The Action Research Program: Experiential Learning in Systems-Based Practice for First-Year Medical Students

ABSTRACT

Problem: Systems-based practice focuses on the organization, financing, and delivery of medical services. The American Association of Medical Colleges has recommended that systems-based practice be incorporated into medical schools’ curricula. However, experiential learning in systems-based practice, including practical strategies to improve the quality and efficiency of clinical care, is often absent from or inconsistently included in medical education. Intervention: A multidisciplinary clinician and nonclinician faculty team partnered with a cardiology outpatient clinic to design a 9-month clerkship for 1st-year medical students focused on systems-based practice, delivery of clinical care, and strategies to improve the quality and efficiency of clinical operations. The clerkship was called the Action Research Program. In 2013–2014, 8 trainees participated in educational seminars, research activities, and 9-week clinic rotations. A qualitative process and outcome evaluation drew on interviews with students, clinic staff, and supervising physicians, as well as students’ detailed field notes. Context: The Action Research Program was developed and implemented at the University of California, San Francisco, an academic medical center in the United States. All educational activities took place at the university's medical school and at the medical center's cardiology outpatient clinic. Outcome: Students reported and demonstrated increased understanding of how care delivery systems work, improved clinical skills, growing confidence in interactions with patients, and appreciation for patients’ experiences. Clinicians reported increased efficiency at the clinic level and improved performance and job satisfaction among medical assistants as a result of their unprecedented mentoring role with students. Some clinicians felt burdened when students shadowed them and asked questions during interactions with patients. Most student-led improvement projects were not fully implemented. Lessons Learned: The Action Research Program is a small pilot project that demonstrates an innovative pairing of experiential and didactic training in systems-based practice. Lessons learned include the need for dedicated time and faculty support for students’ improvement projects, which were the least successful aspect of the program. We recommend that future projects aiming to combine clinical training and quality improvement projects designate distinct blocks of time for trainees to pursue each of these activities independently. In 2014–2015, the University of California, San Francisco School of Medicine incorporated key features of the Action Research Program into the standard curriculum, with plans to build upon this foundation in future curricular innovations.

KEYWORDS:

• systems-based practice
• clinical education
• implementation science
• quality improvement

Acknowledgments

We express gratitude to the patients with whom ARP students interacted and to the cardiology clinic staff and faculty who generously gave of their time and expertise, in particular Rajni Rao and Brenda Mar. We also thank Holly Nishimura for her help with data collection. Finally, we are grateful for the thoughtful suggestions made by this journal's editors and three anonymous reviewers, which resulted in substantial improvements to the article.

Funding

Research reported in this publication was supported by UCSF's Center for Healthcare Value and the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH) under Award Number KL2TR000143. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

Notes

* According to the U.S. ACGME, competency in systems-based practice, “Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.”⁴