants of health that are associated with poor health outcomes. These are competencies that have been around for a very long time, but fortunately there's been a movement the past 15 years to say, "Hey, let's bring that into the norm of medical school day one all the way through residency. So our learners are best prepared at 2031 or 2032 ready to hit the ground running and meet the needs of our patients because that's really what we're here for."

Sara Lamb: One of the things that Jed has really explored is how do you make that something that the students, the trainees, are actually interested in or see as relevant and meaningful to them at that time in their training. But how do you really sort of open their minds to thinking like, these are problems that I can really sink my teeth into and start to help solve.

Jed Gonzalo: Sarah brings up right to the heart of the matter, this engagement piece from the students. I would say by and large, most students see the benefit and need, this is what their calling was to come into medicine, and then they come into medical school and oftentimes we place them in a system that doesn't prioritize this type of learning. But I have seen a shift the past 10 or 15 years that I think steadily learners and faculty, physicians and medical schools are thinking differently about the evolved set of competencies needed for students. But it is remarkably hard, as Sarah knows well, to engage them in these type of learning competencies. But I have found, if you think about the North Star, what does the patient need?

I mean, we have an aging patient population right now. There's going to be a third more patients where we're age 65 over the next 10 years. Those numbers are only going to increase, patients who have no broadband in Southwest Virginia. So how do you address the telehealth competencies that are needed for the patients in those populations? Learners are entering medical schools by and large for the right reasons, and we need to engage where their hearts and minds are. So help them develop to live out their dream of being a physician to meet the needs of people.

Sara Lamb: So Dr. Gonzalo is on the cusp of launching a new program at Virginia Tech and we at the Spencer Fox Cycle School of Medicine are now in our second year of a very new transformed program. And I'm curious, given his prior experiences at other institutions, how he's approaching integrating this educational component into their new program. And then I'd love to sort of learn how we can learn from him and how we can help him learn about our experience as well.

Jed Gonzalo: A comment on a program that I led at Penn State College of Medicine, it was the patient navigation program. This is a program where learners were integrated into clinical care teams to work directly with patients who were in need, the superutilizers, those the nurses and physicians were worried about, those who had poor colonoscopy screening rates or A1Cs that were elevated in clinics. Students were linked up in those teams to help navigate care for those patients to meet the best outcomes. And through that work, they were developing the skills. What I'm most excited about Ï㽶ÊÓƵ of Utah is the student run clinics that you have. I think you have five or six in your model. Sarah's given me the rundown on them.

This is such a remarkable model because learners are brilliant. We bring them in the medical school. If they weren't entering medical school, they would be highly coveted healthcare professionals in any other field. They come into medicine and we place them in observer ships that students are legitimately participating in those clinics, allows them to do two things, meet the needs of patients right in front of them while also learning these health system science, skills that I'm referencing and the clinical skills. So I am looking forward to learning. I think the medical community is really looking forward to learning from you in your clinic. So maybe, Sarah, that's a question for you on what you're excited about in the clinics.

Sara Lamb: Yeah. This has been a remarkable transformation for us to have our students bring value to our communities and to our health systems in the area from day one. And so you're correct, we have five student led clinics. We've had a lot of experience with student clinics for decades in Salt Lake City, but they were never a formal part of our curriculum. And as we were thinking about what we really wanted to accomplish, what was our mission as a medical school, my experience in our dean's office over the last 10, 15 years has been listening to students say, "I feel like I don't matter, and I feel like I'm on the sidelines," sort of that observership sentiment. And when they get into our student-led clinics as volunteers, they feel that altruism comes out. They feel that importance that they bring to patients and communities. And so over these years, we've really grown ahead of steam around the idea that why wouldn't these be part of our formal program?

And with the emergence of the need to teach our students about social determinants of health, health disparities, health equity, this was the perfect place to bring all those things together and to still be able to serve patients and to show the students why these issues matter and why they need to learn it. And they don't need to learn it later. They need to learn it first so that they can really truly understand how important these concepts of health equity, healthcare financing, the barriers to access are and how important the structures around medicine are to helping patients achieve health. Not just what we do as doctors, but everybody else on the team in the social network matter. And so they value them, they work with them. It's been a really exciting change for us in the medical school.

Jed Gonzalo: I wish everybody could see Sarah's face right now. And my face we're so excited about, and I think it really hits on the point of clinical imprinting, the imprinting on learners. We know that learners who practice in high value cost conscious care settings go on to careers where they practice more high value cost conscious care. Those who are in teaming environments and addressing the social determinants of health in their training, they go on to espouse a lot of those traits. That's why I love the Utah model. How do we engage our learners outside of classrooms into those clinical settings very early on to carry that continuum that Sarah I was referring to.

Sara Lamb: Yeah.

Interviewer: So the pathway is the clinical setting, creating opportunities for the students to get out into those clinical settings more quickly. Are there other aspects of that clinical setting that are useful?

Sara Lamb: So I'll just comment here, because this happened this week in a meeting. I have a regular meeting with all of our partners within the clinics that we work with, and this one was in Summit County. And we met and she was talking to me about how they've had two MAs working in their clinic with our students who are now aspiring to go on to medical school. So these are proving to be very rich environments where people who come from disadvantaged backgrounds who are working to care for individuals who are marginalized, see the opportunity of like, "Oh, I could do this. I see what this is really like. I see people who kind of look like me, who are doing this important work that I care about as a young person, but maybe didn't see that I could be a doctor."

So it's proving to be actually a very powerful environment where medical students are able to sort of mentor, encourage and guide young people who may not have thought that medicine was possible for them, and encourage them and say, "You should apply to medical school or you should apply to nursing school, or you should apply to be a PA because we need you." And so it's really actually been an inspiration to us to hear about these stories of people who are coming from the community to come into medicine to care for our populations.

Jed Gonzalo: Yeah, I mean the two themes there that I love is this interprofessional teaming piece that happens very early on. I was a medicine resident several years ago, but I didn't know what a care coordinator was until I was in my R2 year. I mean, that's six years into my training. And I think the models that Sarah and I are discussing today, patient navigation suit run clinics, that early immersion to understand what a nurse practitioner does and what a nurse's role is and a pharmacist, and to have that, what I would term a knowledge ability of that team carries forward with them through their career. And I think that is the best part. The second-best part to me is really this authentic engagement when we shift them out of the observer role and we have them actively engage and they are legitimate participators in that community of practice of care, and they do that in the clerkships, they do that in the fourth year. They do that into their transition to the intern year of whatever specialty they're going into. They're hitting the ground running more quickly, but that is where the learning is happening.

Interviewer: If other institutions are interested in this model, what were some of the challenges that you faced and how could some institutions look at this to overcome those?

Sara Lamb: Early on, when we were developing this idea, people had a lot of concerns that we were putting not yet ready students in front of already vulnerable populations potentially providing less than optimal care to these individuals, and that we were just further establishing the gap and potentially causing harm. The way we've approached it is that these aren't student led clinics that have some random parade of volunteer faculty. These are our paid faculty from the Ï㽶ÊÓƵ of Utah who this is their role within our program is to be there regularly and supervising our students and ensuring that the quality of care is exactly on par with what we provide at Ï㽶ÊÓƵ of Utah Health.

So we've invested our resources in saying this is just as important as learning about biochemistry and gross anatomy. This is part of how we approach our education of health disparities, social determinants of health, health system science and clinical skills and medical decision making and clinical reasoning. It's an investment. There's no question. You have to really make the case for why this is impactful and why this is a good direction to go in because of the authentic nature of it and the impact it has on our trainees and on our faculty. This gives them meaning and purpose back. They feel like this is the joy in medicine and they didn't have it in the revenue-generating centers that they were previously working in for most of their time.

Jed Gonzalo: It reflects a larger paradigm shift in medical education. It takes an ounce of courage, if not more, for a school to engage in programs like this. If we're fulfilling our social accountability mission and we're really driving and using educational science principles, we're saying, "Hey, we want to shift towards this." We're not allowed to have 30 hours of in-class time, but maybe we don't need 15 hours a week on this histology concept. Not that they're not important, but we have to think holistically using a systems thinking lens about what's needed holistically for the learner and then patient populations. But it's hard. I mean, your initial question was what are the challenges? It's a paradigm shift even for our faculty to be able to engage and say, "Hey, what are our goals and how do we engage in that meaningful dialogue to actually get further along where we need to be?

Sara Lamb: I think people were really surprised that we didn't have a hard time recruiting faculty for these roles. The minute we said, "This is an opportunity for you to step into a different space and to work with really early learners." I mean, we're talking like students who are a month into medical school or six weeks into medical school. It's different, but it is so rewarding and the population they serve just makes it even more so.

Interviewer: For somebody listening that wants to perhaps bring this idea back to their institution of getting medical students in front of patients earlier, where are some places that they can look to get some guidance on how to even begin this process? You talked about resources, I'd imagine time, money, probably have to dedicate some people to coming up with what does this plan look like?

Jed Gonzalo: Every medical school's required to have an early clinical experience in the pre-clerkship years. It's a requirement. Everybody does it. So one pragmatic thing, review your learning goals. What is the goal of what we're actually doing in the experience that we got? Can we modify that? Can we tweak that? Can we have learners do more tasks instead of just watching where they can add value to that clinic? There's plenty of literature out there, there's textbooks out there. What are the tangible things you can do the next year that might change one assessment or change a goal that says, "Hey, they're going to add value. They're going to go and work with patients first and then work with the patient on an exit interview on their social determinants of health needs." These are pragmatic things that we can do now in the models that we already have.

Sara Lamb: I'll just say most schools probably support student-run free clinics.

Jed Gonzalo: I think the literature 10 years ago was 60, 65%. I need updated data.

Sara Lamb: We just sent our students to the Society of Student-Run Free Clinics meeting in Philadelphia this year, and they said there were about 200 individuals present. And that obviously would be a mix of students from a variety of schools. I think there are a lot of institutions that could learn from within if they just turn their eye inward and start talking to their own students about where the value is to them and what the value is of these clinics to the communities and to the organizations around them. I think they might be surprised, because this was not my personal idea. This was an idea that came from our students. I said, "Why the heck are we sending our students into these other clinics? We have these clinics that we all love going to. Why can't we make that part of our program?" And it stuck with me for about six years, and I thought, "They are right."

Jed Gonzalo: Go to the clinics you're in. Ask the nurses, ask the leadership, what are the quality of care gaps? Where are the inequities that are happening with our patient populations? Get them on the table and then try to figure out how you can have students add value to meet those gaps, because that's ubiquitous across every medical school.