Doctoring Undercover: updating the educational tradition of shadowing

Figures & data

Table 1. Scaffolding of Doctoring Undercover and Introduction to Clinical Medicine (ICM) courses.

	Doctoring Undercover	Introduction to Clinical Medicine (ICM)
Course Organization
Student Population	Pre-medical students (sophomores, juniors, and seniors)	First-year undergraduate medical students
Class Size and Format	~ 20 students; seminar style	~ 135 students, divided into small seminar sections of ~ 9 students each
Instructor	Single instructor	Two preceptors for each seminar group (one behavioral science faculty member and one clinical faculty member)
Meeting Times	Two meetings per week; 90 minutes each	1–2 meetings per week; 60–120 minutes each
Duration	One semester	1 year
Clinical Experience Requirement	3–4 shadowing visits to a Selective Clinical Experience site (different sites for students); two introductory observational/interview activities at adjacent health sites (same sites for entire class)	Three visits to a Selective Clinical Experience site; four Longitudinal Clinical Experience visits with a single physician in practice; one visit to the Salvation Army Student Clinic; one patient narrative interview
Behavioral Science Topics Biopsychosocial factors that influence the patient/physician relationship related to:
Stress and Wellness	Covered	Covered
Patient Education	Covered	Covered
Pain and Placebos	Not covered	Covered
Grief and Loss	Covered	Covered
Nutrition and Obesity	Not Covered	Covered
Addiction	Covered	Covered
Health Disparities	Covered	Covered
Clinical Ethics	Covered	Covered
Communication Objectives
Role modeling	Observe physician/healthcare role models, with a focus on analyzing communication skills in a healthcare environment with real patients.	Observe and interact with physician/healthcare role models, with a focus on practicing and observing communication skills in a healthcare environment with real patients.
Collaboration	Collaborate with students, faculty, and practitioners from other disciplines to identify and analyze the components of safe and effective patient care.	Collaborate with students, faculty, and practitioners from other disciplines to deliver safe and effective patient care.
Interviewing Skills	Analyze interviewing skills in relation to one or more of the following: taking a sexual history, delivering bad news to a patient, assessing for depression/suicidality, and utilizing behavior change/motivational interviewing strategies.	Demonstrate advanced interviewing skills by taking a sexual history, delivering bad news to a patient, assessing for depression/suicidality, and utilizing behavior change/motivational interviewing strategies.
Reflective Writing Exercises
Format	Blog posts (~750 words each); course begins with instructor-provided prompts and transitions to student generated prompts as students progress	Portfolio assignments; format varies depending on assignment
Frequency	Weekly (mandatory)	Approximately weekly (students can elect to complete additional portfolio assignments to earn a higher grade)
Assessment	Graded with a rubric; 1–2 paragraphs of individualized analytical and editorial feedback from instructor on each post	Graded for completion; Amount of narrative feedback at preceptor discretion
Dissemination and Recognition	All students select two posts for revision and open access publication on course website	Outstanding reflective writing by one or two students is recognized with the ICM Portfolio Award presented annually at convocation

Table 2. Instructor-provided and student-generated observational activities for Doctoring Undercover (as of Spring 2016)^a.

Instructor-Provided Activities

Interview a patient’s family member in the hospital cafeteria

Take the bus to a health appointment. Reflect on transportation as a determinant of health

Map and analyze the waiting area at your shadowing site

Analyze health literature (e.g., posters, pamphlets) at your shadowing site

Observe an interaction between a patient and provider. Quantify one aspect of the interaction (e.g., number of interruptions, questions, physical touch)

Student-Generated Activities

Navigate the hospital in search of target locations. Observe the architecture and design elements of hospital locations.

Shadow a nurse. Analyze nurse-physician interactions and patient interactions with both professionals.

Shadow at the hospital information station. Observe the different patient populations. Observe the interaction between patients and the medical environment from a non-medical perspective.

Observe interactions between patients’ families and hospital employees that do not provide healthcare (e.g., cafeteria and security workers). Analyze how non-healthcare professionals contribute to the hospital’s ‘positive practice environment’ (PPE).

Explore the process behind scheduling a doctor’s appointment from the point of view of the receptionist, the patient, and the doctor.

Observe how the level of formality in professional dress differs across different health fields and medical specialties. Analyze how the formality of practitioners’ clothing affects patient-provider interaction.

Shadow a chaplain or other spiritual leader. Observe the interactions between the chaplain and a patient or patient’s family member.

Observe a physician breaking bad news to a patient and his or her family member. (This bad news doesn’t have to be a fatal diagnosis; it could be as small as an unpaid bill or a diagnosis of the flu.)

Examine an interprofessional interaction between a doctor, nurse, resident, fellow, or office staff member. Pay attention to facial expressions, body language, tone of voice, and length of conversation.

Navigate and experience a health environment with a visual impairment. Simulate a visual impairment, navigate through the healthcare setting of your choice and take note of the infrastructure, accessibility, and resources available.

^aThe web-based shadowing activity guide will be regularly updated based on new student contributions and community feedback.

The most recent version of the guide, including complete activity descriptions and directions, recommended readings, and prompts for reflective writing, can be accessed at http://www.shadowing.healthcare/guide/

Table 3. Thematic analysis of qualitative course feedback.

What did you learn from the course?
Transformative learning experience	Before the course	Sample quotes	After the course	Sample quotes
1) New perspectives regarding medical science disciplines and allied health fields	Medicine is a hard science	‘I hadn’t given much thought to the ’social‘ side of medicine. As a pre-med student, most of my classes can get a bit ''stuck'' in the hard sciences (chemistry, bio-physics) and, frequently, seem a bit monotonous and dull.’	Medicine is also a social science	‘This course was some new fresh activity every week. It was a great escape, weekly, from the typical pre-med iron-clad schedule, and I learned more about the ''people'' side of medicine (and myself).’
	Medicine is a specialized practice	‘Many aspects of medicine were not apparent.’	Medicine is a multi-disciplinary enterprise	‘The class used us to get deeply involved with shadowing sites that were non-traditional. From these sites, we got to see low SES [patient populations], or spirituality’s role in health, or drug abuse management. All these critical sites help develop our perspective of medicine.’
2) New techniques for improving the patient-provider relationship	Focus on acquisition of academic knowledge	‘I was excited to get my grades up and go to med school to learn how to do everything I’ll need to know to treat my patient.’	Awareness of the importance of the patient-provider relationship and familial context	‘There is more to being a doctor than I used to think. I want to have good doctor-patient relationships, and we talked how to improve this relationship. When we talked to a family member of a patient in the hospital it opened my eyes and reminded me to also pay attention to [patients’ families].’
	Focus on clinical procedures	‘When I used to shadow, the only aspect I paid attention to was the actual procedure.’	Focus on techniques for improving patient-provider communication	‘I feel as though I have learned many tips about what to do and what not to do by observing and will certainly remember how important good bedside manner and empathy are.’
3) Increased awareness of psychological, social and cultural aspects of medicine	Little or no exposure to social determinants of health	‘I had little to no actual knowledge on the social determinants of health and how these [affect medicine.]’	Awareness of the physician’s position in a larger system of social and policy determinants	‘By being educated on some different medical policy issues, I gained an awareness of my own stance on these issues.’
	Belief that access to medical care was the sole determinant of health.	‘Before the class, most of my ideas about the shortcomings of the healthcare system were based on the lack of access of many to healthcare.’	Awareness that healthcare access is only one determinant of health	‘I developed an understanding of the interplay between social conditions and healthcare treatment access. I will always remember [the activity in which we used] public transportation to attempt to get to an appointment on time or witnessing a caring nurse consistently support a man with severe Alzheimer’s. Knowledge of treatments and physiology is not enough. We must meet our population where they are. ’
4) Acquisition of strategies for personal reflection on medical practice	Shadowing is a passive activity	‘[I thought shadowing was] simply watching a professional and getting an idea of what a typical day is like.’	Shadowing is a form of active learning	‘[I learned that] you can also gain essential knowledge and experience to make you a successful doctor/nurse/etc. as long as you actively look for it. Shadowing is not supposed to be passive!’
	Limited experience with reflective writing	‘I have only written scientific papers. I had never written anything like a blog post before.’	Reflective writing leads to deeper personal understanding	‘I learned that writing about a topic is the best way to figure what I think about that topic. Writing personal blog post entries rather than formal essay pieces was honestly refreshing. I felt like I could truly write my thoughts in my own voice.’
What advice would you give to future students in the course?
Transformation in learning approach	Before the course	Sample quotes	After the course	Sample quotes
1) Be open-minded and go ‘out of your comfort zone’	Expectations about which shadowing sites would be most beneficial	‘I was disappointed with my shadowing site at first, but have had one of the most rewarding experiences to date!’	Student empowerment in shaping the learning experience	‘Have an open mind. You will get as much out of this course as you’re willing to put into it. Be creative. There is no opinion or idea that is wrong. Question yourself. Allow this class to help you grow.’
	Anxiety about asking questions or speaking in class	‘Don’t be afraid to ask questions or talk to people, whether patients, classmates, or doctors.’; ‘Don’t be like me and stress out about talking to the class.’	Understanding of the role of discomfort in the learning process	‘In this course especially you will gain as a direct result of what you invest. When participating in an activity, go out of your ’comfort zone‘ and your understanding of course content will become personally meaningful.’
2) Put effort into course reflections (field notes, blog posts, shadowing activities)	Skepticism about the value of student-directed course activities	‘At first I was very skeptical about writing blog posts and creating a website.’	Recognition of personal and professional value of student-directed activities	‘Put a lot of effort into the [blog posts and shadowing guide]. These activities have shed a lot of light on what my personality is as well as given me great experiences as I pursue a medical degree.’
	Belief that course activities other than direct shadowing experience were superfluous	‘Don’t rush through the [other parts] of the course because you are only interested in the hands-on shadowing. There is a great deal to be learned that will play a role in what you get out of your shadowing experiences.’	Belief that assignments facilitate lifelong professional identity formation	‘Taking really good field notes will help you in reflecting in years to come.’