Innovation Report
Is a Career in Medicine the Right Choice? The Impact of a Physician Shadowing Program on Undergraduate Premedical Students Jennifer Y. Wang, Hillary Lin, Patricia Y. Lewis, MA, David M. Fetterman, PhD, and Neil Gesundheit, MD, MPH
Abstract Problem Undergraduate (i.e., baccalaureate) premedical students have limited exposure to clinical practice before applying to medical school—a shortcoming, given the personal and financial resources required to complete medical training. Approach The Stanford Immersion in Medicine Series (SIMS) is a program that streamlines the completion of regulatory requirements for premedical students and allows them to develop one-onone mentor–mentee relationships with practicing physicians. The program, offered quarterly since 2007, is an elective available for Stanford University sophomores, juniors, and seniors.
Problem
Exposure of college (i.e., baccalaureate) students to clinical practice is often minimal, which may make it difficult for them to make an informed decision about pursuing medicine as a career.1,2 This limited exposure constitutes a shortcoming of premedical education, especially given the large personal and financial commitment required to complete medical education and training.3 The need for clinical role modeling may be particularly important for students from nonmedical families and/or students with economically disadvantaged backgrounds.4 Please see the end of this article for information about the authors. The authors have informed the journal that they agree that Jennifer Y. Wang and Hillary Lin completed the intellectual and other work associated with the first author. Correspondence should be addressed to Neil Gesundheit, Stanford School of Medicine, Educational Programs and Services, 1265 Welch Rd., MSOB x321, Stanford, CA 94305-5404; telephone: (650) 724-5454; e-mail: [email protected]. Acad Med. 2015;90:629–633. First published online January 6, 2015 doi: 10.1097/ACM.0000000000000615
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Participants apply to the program and, if accepted, receive patient rights and professionalism training. Students shadow the physician they are paired with at least four times and submit a reflective essay about their experience. SIMS program coordinators administered surveys before and after shadowing to assess changes in students’ perceptions and understanding of medical careers. Outcomes The authors observed, in the 61 Stanford premedical students who participated in SIMS between March and June 2010 and completed both pre- and postprogram questionnaires, significant increases in familiarity with physician responsibilities
Some students’ understanding of a physician’s role in health care may be based on the perspective gained from being a patient or from watching highly romanticized television shows, such as Grey’s Anatomy, House, or ER. Through shadowing, premedical students have the opportunity to learn about a physician’s daily responsibilities and challenges, as well as the nature of physician–patient interactions.2 Many students also develop meaningful relationships with their physician mentors, who provide valuable guidance in navigating the challenges of a medical career.5 However, physician shadowing opportunities can be difficult to secure because, in part, identifying a physician in the community willing to host a student can be challenging.6 Furthermore, the growing regulatory environment surrounding patient privacy and information security creates another barrier for premedical students who may not be permitted to shadow in hospitals and clinics without first overcoming legal restrictions.
and in understanding physician–patient interactions. The authors detected no significant changes in student commitment to pursuing medicine. Student perceptions of the value of shadowing—high both pre- and post shadowing—did not change. Next Steps Physician shadowing by premedical baccalaureate students appears to promote an understanding of physician roles and workplace challenges. Future studies should identify the ideal timing, format, and duration of shadowing to optimize the experience and allow students to make informed decisions about whether to pursue a medical career.
In their recent review, Kitsis and Goldsammler7 reported a scarcity of data about physician shadowing programs. Most of the programs they identified were outside of the United States, and of the four U.S. programs they included, only two were at the college student level. The authors also noted the organizational variability among programs, which leaves them especially vulnerable to the same problems affecting other physician shadowing experiences (e.g., maintaining patient confidentiality, enforcing infection control standards, defining the role/duties of the student).7 Herein, we describe a model for a formal undergraduate physician shadowing program that addresses these shortcomings and has been successfully implemented at Stanford University. The Stanford Immersion in Medicine Series (SIMS) offers physician shadowing within the structure of an academic course and delineates standards for patient privacy, infection control, and professionalism. In addition, we describe how we have evaluated the SIMS shadowing program in an effort to understand whether it
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promotes participants’ understanding of the role of the physician and whether it influences participants’ decisions to pursue medicine as a profession. Approach
The SIMS program Stanford University has offered SIMS through the School of Medicine’s Department of Medicine each academic quarter (except for the summer quarter) since 2007. The Undergraduate Advising and Research Center administers the program in collaboration with three Stanford-affiliated sites: Stanford Healthcare, Lucille Packard Children’s Hospital, and the Veterans Affairs Palo Alto Health Care System (Figure 1). Stanford-affiliated physicians practicing at these sites are invited through e-mail to volunteer as mentors. Interested physicians upload basic information about their practices, including their weekly schedule, to an online database that displays each physician’s profile under an anonymous identification number. SIMS participants review this database to find a physician whose schedule and interests align with theirs, and they indicate their preferences to
SIMS students must attend a minimum of four shadowing sessions in a 10-week period, and they must submit a 250- to 500-word reflective essay at the end of the program. Shadowing sessions (the recommended length for each is a minimum of two hours) may consist of observing the physician in outpatient clinics, in the operating room, or during inpatient rounds; accompanying the physician to departmental grand rounds; or holding mentoring meetings outside of the clinical setting. Students who complete the requirements earn undergraduate course credit.
the program coordinators using the physician identification numbers. Stanford sophomores, juniors, and seniors are eligible to apply to SIMS. On the application, students provide shortanswer (paragraph-length) responses to prompts that explore their interest in SIMS as well as mock e-mail messages to physician mentors that demonstrate their professionalism. Applicants are accepted on the basis of their suitability for the program, seniority, and previous participation, plus the availability of physician mentors and other logistical factors. SIMS coordinators pair accepted students one-on-one with a physician mentor, based (as mentioned) on physician specialty preferences and schedule compatibility. Prior to shadowing, students attend an orientation covering professionalism, clinic etiquette, and Health Insurance Portability and Accountability Act regulations. Participating students obtain hospital clearance, complete code of conduct forms, and receive a hospital photo ID badge. Additionally, they must complete the immunizations and other health requirements of Stanford firstyear medical students.
Hospital administration
SIMS program coordinators
Evaluating the SIMS program SIMS coordinators presented a 15-question online survey to students via e-mail both before the shadowing experience began and again after it had ended. The findings presented below result from the questionnaires completed by students participating in SIMS from March to June of 2010. The 2010 survey included questions about student demographics, prior shadowing experiences, and other premedical experiences. Students also rated on a nine-point scale their
University administration
Program oversight and regulatory review
Physician recruitment • Stanford affiliation • Volunteer basis
Student application • Sophomores, juniors, and seniors eligible • Students paired with physician mentors based on availability
Student orientation • Academic course requirements • Compliance procedures • Basic HIPAA and professionalism training
Student compliance • Code of Conduct and HIPAA forms • Other hospital clearance forms • Immunizations • Photo ID badge
Physician shadowing • Minimum of 4 sessions • Each session at least 2 hours • Observation only
Course completion • Reflective essay • Annual physician mentor appreciation event
Figure 1 Summary of the Stanford Immersion in Medicine Series (SIMS) program model. The Stanford University process for developing and sustaining a physician shadowing program for undergraduate premedical students comprises several discrete steps, contained within the framework of an academic course: (1) physician recruitment, (2) student application and selection and subsequent pairing with physicians, (3) student orientation, (4) student compliance completion, (5) the actual physician shadowing experience, and (6) completion of the SIMS course, including the submission of a final reflective essay. These six steps are repeated each academic quarter. Administrative oversight and policy review are ongoing and require a collaborative effort between the SIMS program coordinators, university administration, and hospital administration. HIPAA signifies Health Insurance Portability and Accountability Act.
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agreement with statements concerning their attitudes about a medical career (Figure 2). The postshadowing survey was identical to the preshadowing one, except for the addition of a comments section in which students could report the best and worst parts of their shadowing experience. Surveys were deidentified and assigned anonymous, random numbers. We analyzed data either in aggregate or by matching pre–post survey numbers. We offered no incentives to students for completing the questionnaires. Our study was formally reviewed by Stanford’s institutional review board and was determined not to meet the federal definition of human research. Data analysis We categorized student ratings of the survey statements as follows: we considered a rating of 7, 8, or 9 to be agreement; a 4, 5, or 6, neither agreement nor disagreement; and a 1, 2, or 3, disagreement. Using the paired-proportion t test, we analyzed each statement’s ratings for statistically significant (P ≤ .05) changes in the
percentage of students in each agreement category from pre- to post shadowing. We excluded from analysis the responses of students who did not submit both pre- and postshadowing surveys (as determined by assigned anonymous numbers). Outcomes
Demographics Study participants consisted of all SIMS students participating in the March–June 2010 academic quarter who completed both the preshadowing and postshadowing surveys (Table 1). Of the 75 students who were enrolled at the beginning of the quarter and submitted preshadowing surveys, 61 (81%) remained enrolled and completed the postshadowing survey. Of the 14 students excluded from the study, the majority did not complete the course, and several did not provide postshadowing surveys. Student attitudes To determine whether shadowing through SIMS affected student attitudes
Familiarity with medicine
Preshadowing
toward a career in medicine, we analyzed student agreement with nine statements that addressed the students’ familiarity with the medical profession, their commitment to pursuing a career in medicine, and their perception of the utility of physician shadowing. Significant increases in student familiarity with medicine were detected (Figure 2, top third). Before the shadowing experience, 28 of the students (46%) agreed with the statement “I understand how physicians interact with patients in clinical settings,” whereas 52 (85%) agreed post shadowing (P < .01). Similarly, before participating in SIMS, only 20 of the students (33%) agreed with the statement “I am familiar with what a physician does to fulfill his/her responsibilities,” whereas 42 (69%) agreed post shadowing (P < .01). Finally, only 14 students (23%) agreed with the statement “I understand what a physician does in an academic environment” before the shadowing experience, whereas 28 (46%) agreed post shadowing (P < .05). These increases in familiarity occurred even for students who reported prior shadowing Postshadowing
I understand how physicians interact with patients in clinical settings.a I am familiar with what a physician does to fulfill his/her responsibilities.a I understand what a physician does in an academic environment.b
Commitment to pursuing a career in medicine I would like to be a clinical practitioner. I would enjoy performing the duties of a physician. I would like to be a medical researcher. I want to pursue a career in medicine.
Perceived utility of shadowing Shadowing is useful to determine if medicine is the right career for me. Shadowing is useful to determine which medical specialty is right for me. 0
10
20
30 40 50 60 70 Percent of students in agreement
80
90
100
Figure 2 Agreement of Stanford Immersion in Medicine Series participants with statements on a pre- (March 2010) and postshadowing (June 2010) questionnaire. Students in agreement with a statement gave it a score of 7, 8, or 9 on a nine-point scale. a P < .01; bP < .05.
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Table 1 The Demographics of Stanford Immersion in Medicine Series (SIMS) Participants Who Responded to a Questionnairea Respondent characteristics
No. (% of 61)
Gender Male
23 (38)
Female
38 (62)
Class year Sophomore
36 (59)
Junior
14 (23)
Senior
11 (18)
Major Natural sciences
35 (57)
Social sciences and humanities
20 (33)
Other
6 (10)
Ethnicityb East Asian, Southeast Asian, Asian American
17 (28)
White, Caucasian, European American
30 (49)
Underrepresented in Medicine (Black/African American, Hispanic, Native American, Pacific Islander)8
19 (31)
One or more physician parents Yes
15 (25)
No
46 (75)
Prior shadowing experience No prior shadowing experience
31 (51)
Prior non-SIMS shadowing experience
18 (29)
Prior SIMS shadowing experience
12 (20)
Time spent shadowing per student during study periodc ≤ 10 hours
18 (29)
11–20 hours
38 (62)
The study cohort consisted of the 61 students shadowing through SIMS in March–June 2010 who submitted both the preshadowing and postshadowing surveys. The mean age of the 61 students was 20.2 years (standard deviation: 0.92 years; range 19–22 years). b Percentages do not add up to 100% because students were allowed to select multiple ethnicities. c Percentages do not add up to 100% because of rounding. a
We observed no significant changes in student commitment to pursuing a medical career (Figure 2, middle). We detected modest nonstatistically significant increases in students’ reported desire to be clinical practitioners, anticipated enjoyment in performing the duties of a physician, and interest in being a medical researcher. There was no difference in students’ reported desire to pursue a career in medicine after shadowing compared with before; however, notably, 52 of the 61 students (85%) had already reported agreement with the statement “I want to pursue a career in medicine” before shadowing.
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After watching TV shows like ER and Medical Mystery Diagnosis, where things are highly dramatized, it was nice to see the real-life pace and approach that a medical professional takes in working with patients and carrying out surgery.
Other “best” experiences identified by students on the survey included the following: “getting to sit in on patient visits in the clinic,” “understanding how the physician reasons and comes to conclusions,” “being on rounds,” and “being in the [operating room].” For a few participants, the shadowing experience provided insight that a nonphysician role in health care might be more suitable. For example, one student commented: Throughout the quarter, I had been struggling to decide whether I wanted to pursue becoming a [physician assistant] or a physician. Ultimately, I decided to work towards a PA license. My shadowing experience showed me the roles of nurses, nurse practitioners, medical students, residents, fellows, and attending physicians in a teaching clinic, and I got to see that there are more options for medical careers than medical school.
5 (8)
≥ 21 hours
experience through SIMS or another venue (not shown).
reported were related to observing physician–patient interactions and becoming familiar with daily physician activities. To illustrate, one student commented,
Finally, we observed no differences in student agreement with statements describing their perceptions of the utility of shadowing; perceptions were high both pre- and post shadowing (Figure 2, bottom). Student narratives To gain insight into the features of shadowing that were most impactful, we asked students to identify on the postshadowing survey “the best [and worst] parts of the physician shadowing experience.” We analyzed students’ responses to these questions, as well as the assigned reflective essays they wrote about their shadowing experiences. The most common positive features of the shadowing experience that students
Likewise, another student wrote, “I saw this quarter some of the things that influenced me to decide as a sophomore that I didn’t think medicine was the right profession for me.” This same student also commented that “being reminded of this firsthand confirmed my doubts.” Another benefit of the SIMS program that students often identified was the opportunity to build a mentoring relationship with a physician. One student noted that she enjoyed “so much personal attention from a busy physician–scientist.” Many others appreciated the openness with which their physician mentor addressed questions about work–life balance or their kindness in alleviating anxieties about applying to medical school or being in a medical environment. Discussion
Our introduction of the SIMS program, which incorporates many of the general principles proposed by Kitsis and
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Innovation Report
Goldsammler,7 demonstrated that the implementation of a successful physician shadowing program is possible in a university setting by following a series of well-organized steps (Figure 1). Our experience has been that by investing two to three hours of time for training and administrative preparation, most students are able to begin shadowing their physician mentors within two to three weeks of the orientation session. The results of our evaluation of SIMS suggest that shadowing is valuable in providing greater insight into the roles and responsibilities that physicians assume. Interestingly, our results indicate little change in students’ desire to pursue a career in medicine after shadowing, possibly because most students entering our program had already committed to a career in medicine. Thus, the experience for many of our students was confirmatory rather than revelatory. For some students, however, the shadowing experience became a pivotal point in their career decision-making process. SIMS exposed them to the day-to-day realities of clinical practice that made medicine less appealing. Likewise, some SIMS participants gained exposure to other, alternative career paths within health care that were, for them, more attractive than medicine. By increasing student knowledge about the profession and by demystifying and deromanticizing the roles that physicians assume in medical practice, shadowing can help inform students’ decisions about pursuing—or not pursuing—a career in medicine. Further, the opportunity to develop mentor–mentee relationships with physicians was another notable outcome that our students reported valuing highly. As mentioned, these relationships could be particularly important for students from groups traditionally underrepresented in medicine, who may not have family members or other adult role models to advise them about a medical career.8 Next Steps
Future research may reveal whether such baccalaureate programs increase the likelihood that college students, especially those from groups often
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underrepresented in medicine, pursue medical education and eventually a career in medicine.
better inform their decision to pursue a career in medicine.
Our small sample from a single, private West Coast university may not accurately reflect the premedical student population at other institutions; thus, developing similar structured programs elsewhere will help determine the generalizability and potential benefit of formal baccalaureate physician shadowing programs. Furthermore, the apparently minimal impact of shadowing on career decision making that we observed may have been biased by our particular study cohort, composed of college sophomores, juniors, and seniors who may have already committed to applying to medical school. Given that over 80% of our group indicated an interest in pursuing a medical career before shadowing, students with more ambivalence toward a medical career may not have been well represented. A future study could assess whether undergraduate freshmen with less certain career goals would be more influenced by early exposures to the clinical setting through shadowing. It will also be important to identify the amount of shadowing that is needed to confer benefit in terms of increasing student familiarity with the medical profession. Finally, future research may also help define the ideal structure of a baccalaureate shadowing program— that is, which elements (observation, discussion, written reflection) are most beneficial.
Other disclosures: None reported.
Although SIMS has been successful at our institution, it is important to recognize that establishing and sustaining a physician shadowing program can be challenging. Physician mentor recruitment and program oversight to ensure regulatory compliance and student satisfaction are critical. Undergraduate institutions may vary in their hospital affiliations, risk management policies, or availability of administrative support, all of which may affect the feasibility of our model elsewhere. Nonetheless, we hope that the SIMS program serves as one example of a means for creating a formalized opportunity for premedical undergraduates to shadow physicians and
Funding/Support: None reported.
Ethical approval: The research contained herein has been reviewed by Stanford University’s institutional review board (IRB). The IRB determined that the study does not meet the federal definition of research. Ethical approval was waived for this study. Previous presentations: Data from this study were presented in abstract form at the meeting of the Western Group on Educational Affairs, Stanford, California, May 2011. J.Y. Wang is a senior medical student, Stanford School of Medicine, Stanford, California. H. Lin is a senior medical student, Stanford School of Medicine, Stanford, California. P.Y. Lewis is an undergraduate premedical adviser, Stanford University Office of Undergraduate Advising and Research, Stanford, California. D.M. Fetterman is professor of business, University of Charleston, Charleston, West Virginia, and professor of anthropology, San Jose State University, California, and president, Fetterman & Associates, San Jose, California. N. Gesundheit is professor of medicine and associate dean for student advising, Stanford School of Medicine, Stanford, California.
References 1 Kitsis EA. Shining a light on shadowing. JAMA. 2011;305:1029–1030. 2 Stoeckle JD, Ronan L, Ehrlich C, Roberts D. The uses of shadowing the doctor—and patient: On seeing and hearing their work of care. J Gen Intern Med. 1993;8:561–563. 3 Teitz CC. Shadowing physicians. JAMA. 2011;305:2414. 4 Freischlag JA. Shadowing physicians. JAMA. 2011;305:2415. 5 Straus SE, Johnson MO, Marquez C, Feldman MD. Characteristics of successful and failed mentoring relationships: A qualitative study across two academic health centers. Acad Med. 2013;88:82–89. 6 Davis JM, Anderson MC, Stankevitz KA, Manley AR. Providing premedical students with quality clinical and research experience: The Tobacco Science Scholars Program. WMJ. 2013;112:195–198. 7 Kitsis EA, Goldsammler M. Physician shadowing: A review of the literature and proposal for guidelines. Acad Med. 2013;88:102–110. 8 Merchant JL, Omary MB. Underrepresentation of underrepresented minorities in academic medicine: The need to enhance the pipeline and the pipe. Gastroenterology. 2010;138:19–26.e1–e3.
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Is a Career in Medicine the Right Choice? The Impact of a Physician Shadowing Program on Undergraduate Premedical Students Jennifer Y. Wang, Hillary Lin, Patricia Y. Lewis, MA, David M. Fetterman, PhD, and Neil Gesundheit, MD, MPH
Abstract Problem Undergraduate (i.e., baccalaureate) premedical students have limited exposure to clinical practice before applying to medical school—a shortcoming, given the personal and financial resources required to complete medical training. Approach The Stanford Immersion in Medicine Series (SIMS) is a program that streamlines the completion of regulatory requirements for premedical students and allows them to develop one-onone mentor–mentee relationships with practicing physicians. The program, offered quarterly since 2007, is an elective available for Stanford University sophomores, juniors, and seniors.
Problem
Exposure of college (i.e., baccalaureate) students to clinical practice is often minimal, which may make it difficult for them to make an informed decision about pursuing medicine as a career.1,2 This limited exposure constitutes a shortcoming of premedical education, especially given the large personal and financial commitment required to complete medical education and training.3 The need for clinical role modeling may be particularly important for students from nonmedical families and/or students with economically disadvantaged backgrounds.4 Please see the end of this article for information about the authors. The authors have informed the journal that they agree that Jennifer Y. Wang and Hillary Lin completed the intellectual and other work associated with the first author. Correspondence should be addressed to Neil Gesundheit, Stanford School of Medicine, Educational Programs and Services, 1265 Welch Rd., MSOB x321, Stanford, CA 94305-5404; telephone: (650) 724-5454; e-mail: [email protected]. Acad Med. 2015;90:629–633. First published online January 6, 2015 doi: 10.1097/ACM.0000000000000615
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Participants apply to the program and, if accepted, receive patient rights and professionalism training. Students shadow the physician they are paired with at least four times and submit a reflective essay about their experience. SIMS program coordinators administered surveys before and after shadowing to assess changes in students’ perceptions and understanding of medical careers. Outcomes The authors observed, in the 61 Stanford premedical students who participated in SIMS between March and June 2010 and completed both pre- and postprogram questionnaires, significant increases in familiarity with physician responsibilities
Some students’ understanding of a physician’s role in health care may be based on the perspective gained from being a patient or from watching highly romanticized television shows, such as Grey’s Anatomy, House, or ER. Through shadowing, premedical students have the opportunity to learn about a physician’s daily responsibilities and challenges, as well as the nature of physician–patient interactions.2 Many students also develop meaningful relationships with their physician mentors, who provide valuable guidance in navigating the challenges of a medical career.5 However, physician shadowing opportunities can be difficult to secure because, in part, identifying a physician in the community willing to host a student can be challenging.6 Furthermore, the growing regulatory environment surrounding patient privacy and information security creates another barrier for premedical students who may not be permitted to shadow in hospitals and clinics without first overcoming legal restrictions.
and in understanding physician–patient interactions. The authors detected no significant changes in student commitment to pursuing medicine. Student perceptions of the value of shadowing—high both pre- and post shadowing—did not change. Next Steps Physician shadowing by premedical baccalaureate students appears to promote an understanding of physician roles and workplace challenges. Future studies should identify the ideal timing, format, and duration of shadowing to optimize the experience and allow students to make informed decisions about whether to pursue a medical career.
In their recent review, Kitsis and Goldsammler7 reported a scarcity of data about physician shadowing programs. Most of the programs they identified were outside of the United States, and of the four U.S. programs they included, only two were at the college student level. The authors also noted the organizational variability among programs, which leaves them especially vulnerable to the same problems affecting other physician shadowing experiences (e.g., maintaining patient confidentiality, enforcing infection control standards, defining the role/duties of the student).7 Herein, we describe a model for a formal undergraduate physician shadowing program that addresses these shortcomings and has been successfully implemented at Stanford University. The Stanford Immersion in Medicine Series (SIMS) offers physician shadowing within the structure of an academic course and delineates standards for patient privacy, infection control, and professionalism. In addition, we describe how we have evaluated the SIMS shadowing program in an effort to understand whether it
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promotes participants’ understanding of the role of the physician and whether it influences participants’ decisions to pursue medicine as a profession. Approach
The SIMS program Stanford University has offered SIMS through the School of Medicine’s Department of Medicine each academic quarter (except for the summer quarter) since 2007. The Undergraduate Advising and Research Center administers the program in collaboration with three Stanford-affiliated sites: Stanford Healthcare, Lucille Packard Children’s Hospital, and the Veterans Affairs Palo Alto Health Care System (Figure 1). Stanford-affiliated physicians practicing at these sites are invited through e-mail to volunteer as mentors. Interested physicians upload basic information about their practices, including their weekly schedule, to an online database that displays each physician’s profile under an anonymous identification number. SIMS participants review this database to find a physician whose schedule and interests align with theirs, and they indicate their preferences to
SIMS students must attend a minimum of four shadowing sessions in a 10-week period, and they must submit a 250- to 500-word reflective essay at the end of the program. Shadowing sessions (the recommended length for each is a minimum of two hours) may consist of observing the physician in outpatient clinics, in the operating room, or during inpatient rounds; accompanying the physician to departmental grand rounds; or holding mentoring meetings outside of the clinical setting. Students who complete the requirements earn undergraduate course credit.
the program coordinators using the physician identification numbers. Stanford sophomores, juniors, and seniors are eligible to apply to SIMS. On the application, students provide shortanswer (paragraph-length) responses to prompts that explore their interest in SIMS as well as mock e-mail messages to physician mentors that demonstrate their professionalism. Applicants are accepted on the basis of their suitability for the program, seniority, and previous participation, plus the availability of physician mentors and other logistical factors. SIMS coordinators pair accepted students one-on-one with a physician mentor, based (as mentioned) on physician specialty preferences and schedule compatibility. Prior to shadowing, students attend an orientation covering professionalism, clinic etiquette, and Health Insurance Portability and Accountability Act regulations. Participating students obtain hospital clearance, complete code of conduct forms, and receive a hospital photo ID badge. Additionally, they must complete the immunizations and other health requirements of Stanford firstyear medical students.
Hospital administration
SIMS program coordinators
Evaluating the SIMS program SIMS coordinators presented a 15-question online survey to students via e-mail both before the shadowing experience began and again after it had ended. The findings presented below result from the questionnaires completed by students participating in SIMS from March to June of 2010. The 2010 survey included questions about student demographics, prior shadowing experiences, and other premedical experiences. Students also rated on a nine-point scale their
University administration
Program oversight and regulatory review
Physician recruitment • Stanford affiliation • Volunteer basis
Student application • Sophomores, juniors, and seniors eligible • Students paired with physician mentors based on availability
Student orientation • Academic course requirements • Compliance procedures • Basic HIPAA and professionalism training
Student compliance • Code of Conduct and HIPAA forms • Other hospital clearance forms • Immunizations • Photo ID badge
Physician shadowing • Minimum of 4 sessions • Each session at least 2 hours • Observation only
Course completion • Reflective essay • Annual physician mentor appreciation event
Figure 1 Summary of the Stanford Immersion in Medicine Series (SIMS) program model. The Stanford University process for developing and sustaining a physician shadowing program for undergraduate premedical students comprises several discrete steps, contained within the framework of an academic course: (1) physician recruitment, (2) student application and selection and subsequent pairing with physicians, (3) student orientation, (4) student compliance completion, (5) the actual physician shadowing experience, and (6) completion of the SIMS course, including the submission of a final reflective essay. These six steps are repeated each academic quarter. Administrative oversight and policy review are ongoing and require a collaborative effort between the SIMS program coordinators, university administration, and hospital administration. HIPAA signifies Health Insurance Portability and Accountability Act.
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agreement with statements concerning their attitudes about a medical career (Figure 2). The postshadowing survey was identical to the preshadowing one, except for the addition of a comments section in which students could report the best and worst parts of their shadowing experience. Surveys were deidentified and assigned anonymous, random numbers. We analyzed data either in aggregate or by matching pre–post survey numbers. We offered no incentives to students for completing the questionnaires. Our study was formally reviewed by Stanford’s institutional review board and was determined not to meet the federal definition of human research. Data analysis We categorized student ratings of the survey statements as follows: we considered a rating of 7, 8, or 9 to be agreement; a 4, 5, or 6, neither agreement nor disagreement; and a 1, 2, or 3, disagreement. Using the paired-proportion t test, we analyzed each statement’s ratings for statistically significant (P ≤ .05) changes in the
percentage of students in each agreement category from pre- to post shadowing. We excluded from analysis the responses of students who did not submit both pre- and postshadowing surveys (as determined by assigned anonymous numbers). Outcomes
Demographics Study participants consisted of all SIMS students participating in the March–June 2010 academic quarter who completed both the preshadowing and postshadowing surveys (Table 1). Of the 75 students who were enrolled at the beginning of the quarter and submitted preshadowing surveys, 61 (81%) remained enrolled and completed the postshadowing survey. Of the 14 students excluded from the study, the majority did not complete the course, and several did not provide postshadowing surveys. Student attitudes To determine whether shadowing through SIMS affected student attitudes
Familiarity with medicine
Preshadowing
toward a career in medicine, we analyzed student agreement with nine statements that addressed the students’ familiarity with the medical profession, their commitment to pursuing a career in medicine, and their perception of the utility of physician shadowing. Significant increases in student familiarity with medicine were detected (Figure 2, top third). Before the shadowing experience, 28 of the students (46%) agreed with the statement “I understand how physicians interact with patients in clinical settings,” whereas 52 (85%) agreed post shadowing (P < .01). Similarly, before participating in SIMS, only 20 of the students (33%) agreed with the statement “I am familiar with what a physician does to fulfill his/her responsibilities,” whereas 42 (69%) agreed post shadowing (P < .01). Finally, only 14 students (23%) agreed with the statement “I understand what a physician does in an academic environment” before the shadowing experience, whereas 28 (46%) agreed post shadowing (P < .05). These increases in familiarity occurred even for students who reported prior shadowing Postshadowing
I understand how physicians interact with patients in clinical settings.a I am familiar with what a physician does to fulfill his/her responsibilities.a I understand what a physician does in an academic environment.b
Commitment to pursuing a career in medicine I would like to be a clinical practitioner. I would enjoy performing the duties of a physician. I would like to be a medical researcher. I want to pursue a career in medicine.
Perceived utility of shadowing Shadowing is useful to determine if medicine is the right career for me. Shadowing is useful to determine which medical specialty is right for me. 0
10
20
30 40 50 60 70 Percent of students in agreement
80
90
100
Figure 2 Agreement of Stanford Immersion in Medicine Series participants with statements on a pre- (March 2010) and postshadowing (June 2010) questionnaire. Students in agreement with a statement gave it a score of 7, 8, or 9 on a nine-point scale. a P < .01; bP < .05.
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Table 1 The Demographics of Stanford Immersion in Medicine Series (SIMS) Participants Who Responded to a Questionnairea Respondent characteristics
No. (% of 61)
Gender Male
23 (38)
Female
38 (62)
Class year Sophomore
36 (59)
Junior
14 (23)
Senior
11 (18)
Major Natural sciences
35 (57)
Social sciences and humanities
20 (33)
Other
6 (10)
Ethnicityb East Asian, Southeast Asian, Asian American
17 (28)
White, Caucasian, European American
30 (49)
Underrepresented in Medicine (Black/African American, Hispanic, Native American, Pacific Islander)8
19 (31)
One or more physician parents Yes
15 (25)
No
46 (75)
Prior shadowing experience No prior shadowing experience
31 (51)
Prior non-SIMS shadowing experience
18 (29)
Prior SIMS shadowing experience
12 (20)
Time spent shadowing per student during study periodc ≤ 10 hours
18 (29)
11–20 hours
38 (62)
The study cohort consisted of the 61 students shadowing through SIMS in March–June 2010 who submitted both the preshadowing and postshadowing surveys. The mean age of the 61 students was 20.2 years (standard deviation: 0.92 years; range 19–22 years). b Percentages do not add up to 100% because students were allowed to select multiple ethnicities. c Percentages do not add up to 100% because of rounding. a
We observed no significant changes in student commitment to pursuing a medical career (Figure 2, middle). We detected modest nonstatistically significant increases in students’ reported desire to be clinical practitioners, anticipated enjoyment in performing the duties of a physician, and interest in being a medical researcher. There was no difference in students’ reported desire to pursue a career in medicine after shadowing compared with before; however, notably, 52 of the 61 students (85%) had already reported agreement with the statement “I want to pursue a career in medicine” before shadowing.
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After watching TV shows like ER and Medical Mystery Diagnosis, where things are highly dramatized, it was nice to see the real-life pace and approach that a medical professional takes in working with patients and carrying out surgery.
Other “best” experiences identified by students on the survey included the following: “getting to sit in on patient visits in the clinic,” “understanding how the physician reasons and comes to conclusions,” “being on rounds,” and “being in the [operating room].” For a few participants, the shadowing experience provided insight that a nonphysician role in health care might be more suitable. For example, one student commented: Throughout the quarter, I had been struggling to decide whether I wanted to pursue becoming a [physician assistant] or a physician. Ultimately, I decided to work towards a PA license. My shadowing experience showed me the roles of nurses, nurse practitioners, medical students, residents, fellows, and attending physicians in a teaching clinic, and I got to see that there are more options for medical careers than medical school.
5 (8)
≥ 21 hours
experience through SIMS or another venue (not shown).
reported were related to observing physician–patient interactions and becoming familiar with daily physician activities. To illustrate, one student commented,
Finally, we observed no differences in student agreement with statements describing their perceptions of the utility of shadowing; perceptions were high both pre- and post shadowing (Figure 2, bottom). Student narratives To gain insight into the features of shadowing that were most impactful, we asked students to identify on the postshadowing survey “the best [and worst] parts of the physician shadowing experience.” We analyzed students’ responses to these questions, as well as the assigned reflective essays they wrote about their shadowing experiences. The most common positive features of the shadowing experience that students
Likewise, another student wrote, “I saw this quarter some of the things that influenced me to decide as a sophomore that I didn’t think medicine was the right profession for me.” This same student also commented that “being reminded of this firsthand confirmed my doubts.” Another benefit of the SIMS program that students often identified was the opportunity to build a mentoring relationship with a physician. One student noted that she enjoyed “so much personal attention from a busy physician–scientist.” Many others appreciated the openness with which their physician mentor addressed questions about work–life balance or their kindness in alleviating anxieties about applying to medical school or being in a medical environment. Discussion
Our introduction of the SIMS program, which incorporates many of the general principles proposed by Kitsis and
Academic Medicine, Vol. 90, No. 5 / May 2015
Innovation Report
Goldsammler,7 demonstrated that the implementation of a successful physician shadowing program is possible in a university setting by following a series of well-organized steps (Figure 1). Our experience has been that by investing two to three hours of time for training and administrative preparation, most students are able to begin shadowing their physician mentors within two to three weeks of the orientation session. The results of our evaluation of SIMS suggest that shadowing is valuable in providing greater insight into the roles and responsibilities that physicians assume. Interestingly, our results indicate little change in students’ desire to pursue a career in medicine after shadowing, possibly because most students entering our program had already committed to a career in medicine. Thus, the experience for many of our students was confirmatory rather than revelatory. For some students, however, the shadowing experience became a pivotal point in their career decision-making process. SIMS exposed them to the day-to-day realities of clinical practice that made medicine less appealing. Likewise, some SIMS participants gained exposure to other, alternative career paths within health care that were, for them, more attractive than medicine. By increasing student knowledge about the profession and by demystifying and deromanticizing the roles that physicians assume in medical practice, shadowing can help inform students’ decisions about pursuing—or not pursuing—a career in medicine. Further, the opportunity to develop mentor–mentee relationships with physicians was another notable outcome that our students reported valuing highly. As mentioned, these relationships could be particularly important for students from groups traditionally underrepresented in medicine, who may not have family members or other adult role models to advise them about a medical career.8 Next Steps
Future research may reveal whether such baccalaureate programs increase the likelihood that college students, especially those from groups often
Academic Medicine, Vol. 90, No. 5 / May 2015
underrepresented in medicine, pursue medical education and eventually a career in medicine.
better inform their decision to pursue a career in medicine.
Our small sample from a single, private West Coast university may not accurately reflect the premedical student population at other institutions; thus, developing similar structured programs elsewhere will help determine the generalizability and potential benefit of formal baccalaureate physician shadowing programs. Furthermore, the apparently minimal impact of shadowing on career decision making that we observed may have been biased by our particular study cohort, composed of college sophomores, juniors, and seniors who may have already committed to applying to medical school. Given that over 80% of our group indicated an interest in pursuing a medical career before shadowing, students with more ambivalence toward a medical career may not have been well represented. A future study could assess whether undergraduate freshmen with less certain career goals would be more influenced by early exposures to the clinical setting through shadowing. It will also be important to identify the amount of shadowing that is needed to confer benefit in terms of increasing student familiarity with the medical profession. Finally, future research may also help define the ideal structure of a baccalaureate shadowing program— that is, which elements (observation, discussion, written reflection) are most beneficial.
Other disclosures: None reported.
Although SIMS has been successful at our institution, it is important to recognize that establishing and sustaining a physician shadowing program can be challenging. Physician mentor recruitment and program oversight to ensure regulatory compliance and student satisfaction are critical. Undergraduate institutions may vary in their hospital affiliations, risk management policies, or availability of administrative support, all of which may affect the feasibility of our model elsewhere. Nonetheless, we hope that the SIMS program serves as one example of a means for creating a formalized opportunity for premedical undergraduates to shadow physicians and
Funding/Support: None reported.
Ethical approval: The research contained herein has been reviewed by Stanford University’s institutional review board (IRB). The IRB determined that the study does not meet the federal definition of research. Ethical approval was waived for this study. Previous presentations: Data from this study were presented in abstract form at the meeting of the Western Group on Educational Affairs, Stanford, California, May 2011. J.Y. Wang is a senior medical student, Stanford School of Medicine, Stanford, California. H. Lin is a senior medical student, Stanford School of Medicine, Stanford, California. P.Y. Lewis is an undergraduate premedical adviser, Stanford University Office of Undergraduate Advising and Research, Stanford, California. D.M. Fetterman is professor of business, University of Charleston, Charleston, West Virginia, and professor of anthropology, San Jose State University, California, and president, Fetterman & Associates, San Jose, California. N. Gesundheit is professor of medicine and associate dean for student advising, Stanford School of Medicine, Stanford, California.
References 1 Kitsis EA. Shining a light on shadowing. JAMA. 2011;305:1029–1030. 2 Stoeckle JD, Ronan L, Ehrlich C, Roberts D. The uses of shadowing the doctor—and patient: On seeing and hearing their work of care. J Gen Intern Med. 1993;8:561–563. 3 Teitz CC. Shadowing physicians. JAMA. 2011;305:2414. 4 Freischlag JA. Shadowing physicians. JAMA. 2011;305:2415. 5 Straus SE, Johnson MO, Marquez C, Feldman MD. Characteristics of successful and failed mentoring relationships: A qualitative study across two academic health centers. Acad Med. 2013;88:82–89. 6 Davis JM, Anderson MC, Stankevitz KA, Manley AR. Providing premedical students with quality clinical and research experience: The Tobacco Science Scholars Program. WMJ. 2013;112:195–198. 7 Kitsis EA, Goldsammler M. Physician shadowing: A review of the literature and proposal for guidelines. Acad Med. 2013;88:102–110. 8 Merchant JL, Omary MB. Underrepresentation of underrepresented minorities in academic medicine: The need to enhance the pipeline and the pipe. Gastroenterology. 2010;138:19–26.e1–e3.
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