Medical student shadowing on hospital medicine direct‐care services

Physician shadowing, or observation of the day-to-day work of a physician, is a time-honored way to introduce students to medical careers and patient care but can be challenging to implement.1, 2 Hospital medicine (HM) requires broad expertise in clinical and health systems sciences and provides an opportune environment for valuable and diverse clinical shadowing experiences. Coinciding with HM's growth as a field, HM direct-care services (HM-DCS), or services in which a hospitalist is the sole primary provider, are increasingly utilized in medical education.3 The clinical practice of HM, however, is demanding, and some may fear incorporating early learners on HM-DCS may cause greater provider stress, distracting multitasking, and lower productivity.4-6 More than ever before, hospitalist educators must navigate tensions between clinical demands and the educational mission.7, 8 A key strategy offered by HM leaders is developing innovative educational opportunities beyond traditional teaching services.9 A well-designed shadowing program can meet this need, and hospitalist educators can excel in creating such programs with a thoughtful approach to design, implementation, and evaluation. Applying Kern's approach to curriculum development and central strategies of implementation science,10, 11 we present a model of preclerkship (i.e., first and second-year medical student) shadowing on HM-DCS at the Pritzker School of Medicine (PSOM) at the University of Chicago Medicine (UCM) that demonstrates how HM-DCS can be successful learning environments for shadowing students while facilitating satisfying teaching opportunities for hospitalists. Before 2021, PSOM students lacked formal opportunities to shadow in HM. To meet this need, the Section of HM at UCM partnered with PSOM to create an HM-DCS shadowing intervention, or Hospital Medicine Shadowing Experience (HMSE), available to first- and second-year PSOM students and UCM hospitalists. UCM, a tertiary academic medical center, has 13 general medicine and subspecialty HM-DCS comprising medically and psychosocially complex patients. HM-DCS cap at 11–14 patients and are staffed by approximately 70 hospitalists with varying teaching responsibility levels. Seven-day HM-DCS rotations begin Monday, Wednesday, or Thursday. PSOM, whose campus is adjacent to UCM, has roughly two preclerkship years followed by clinical rotations. Classes are approximately 88 students. We chose DCS for shadowing students because, unlike traditional teaching services with interns, residents, and other students, they enable a 1:1 apprentice-teacher model, which may allow a more direct interface with patient care and the health system and enhance physician role-modeling and mentorship while not overcrowding traditional teaching services with additional learners. We first identified stakeholders and considered facilitators and barriers to implementation in our context. Based on these, we decided participation would be voluntary, students and hospitalists would be paired 1:1, and shadowing would last a minimum of 2 h and occur on Sundays. We considered that restricting shadowing to Sundays could decrease exposure to the scope of HM practice but accepted this tradeoff in favor of reasons such as accommodating student class schedules. To establish program objectives, we conducted a prepilot needs assessment from February to March 2021. General advertisements were disseminated via email. Students and hospitalists were paired based on availability. The only prepilot guideline was shadowing should last at least 2 h. Within 2 weeks of participation, students and hospitalists were asked to provide narrative feedback. We reassessed facilitators and barriers following feedback review and established the following formal HMSE objectives: (1) educate students about HM careers; (2) provide students clinical education; (3) enhance students' professional identity formation (PIF)—that is, the process through which students come to think, act, and feel like physicians—through preceptor role modeling and experiential learning12; (4) provide hospitalists satisfying teaching opportunities; and (5) minimize clinical disruption. Table 1 outlines key implementation strategies. The full pilot was subsequently formulated. HMSE was piloted from April 2021 to June 2023. Several HMSE components were modified or introduced based on the needs assessment. For example, we implemented a hospitalist tip sheet highlighting strategies to streamline workflow, teach and engage students, discuss HM careers, and be a physician role model (Table 2). Tailored advertisements were disseminated each fall and spring. HMSE components were iteratively refined following the annual survey analysis. Meet your student around 8–9 a.m. after independently chart-reviewing patients, addressing "fires," and seeing patients for whom early discharge is planned. Complete notes and sign-out after shadowing is over. Ask your students what they want to get out of the shadowing experience. Give a 2–3 sentence patient summary before entering each patient room. Invite your student to start patient interviews and participate in physical exams. Connect basic science and pathophysiology to clinical medicine at the bedside. Briefly discuss your assessment and plan while seeing or after seeing each patient. Highlight psychosocial barriers and other health systems domains of patient care (e.g., interprofessional collaboration, hospitalization and discharge structures and processes, high-value care, health policy and economics, health technology, and ethics). Invite your student to enter orders and pages in Epic. Have your student listen in on calls with consultants. Discuss the pathway to become a hospitalist. Discuss quality improvement, clinical operations, medical education, and other nonclinical career opportunities. Discuss why you went into hospital medicine. Discuss what you find most rewarding about the practice of hospital medicine. Discuss what you find most challenging about the practice of hospital medicine. Demonstrate clinical expertise. Demonstrate respect, empathy, compassion, and a patient-centered approach. Demonstrate a collaborative spirit with other care team members. Create a positive, supportive educational environment and show interest in the growth of your students. Have a positive outlook! One week following participation, student and first-time hospitalist participants received survey invitations (Appendix A). Participants were surveyed over three academic years (AYs) from 2020 to 2023. Fifty-two students shadowed 19 unique hospitalists over 55 instances. Student participation increased after the first AY and was stable thereafter; hospitalist participation was similar across AYs (Appendix B). Student and hospitalist survey response rates were 95% (52/55) and 84% (16/19), respectively. Students shadowed for a mean 3.3 h (SD 1.0) on a mean 10.1 patients (SD 3.1). Most (79%) reported direct-clinical engagement (e.g., taking histories). Twenty-one percent of students observed consultation with a specialist, and 75% discussed nonclinical HM career opportunities (e.g., quality improvement). Students and hospitalists were highly satisfied with HMSE. Among students, 98% were satisfied overall with HMSE; 98% were satisfied with hospitalist role modeling; 98% with clinical teaching; and 85% with direct-clinical engagement. Among hospitalists, 88% were satisfied overall with HMSE with 94% satisfied with the opportunity to teach (Appendix C). Satisfaction was stable across AYs (Appendix D). All students reported an increased understanding of HM clinical practice, 95% reported an increased understanding of nonclinical HM opportunities, and over half (56%) reported increased interest in pursuing an HM career. We were additionally interested in measuring the impact of HMSE on HM-DCS clinical workflow. Nearly all hospitalists (94%) perceived workflow disruption. It was not feasible to assess certain disruption endpoints, like delays and omissions in placing orders and consults. Thus, to assess whether shadowing resulted in delays in hospitalist work completion, we examined the following electronic health record (EHR) data: (1) mean time of progress note and discharge summary entry; (2) mean percentage of notes copied from prior notes; (3) mean number of discharge orders placed; and (4) and mean time of discharge order entry. Data were collected for patients on the hospitalist preceptors' census on shadowing Sundays and the immediately preceding non-shadowing Saturdays, which had similar mean total notes and mean new admissions. The mean time of note entry was 44 min later on shadowing versus nonshadowing days (p < .001). Mean time of discharge order entry was 51 min later on shadowing days, but this difference was not significant (p = .15); differences for other measures of workflow disruption also were not significant (Appendix E). We describe a successful model for preclerkship medical student shadowing on HM-DCS. HMSE educated students about HM careers. Further, HMSE was a feasible and sustainable teaching opportunity for hospitalist educators. Here, we highlight several important findings for HM groups implementing shadowing experiences for early learners on HM-DCS. In medical education, PIF derives from a complex network of social interactions, experiential learning, and explicit and tacit knowledge acquisition.12 Consequently, role modeling exerts an important influence on medical student career choices and shapes students' PIF through clinical teaching.13, 14 Our survey data, including high student-reported interest in HM following HMSE, supports success in achieving our objectives of educating students about HM, providing clinical education and engagement, and promoting physician role modeling, which was consistently rated very highly. While favorable for students in the short term, we believe the impact of HMSE could also influence student PIF, whether students decide to become hospitalists or not. For example, the extremely positive experience students reported having with hospitalist role models in HMSE could improve perceptions about HM and even strengthen interprofessional collaboration between future physicians in HM and non-HM specialties. HMSE does not aim to turn every student into a hospitalist, but rather to highlight the unique role and expertise hospitalists bring as leaders of inpatient teams, a feature supported by the high number of students reporting better understanding of both clinical and nonclinical elements of HM. We predicted clinical disruption would be our greatest implementation barrier. Unsurprisingly, nearly all hospitalist respondents perceived workflow disruption. While all objective measures of workflow disruption trended in the direction supporting this perception, only the difference in mean note entry time reached statistical significance. It is plausible, however, that the nonsignificant differences for our other workflow measures reflect type II error given our sample size. Despite the challenge of workflow disruption, we maintained stable hospitalist participation and high satisfaction throughout the pilot which supports success in achieving our last objective of mitigating disruption. This is especially important given the current climate of diminished teaching opportunities throughout the HM landscape and the need to develop additional venues for clinical teaching.7, 8 Future work describing measures of hospitalist workflow should incorporate contributions hospitalists perceive from educational responsibilities, such as those in HMSE.15 We also recognize student survey feedback has the potential to aid faculty promotion. Although our results were not linked to official learner evaluations, we recommend that other groups employing shadowing models consider the value of program evaluation for this purpose, particularly for faculty with high clinical responsibilities and fewer opportunities to receive learner evaluations. DCS are valuable clinical learning environments, even for early learners. We believe HMSE has the potential for future dissemination not only for HM groups at other institutions but also on DCS in non-HM specialties.16 For groups considering the HMSE model in their own context, we advise special attention to implementation science principles—especially in settings with higher patient loads which could adversely impact implementation—and recommend a methodical approach that includes conducting a thorough stakeholder analysis to identify facilitators and barriers, developing theory-based strategies to leverage facilitators and mitigate barriers, systematically measuring outcomes aligned with objectives, and iteratively modifying HMSE in response to evolving results. A structured shadowing intervention on HM-DCS can educate students about HM and may contribute to career exploration and PIF. Utilizing DCS for shadowing experiences may also enhance career satisfaction for hospitalist educators. The authors are grateful to all students and hospitalists who participated in this educational innovation. The authors also thank the Pritzker School of Medicine and the Section of Hospital Medicine of the University of Chicago for their support. The authors declare no conflict of interest. This program was granted exemption by the University of Chicago Institutional Review Board (IRB21-0629). STUDENT SURVEY Please complete the survey below. Thank you! Please enter the last letter of your last name followed by the last four digits of your phone number. For example, Jane Smith 123-456-7899 would be entered as "h7899" ____________________ 1st year medical student 2nd year medical student Female Male Nonbinary Prefer not to say Hospital medicine (inpatient) General internal medicine (outpatient) Internal medicine subspecialty (e.g., cardiology) Other If other, please specify. _________________________ Yes No Gain clinical experience Learn more about a career in hospital medicine Learn more about clinical medicine in general Meet attending physicians Other If other, please specify. _________________________ Before participating in this shadowing experience, how much did you know about hospital medicine compared to other medical specialties with respect to the following: Much less Somewhat less About the same Somewhat more Much more Much less Somewhat less About the same Somewhat more Much more Much less Somewhat less About the same Somewhat more Much more Not at all interested A little bit interested Interested Extremely interested Unsure What was the approximate number of hours (rounded to nearest whole number) that you spent shadowing? __________ What was the approximate number of patients you saw? __________ Cardiology (e.g., heart failure, poor blood pressure control) Pulmonology (e.g., chronic obstructive pulmonary disease, asthma, pulmonary embolism) Nephrology (e.g., acute kidney injury, electrolyte abnormality) Infectious Disease (e.g., pneumonia, osteomyelitis, abscess) Gastroenterology (e.g., diarrhea, liver disease) Endocrinology (e.g., poor diabetes control) Rheumatology (e.g., lupus, gout flare) Hematology (e.g., anemia, sickle cell pain crisis) Oncology (e.g., complications of cancer) Neurology/Psychiatry (e.g., altered mental status, seizure, depression) Other If other, please specify. _________________________ Issues relating to substance use Underinsurance or uninsured status Barrier to hospital discharge (e.g., delays in post-acute care placement, inadequate home support) Challenge in communication or disagreement with a patient or family member Difficulty adhering to treatment Other If other, please specify. _________________________ Yes No Yes No History taking—did you perform any part of the history taking of a patient? Physical examination—did you perform any part of the physical exam of a patient? Assessment and plan—did you discuss the clinical assessment and plan of care of a patient? After participating in this shadowing experience, please rate your satisfaction with the following elements: Extremely unsatisfied Unsatisfied Neutral Satisfied Extremely satisfied Extremely unsatisfied Unsatisfied Neutral Satisfied Extremely satisfied Extremely unsatisfied Unsatisfied Neutral Satisfied Extremely satisfied Extremely unsatisfied Unsatisfied Neutral Satisfied Extremely satisfied Extremely unsatisfied Unsatisfied Neutral Satisfied Extremely satisfied Any comments about your attending physician's teaching that you would like to share? _________________________ After participating in this shadowing experience, have you had any change in your: Significantly decreased Decreased Stayed the same Increased Significantly increased Significantly decreased Decreased Stayed the same Increased Significantly increased Significantly decreased Decreased Stayed the same Increased Significantly increased Significantly decreased Decreased Stayed the same Increased Significantly increased Yes No Any comments about the Hospital Medicine Shadowing Experience that you would like to share? _________________________ HOSPITALIST SURVEY Please complete the survey below. Thank you! How many years have you been an attending physician? Please round to nearest whole number. __________ How many years have you been an attending physician with the Section of Hospital Medicine at UChicago Medicine? Please round to nearest whole number. __________ Female Male Nonbinary Prefer not to say To gain more experience teaching To fulfill a professional requirement (e.g., Passport requirement, service/citizenship needs for promotion) To help students gain exposure to hospital medicine To recruit students to the field of hospital medicine To assist the medical school community in filling a need for shadowing/early clinical exposure To meet more medical students Other If other, please specify. _________________________ How much did shadowing disrupt the following: Not at all Little Some Much Very much Not at all Little Some Much Very much Very uncomfortable Somewhat uncomfortable Neutral Comfortable Very comfortable After participating in this shadowing experience, please rate your satisfaction with the following: Extremely unsatisfied Unsatisfied Neutral Satisfied Extremely satisfied Extremely unsatisfied Unsatisfied Neutral Satisfied Extremely satisfied Extremely unsatisfied Unsatisfied Neutral Satisfied Extremely satisfied Yes No Any comments about the shadowing experience that you would like to share? _________________________ Table B1 Figure C1 Figure D1 Table E1