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bf84ab9b24e1ee5737779dc8ee2123f6-huge-deMedical students across the country are calling for their institutions to provide leadership training. But once that training became a reality at Brown, these two med students learned that community leadership isn't as straightforward as it may seem. 

By Denise Marte and Matthew Perry

Our first week of classes at Brown Medical School was a whirlwind introduction to the social determinants of health. Before diving into the basic science curriculum, we gave our attention to systemic healthcare problems such as insurance gaps, spiraling costs, and health inequality. One lecture ended with a particularly memorable line, “Our healthcare system is a mess, but you all are going to fix it.” No pressure though.
Medical education doesn’t typically include leadership training sufficient to take on this mandate. But as the system has become more complex, medical schools have begun to implement important and necessary new strategies to equip students to tackle structural problems in the field. Here at Brown, the Primary Care-Population Medicine MD-ScM program and its Leadership in Healthcare course are two examples. We value these courses and the opportunity they provide to build an important skillset, but translating these skills into community work is complicated. As our faculty create these programs and students begin to complete the courses, we must stop and challenge the assumptions of what it means to learn leadership as students in a new place.
Our medical school employs an active learning model. That means that much of our learning is hands-on and takes place in a community setting. But are we mindful of the possible consequences of learning and practicing a lead-first mentality in those environments? Doctors have a specialized set of skills and knowledge which can be a powerful resource in any setting. But when we step out of the hospital, those skills may be more useful when they are guided by the expertise of those who live in the communities in which we are learning, working, and presumably leading. For that to be possible, we need to reconsider our default position as leaders. More generally, our leadership training should involve fostering accountable relationships in which we see ourselves as partners first.
If medical schools are to teach leadership, we must consider the context of that education. At Brown, as must be the case at many universities, many students are new to the area and unfamiliar with the values, needs, and challenges of the people living there. Yet healthcare leadership training encourages students to take the lead at the local level. While we are learning to study structural problems and propose interventions, are we sure that we’re identifying the issues our communities consider most important?
Leadership training in medical school teaches students to bridge medicine and social services with an eye toward preventive care. As such, the subjects and environments of student activities are broadening. For students at Brown, research themes range from food security and addiction intervention to healthcare in prisons. These themes often play out in work with vulnerable communities. But the power dynamics involved in such interactions are complicated. While in school, through academic guidance and mentoring, we are learning methods and best practices as we go. But this new work takes many of us outside of traditional healthcare settings, where we are often unsupervised. To uphold our ethical principles, we must ask ourselves if increased community involvement within the framework of leadership training requires new mechanisms of accountability.
For example, as we work on these projects, it is not always feasible for community members to give us feedback. As a result, measures to ensure we are doing no harm are limited. What happens if our projects are having unintended consequences in a community with no routes of access to our administration? Conversely, if student projects are having a positive impact, how do we lend them continuity after we graduate?
What we are learning through our coursework is that teaching leadership in med school is still uncharted territory. It’s a work-in-progress and, fortunately at Brown, a collaborative process with our faculty.
In partnership with student-led efforts, our administration is taking steps to create structures of accountability and continuity. As our Office of Diversity and Multicultural Affairs expands, community oversight is becoming part of its mandate. An upcoming community advisory board aims to bring together different voices from Rhode Island with various non-medical backgrounds. Our administration is considering how existing student projects, whether they involve leadership, community service, or both, can be incorporated into the curriculum for credit, lending those projects continuity and oversight.
One novel idea is the creation of ‘interest clusters,’ whereby before initiating our own projects, students join pre-existing groups that align them with relevant community organizations and services. Within these clusters, students can engage in clinical work, service-learning, or activism. This structure would ultimately help them understand the self-defined values, needs, and challenges of their population of interest before designing their research. They can lend their energy to continuing and improving existing efforts, with oversight from students who are further along in their training and from non-medical organizations. Still, it remains a challenge to foster these structures without burdening our community partners – a longstanding challenge of service-learning models.
Still, continuing to work toward creating best practices is important. If medical students forge into unknown communities with a lead-first mentality before we learn about the people we claim to lead, we will lose the trust of our patients before we even become doctors. It is vital for medical students and healthcare professionals to handle leadership with care. We must be intentional about when and how we see ourselves as leaders and be humble enough to take a backseat when appropriate.
Denise Marte is a third-year medical student at the Warren Alpert Medical School of Brown University. She is interested in primary care and emergency medicine. Born and raised in the Bronx, NY, she plans to return one day and join the leaders transforming New York City’s healthcare system.
Matthew Perry is a third-year medical student in the Primary Care-Population Medicine program at the Warren Alpert Medical School of Brown University. He hopes to practice in primary mental healthcare and to join in the work of dismantling structural barriers to health and well-being.

Read more about medical school leadership training. 
Posted by Sonya Collins on Jun 15, 2017 11:57 AM EDT
a489388c101eec3190f11689d135a820-huge-08At PCP, we are firm believers that students have a lot to offer when it comes to innovating and improving primary care delivery and training.  Our co-founding president speaks about this frequently, often citing the example of a student who used Google Docs to streamline patient flow at a clinic. When pre-med Avanthi Jayaweera heard this story, she couldn't wait to try out Google docs at the clinic where she was a volunteer. Here's what she wrote about the experience in this post from our archives.

By Avanthi Jayaweera

During my sophomore year of college as a pre-med, I volunteered at the front desk of a free clinic, where it was typical to see patients waiting sometimes for more than two hours. At first I figured it was just because some patients took longer to examine than others. It wasn’t until I got certified as a nurse’s aid and started working in the medical department at the same clinic that I found out what was really going on.

It wasn’t that the doctors were taking longer to examine some patients; it was that the  medical staff didn’t always know that they had a patient waiting in the first place.

Our clinic has a pharmacy, dental, mental health and medical department, three of which are managed by the front desk staff. When a medical patient signs in, the receptionist puts the patient’s chart in a bin to let the medical staff know that a patient has arrived. There is no bell, no blinking light, so a nurse would only know when a patient  checks in by peeking down the hall every so often to see if a chart is in the bin. The bin was often blocked by hall traffic, closet doors and even carts filled with prescriptions, so the staff wouldn’t see the chart until long after the patient had arrived. And when the front desk couldn’t find the patient’s chart to begin with, the medical staff again wouldn’t know till much later – if at all – that a patient was in the waiting room.

So it was possible that our department wouldn’t realize  that someone was patiently waiting to be seen until we cleaned up at the end of the day, after all the doctors had left, and happened to find the lone patient still waiting in the lobby. I felt terrible whenever this happened. They had been waiting for hours, and all we could do was offer to reschedule their appointment.

Ideally, medical staff would peek down the hall at regular intervals, see the chart in the bin, room the patient and put a colored clip on the door of the room. Each doctor had a color, so he or she would know if the room held a patient that was waiting for them. But even after the patient was roomed, it was still possible for doctors to miss their patients.

Once, a physician asked me and another staff member if she had any other patients to see. Since the volunteer nurse who triaged her patients wasn’t present at the moment, we told her that if she didn’t see any rooms marked with a red clip, she was done for the day. However, there was a cabinet next to one of the examination rooms that made it impossible to see the clip from where we were standing. Naturally, we found another patient waiting in that examination room at the end of the day. Again, all the physicians had already left. These kinds of situations  occurred so often that I frequently found myself brainstorming ways to check in, room and see our patients more efficiently. I actively monitored the bin to make sure patients were triaged as soon as they came in. I even organized and labeled documents in separate folders to make it easier for the volunteers to triage patients, but this still didn’t fix the core problem.

Finally a light bulb went off at the annual AMSA convention when I heard Dr. Andrew Morris-Singer mention using Google Docs to manage patients more efficiently. This system would be perfect to use at our clinic, I thought. At my next shift, I spoke to a director at the clinic to discuss how we could use a Google Doc to track patients and facilitate easier communication between the front desk and the medical department. The front desk staff would note in the doc that they had checked a patient in, and then the medical staff would see the update to the doc on their own computers at their station. No longer would it be necessary to crane their necks down the hall and squint to see a chart in the bin.

Once I got the okay, I began creating a table that would provide enough information to sign patients in and give the medical staff the entire responsibility of  managing the medical charts at all times. After using the Google Doc for just a couple of days, the entire clinic was so impressed. The front desk had no more charts to deal with and the nurses were able to track and manage each patient from the time they walked in to the time they left.  The physicians and other staff members also started using the Google Doc as a reference to determine where each patient was instead of searching for colored clips on doors.

After just one week, staff members were telling me how much the new system had improved patient management. And for the first time, patients were telling me "Wow, that was fast!" as I took them to their rooms. I’m relieved that I don’t have to apologize for long waits anymore. And I still can’t believe that as a volunteer, and an undergrad at that, I actually implemented a system that radically changed how our clinic runs, streamlined clinician work flow and improved patient experience.  Even though I may not be a physician yet, I can still take part in making a direct improvement in our healthcare system.  

Avanthi Jayaweera wrote this piece in 2013 as undergrad at Virginia Tech before she graduated with a dual degree in Biological Sciences and Spanish. 
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Posted by Sonya Collins on Jun 8, 2017 2:04 PM EDT
da474602de887d6e3a7251ba89d443d6-huge-chThis medical student was skeptical -- and a little embarrassed -- about learning mindfulness-based stress reduction (read: meditation), so he was surprised to realize that he had gained a valuable tool that he hopes other primary care providers will embrace. 

By Charles Ebersbacher

During the year that I took off from medical school to complete my MBA, I enrolled in a stress-reduction study. I’d become interested in preventive medicine but found the diet and exercise aspects of it easier to grasp than stress reduction. By participating in a study, I thought I might learn some stress-reducing techniques that could help some of my patients. I only had to commit to six hours of questionnaires and saliva testing to earn $70. And, if randomized to the mindfulness-based stress reduction arm, I might get to spend two hours a week for six weeks learning mindfulness-based stress reduction (MBSR). Fortunately, I did.
My first exposure to the concept of mindfulness was during medical school orientation. I’ve practiced sporadically since then – usually by lying on an osteopathic manipulative therapy table and listening to a guided mindfulness video on YouTube as a break from studying. Though to the untrained eye, it might have looked as if I was procrastinating or taking a nap.
I had heard of studies that showed a reduction in physician errors and improved pain management among those that practice MBSR. But even after my exposure to mindfulness, I still felt a little embarrassed about practicing it. Some students and physicians see mindfulness as alternative medicine and not “sexy” enough to study, so I didn’t want to be associated with it. I didn’t like to be seen at the weekly training provided as part of the study, and I don’t like using the phrase “meditation.” The only person whom I told that I was in the study was my girlfriend. I made sure not to be seen by anyone else as I headed there with my yoga mat. In order to avoid small talk and the chance of running into anyone, I showed up as close to the start time as possible – not very mindful.
But I got so much more from the study than a touchy-feely, new age way to manage stress. Although mindfulness may seem like a personal activity, I found the group setting instrumental for understanding some of its complexities. The class made me accountable for meditation, making me do it every day and discuss it every week with the group. Others shared the same difficulties I experienced, such as an active mind or the urge to move after lying still for 45 minutes, like we did in the first exercise of the course. I wanted to crawl out of my skin after lying still for so long. Fortunately, others shared this same experience giving me peace of mind and allowing me to further relax on future exercises.
Looking back, it’s interesting that I thought I could grasp the diet and exercise parts of preventive care but not the stress reduction. Mindfulness is like healthy diet and exercise in many ways. You don’t always want to eat right or exercise, but when you do it – just like when you practice mindfulness – you feel better. And just as you can’t expect results from one workout or one healthy meal, you cannot expect stress to disappear after one mindfulness meditation session. All three require practice and dedication to yield results. Also like diet and exercise, mindfulness practice is best enjoyed when practiced in a variety of ways. No one wants to do the same workout or eat the same healthy meal every day. Likewise, I don’t do the same meditation exercise every day. I didn’t realize this until deeper study, but there are numerous techniques. Those who embark on this journey, I think, will be pleasantly surprised by the results just as those who train for a 5k, half-marathon, or greater, and prove to themselves they can do it. 

Mindfulness might be particularly useful in primary care practices. While providers routinely discuss stress reduction with patients, now that I’ve experienced it, I’m not sure we understand what we are discussing. For example, stress reduction in a group setting may have a more significant impact than trying it alone, but I’m not sure primary care providers are recommending that. Clinicians who understand the tools for stress management, such as mindfulness, will be better equipped to help their patients.
What’s more, mindfulness can be a powerful tool for clinicians themselves. When I first learned about mindfulness, I saw it only as a potential technique for patients, but I see now that it will be just as beneficial to me personally. Mindfulness is not only about stress reduction but training your mind to focus on the present, the current patient, or even removing yourself from your patients and enjoying life outside of medicine. Through mindfulness, I learned how to accept what was going on in my head, categorize it, and make a mindful choice as to whether I wanted to address the thought now or later. A mindfulness routine could allow primary care providers to more efficiently process all the complaints, medications, and regulations each patient has. Increased efficiency may lead to improved patient interactions and ultimately improved care. As burnout in healthcare reaches epidemic levels, we could all benefit from a little mindfulness.

Charles Ebersbacher is a third-year student at Ohio University Heritage College of Osteopathic Medicine. He is interested in innovative patient care and lifestyle medicine.  

Want to read more about complementary and alternative medicine? 
Posted by Sonya Collins on Jun 1, 2017 1:46 PM EDT
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