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Medical Students Explore Healthcare Delivery Improvement with Clinical Microsystems Clerkship

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CMC cohort in radiology session

Radiology fellow William Kerridge, MD (seated), leads first-year medical students (l-r: Angela Mendoza, Marci Rosenberg, Nathan Kim, David Su) in a CMC ultrasound session with a standardized patient.
Photos: Megan O'Connor

By Marci Rosenberg, MSTP1

The medical students in UCSF’s entering class of 2016 had many reasons to be excited when school started back in August. Like the first-years that came before, these students were thrilled - and a bit anxious - to immerse themselves in the both revered and feared process of becoming a physician. But this particular class of medical students, of which I am a part, had the unique privilege of being the first group of learners to participate in the School of Medicine’s newest curriculum, Bridges.

The launch of Bridges, which came 15 years after the last revamping of the School of Medicine’s curriculum, was previously covered with much fanfare. Bridges represents a fairly dramatic shift in the way UCSF approaches medical education, with restructured coursework and brand-new curricular components. To me, one of the most striking and intriguing changes is the debut of the Clinical Microsystems Clerkship (CMC).

Coaching Over Time

The grand magic of CMC starts, paradoxically, with its smallness. The entire medical school class has been split into twenty-eight groups of 5-6 students, each with their own physician “coach.” The coaches wear many hats, serving as teachers, mentors, problem-solvers, and advisers to their students. Wonderfully, it seems that the benefits go both ways; the coaches were not reluctantly looped in, but are rather willing and eager participants. My coach is Stephanie Rennke, MD, associate clinical professor of medicine and site director of the CMC. “One of the most rewarding aspects of being a coach is the opportunity to mentor and watch the student's progress as part of a longitudinal experience. I really enjoy watching them gain skills and confidence,” says Rennke. “The students are making a direct impact on patient care and on the health system and they are able to see those changes in real time.”

Andrea Marmor, MD, a pediatrician and coach, shares: “I was thrilled when I saw the description of the coaching program, and realized that it was going to provide a longitudinal connection for students in all four years, combine teaching and advising in an unique role, connect the clinical setting with the classroom setting in a realistic way, and provide faculty time and training to do it justice. [Applying to be a coach] was a no-brainer for me.” The shared enthusiasm by Rennke and Marmor is heartening, as the coach’s relationship is one that is meant to last—students will be linked with their coach for the duration of their medical school years.

medical student performs ultrasound
Medical student David Su uses ultrasound on a standardized patient.

Moving from Standardized Patients to Clinical Site

Once a week during Foundations 1, the first one-and-a-half years of medical school, each CMC group meets for a full day. In one half-day, students and coaches engage in structured learning around the art of doctoring, developing skills in such areas as effective communication, medical note writing and physical examination techniques. One of my favorite parts of these sessions is interacting with standardized patients. Standardized patients (or SPs, as we so fondly call them) are acting professionals who present clinical scenarios as patients with great skill. Although the SPs are, in reality, healthy, they do an impressive job of portraying an illness with authenticity as we take a history and do a physical exam on them. At the end of an SP encounter, the SP and the student debrief, each discussing what went well, and what could be improved. My SPs have provided me with insightful feedback; for example, one SP commented that when I need to pause and think, I should verbally let him know, instead of awkwardly looking away while I gather my thoughts.

Students spend their other half-day of CMC in the clinical site in which their coach works (in Bridges-speak, this is the clinical microsystem). Clinical microsystem sites, which are located at UCSF Health facilities, Zuckerberg San Francisco General Hospital and the San Francisco Veterans Affairs Medical Center (SFVAMC), cover quite a range of care delivery environments, from inpatient adult medical units to outpatient pediatric subspecialty clinics. During their time on-site, students apply the techniques they’ve been studying during the structured learning portion of CMC, and, in a break with previous years’ curricula, work on health systems improvement projects.

These projects have taken on many different forms. My health systems improvement project, a collaboration with fellow first-year Beáta Ďurčanová, is looking into measures to help reduce the incidence of delirium in hospitalized patients. For my classmates Sophie Crinion and Camilo Bolds, health systems improvement work consists of collaborating with an interprofessional team at the SFVAMC on an initiative to increase mobility among hospitalized patients, called the Everybody Moves project. In describing her experience, Sophie explains, “As a runner, I know the importance of movement in my own life and I love encouraging people to move...it’s really great to be working on a project that impacts every patient regardless of their diagnosis.”

A sampling of my other classmates’ projects:

  • Developing a better understanding of the barriers that prevent physicians and patients from completing advanced care planning
  • Rigorously assessing the outcomes of post-procedure back pain patients with an eye towards creating a national database that provides recommended benchmarks for pain and quality of life measures
  • Generating tools to help providers consistently discuss HIV pre-exposure prophylaxis medication with all of their patients
  • Crafting multi-lingual tutorials to increase non-English-speaking patients’ access to UCSF’s electronic patient portal

These projects are a key defining feature of CMC. By offering formalized education around health systems improvement work, UCSF is showing its commitment to broadening the view of medical students regarding the factors that affect a patient’s healthcare experience. Through CMC and my Foundational Science courses, I have learned about concepts such as how to diagnose an illness or why a person may develop a particular illness. CMC has also provided me with resources surrounding when (and how) to request help from my interprofessional team members (e.g., nurses, physical therapists, social workers), how to rigorously design and test a needed quality improvement measure, and why even seemingly simple improvements to a healthcare system might fail. For me, all of this learning has been a powerful lesson that physicians are not the be-all and end-all of a person’s medical care. I will eventually work in a system, with other professionals, using the best practices that my organization has set, and it behooves me to always remember that what I do is but one of very many components that influence how my patients will remember their healthcare experiences.

CMC group
Marci Rosenberg (far left) with her CMC group coach Stephanie Rennke, MD, and fellow students Nathan Kim, David Su, Beáta Ďurčanová, Megan Winkelman and Angela Mendoza (l-r)

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For a broader glimpse of first-year medical student life, check out Crossing Bridges, a Synapse column in which five of my classmates have been thoughtfully reflecting on their experience in Bridges.