Value-added Medical Education

Well first time for those of you who are good for the first time today this is our first Dean's forum and a couple of years since we've had our game so we're very excited to reinvigorate it we over the next two years our sessions will focus on health system science to give us all familiar because this is one of our games priorities integrated health system science into our medical school curriculum and to meet all the things that we do and we all know that it's not really fair if we try to convey a message to the medical students and residents that we ourselves are not very familiar with so we know and fully recognize that faculty develop so without further ado I will turn it over to Dean Lierman to introduce thank you dr. wicker so welcome back to those of you who had the pleasure of joining us for lunch today for a wonderful overview of the history of what is now become become known as Health System science as it's a pillar of medical education and to those of you who weren't with us for lunch today I will do the brief briefer version of dr. Gonzales embarrassingly long introduction from noon so he is currently an associate professor at Penn State College of Medicine where he is also the associate dean for health systems science education the brief version of this bio is that he went to University of Scranton graduating in 2002 in biology and philosophy got his MD from Penn State in 2006 completed his intro medicine residency freslin C or VI Deaconess Medical Center in Boston earning the sorts of awards and accolades along the way and then went on to do a fellowship at the University of Pittsburgh and general Pro medicine and medical education getting a Masters of Science degree in medical education and clinical research joined rejoining the folks at Penn State in 2012 where he was very rapidly through the ranks to his current positions fun fact in the last 24 months just 24 months probably 23 months to be honest how many publications has JIT head anyone want to get someone's club meting him right now you'll have five more so that's we're good with good data he's been a busy busy colleague twenty publications in twenty four months in journals such as academic medicine journal of general trauma medicine and others so we're very very grateful that he's given up his time to be with us for not one not two but three talks and the this session this afternoon will focus on a different aspect of this one that we think is really it's intriguing because it gives us a lot of creativity and how we imagine creating an experiential learning opportunity for students that may add value to the health system so very intriguing that instead of given and taketh away that it it helps both so we're very much looking forward to your session Jen thank you so thank you again for having me at an awesome day it means to lead people hospitality 1/3 away and for embarrassing me on that introduction I really appreciate that so I really want this to be about you about your school nights and my evaluator vote so we had a few questions at noon time trying to reverse that - so you're gonna I'm gonna be asking you questions so contribute I want it to be more about helping you my told the designers I have told cherry before like it would be if I left here and I didn't have any impact it's not influencing your work that would have been a disappointment for me so I really want to help you so you've got questions and I think the group's out of a meeting today I'm being very honest Sam getting on an airplane tomorrow I will tell you the skinny on the challenges that we have tomorrow sessions on the challenges but also the really interesting concept that I think has been around a little bit in the literature for 4050 years really as ready to be articulated in 2014 then you see a number of publications and now we're writing the textbook the textbook should be done so here's some of the objectives and will define value-added identified challenges seventy-eight examples and pre Clarkson and clerkship phases that's how I'm kind of breaking that up but again I want it to be about you how this can be you can develop your value-added role they just wait if that's task force submitted their report to the amendment on the beat and then there is value added volts and developing a new type of model for your medical students so that's the framing I want you to be thinking about that's what I wrote up here but keep it here in their mind value edit roles yours full of minutes and what are the opportunities what the opportunities you see is some work walking through some of this boy that's a nice idea I had about this clinic work in psychiatry diamond communi medicine or in the community and then we're going to go into the challenges some of me we're talking about concept but I want you to be thinking about opportunities and challenges have you comment on those negative something the way that everything teams think about how you can actualize this so here's your first stop point for our medical students an asset or a liability in the context of care deliveries I have liability in quotes because they don't be legal liability we want from the profits where we while I was but this a end to the brand spend extra time of going over various issues trying to explain some occasion or advance so like I thought they ended tell me more value added to the team much of the we're teaching that you wanted to provide to the students but also directed raises and elevates his academic lens on the whole process perfect that was up that's the main finding in a study of 99 about the value of medical suits other thoughts gotta go for asset can people they used to be more of an asset when they could do one and then we went to this pitayas than where they could do anything and we're starting to come out of it and like write notes that I don't have to we do the know I mean I supervise what they're doing and to check there behind them that's a that's a time you know comping a patient down that st. just because they felt that the liability comes in only when they really can't do any of that and that was purely slowly death I have to teach them what's your specialty become like GYN oncologist so could you just compare how long have you been a breakfast say ten fifteen years ago you're you compare and contrast a little bit about the value that students brought to see here two thousand two thousand five now how has it changed they did a lot more Batman I can't use their notes they were around so if they are around morons very aged I 20 gone around is my tribute to the hours call Paul must be more alcohol I know some of the educators here told me there's not a lot of call taking about medical students here there's a little bit but that's a trend in many it's a little bit to sort of get a taste to them but it doesn't give us the taste about that longitudinal presence on the team one of my colleagues who were preceptors and more in kind of a private typist mode they liability because some of the issues that he just talked about plus just the Tama factory based businesses please I have a student is going to be an office tomorrow consider EFI Dutch best the downside I would look at it because in a sense this is what I hear we'll pay you view is an accent that's told you have a student as an S I think it's it keeps you on your toes for the day to kind of study the patients that I'm seeing that they will more care to remain forever yours there's this access value keys around this milieu of academic discussion crap I got to be on my toes because the learners there versus the liability because it's going to slow me down our new generation that this process flow is not really great there you can feel the tension that's existing and a lot of people would say what to abuse em all right over your name it's a little fluffy that responses a little fluffy when it hits the bottom line I've got on our community educational delivery to way too I think we talk about how systems for example health systems and our medical students they're going to hopefully bring with them a different set of knowledge of perspectives that potentially their preceptor remain on our share value so we also have that bottom-up educational for summarizes patient care or to the academic session probably took both aspects of that mr. smart thinking we we I've said earlier I mean under appreciate and they would be sought-after prizes in the workforce here we bring him in stick them in a room for you stay sick one or my money and then we'll see shows we don't do that but partly we do it what's a piggyback on that students can often identify areas that are blind spots so when you're in agent care for years he cares to develop so her skirt was changed behavior change of chronic disease management why is it chanax not coming control diabetes is this person having so I planned them to be a great asset in primary care with providing the conversations that take longer and then had to do more with they can come up with some fans balance an asset a liability it depends which metric you look at or which outcome you look at the data would suggest this is work from Judy shadow pen knowing the general 986 a couple other studies that having a learner and clinical stage for half-day it adds 30 or 60 minutes to your day so from a health system perspective from an RV you generation perspective you probably do take a hit unless you're in a longitudinal relationship over time one of the main argument for allowing season-long purchase over time is that they're embedded in they become part of team a trust develops and year on month three four five and six and over time you're kind of more for good walking but this challenge of whether or not they're a better reliability most people would argue that medical students are a liability web analysis flow and general revenue generation standpoint you can disagree you disagree though I mean that's what most people would say and what the literature is really spotty it's not a lot out there but that's what spawned this definition of value out of mind conjugation experiential roles for students and practice environments that impact patient and population health outcomes costs or other processes they're also enhancing their learning I was even talking working your background I remember asked in the question of the group and there was no more winner a guy who was sitting on the ground research there absolutely fantastic and he went off for two minutes and how much we make an impact report phone his wife was sitting next to me she tapped him on the shoulder honey you do realize we map out your week and if you're what learners on Wednesday we will need dinner together exactly I make dinner for 9 p.m. 6 p.m. so within his mindset like this is part of my job and identity but his wife is the one thing if there is a as well give me a moment to take the stand this is a cost-benefit scorecard that we built that's in one of our papers how can medical students have value this is a couple years old at this point I think and it is potentially something for you to consider a new build your goals this is where you wrote the paper because we wanted oh so we're thinking about building the program's to think about how they can add out your comment about added value there there might be something in here our educational system that value that doesn't necessarily neither having value to rotation out that's in a different box so maybe you're a tactical patient outcome maybe you're impacting the educational environment or the health system maybe maybe the health system you you have I heard from your clinical chairs last hour that here's one your primary mission this community health improving the communities so there is a value for the medicals will be thinking about having learners in roles that are doing country for for the estate's amount of community and it brings this positive feel that the medical school is part of our community and trying to fulfill that mission and might not know about patient outcome doesn't necessarily move an educational piece but it might be wondering about a community's not sure there's all these couple of times today and curriculum development one wants anything here a minute you put something into a curriculum something has to move and come out so same thing with the value equation if you're gonna invest time here you're you're not invest in time and something else that needs to be thought through now they're bringing another value the concept that one high end care I mean I told my family if I ever get sick and I can't speak take me to a few but why what is the differentiator in our community of scholars because they challenged me because they thank you I tell people our plan is to teach you need to know what you're doing or you should know what to do you know so it's a higher level of understanding or morals more secure I hope that's right but there's not a lot of data to suggest that that's necessarily true I'm not sure how to do that study by the way but I agree with you in German so here's some of the work about how the learners can take on new roles to test I'll sort of they might have new versus old because I think is the first differentiator there's different ways to look at value-added rolls its current roles that already exist current preceptorship plates been said that evolve and take on new new tasks or it could be a totally new build in a brand new role that never existed old versus new so this is some of what medical educators and systems leaders came up with a couple years ago about how learners can add value could be in the direct patient care box are they really taking a robust history they're doing it for didactic purposes are they really doing it to add value to the care team maybe they in the other medicine consults really smart if we organize the structure of the curricular experience that they can add value by providing evidence-based how we do with our fortifications like this right now a lot of agencies that do we allow our learner to educate patients or to be advocates for our patients at this time a discharge and a primary care plan I mean do we really do that what do you think kind of interesting I think it probably depends on the institution but I think that one thing that is but some of it might be a sort of a cultural self-fulfilling prophecy but if we've if it's our familias that you know over time the students have gotten over that well mark lines and swords taken out of some of the station care then they potentially go in not either or not understanding or not feeling like they can contribute and then so they aren't it's uncomfortable and difficult to get in there exactly and so they might be united in their sort of marginalizing themselves and that sort of continues especially like you said that they're not integrated into the team they're not a trusted team member or very own identity and they're only with the service for a week or so they'd hardly be able to get in there and leave Bildad but I think that if we had set tact and you remember in medical school the students key they convicted me more baby chuckling Paige talk to the new mom about some frequently asked question you felt really proud of being able to do that they're setting all the sudden for the of all the rules it's how we structured the experiences that I think many people would argue that were falling a bit short we can structure them in the certain ways to enhance that value add and independent language for the setting a box for the terror center they don't meet our new goals that's where the patient navigator program comes in which I'll comment on second Penn State we've pilot in all these these are programs that are going on at least thirty forty med schools are piloting to some degree this metal box at the Carrick centers I'll highlight the say pianist this is a role that we gave students that we've embedded in emergency department we taught them the act of illogical observe leave your assumptions at the door go into a clinical space observe and take your time immerse yourself into it and identify what gaps you see for my patient care identify gaps and they come up with themes on patient experience we emergency they come up with five things on whack care is failing in the emergency room and they're drawing pictures of there's a big tornado outside it's really quiet in here and they identify what it is and we submit it for one of the national conferences and I walk up to the poster and we have it up all the results here there's a poster here from a West Coast health system will hire ethnographers a $250,000 and those Veritaserum with that kind of documentation screen and they will say on darn results are smart and if you think they didn't learn by going to artists really see the patients experience from that state from analyst or an ethnography we argued a just right there learning by immersing but it's how we structure the experiences that allows so that's another this a pilot that's going on and a couple medical suppose this idea that we're working on in at Penn State in a fourth year of building a fourth year elective this idea that I learned from the embedded for the medicine service or a team and their whole job is to be this part of the team but your job is to find the value pieces quality over cost what's high cost on this team that can be curve PPI use medications laboratory results what's a patient safety issue and that transfer for emergency medicine the medicine they identify that how do you how do you submit that the state earthquake their job is to be the chief of value on that service so pilots going on in some med schools if it's gonna go well but those who were electing in I don't like that the population health manager one may know is positive that you're talking about scribes to deploy it had a couple of freshmen clinical students who were scribes the Canada gunnery school and it is appreciably different in the first week in medical school the language of course that they know but then you want said that thought because when I get to the mapping I say eighteen point about valuable it's like a new one for building and these are not to the learning each other so foreshadowing ancient sense this third fella that we talk about at noon to me is opening the door for us to shine light on a new learning agenda to learn about insurance and policies social determinants of health so the question I ask when it comes to scribes or the Fordham program that focuses on EMT services where is the learning mapping to I think there's a question if you need to think about here whatever experiences you notice what's the intent of learning because medical scribe is quite different than the Met navigator this is my main conceptual slide this time some way in a languor of communities of practice model but for me it really summarizes everything that we are we talked about it so on the right is this theoretical hugs of the clinical community of practice patients at the center of interprofessional care team ideally integrated working turning on all cylinders for that patient but the medical education paradigm the two main experiences that we have our preceptor ships and service line so two requirements by the LCD service are been around 4050 years according to recent issues 400 name that but there's a chasm between like we call the mini imam khomeini position model that you place every the experiences than you over time they can grow into the physician you know in the clinical community of practice where they're expected to do diagnostics and therapeutics of the traditional physician will naturally there's a chasm at iron because we don't expect the first medical students and prescribe will you know related to the non follow for the past their supervisor time so by by the fault the traditional model is a time capsule we can't get them into fits into the clinical community of practice so why does it matter because this is where the learning happens you gotta be a legitimate participate in the work because the minute you legitimately participate in the minute that you're active selphie need to not work better empowerment to engage in it and then learn from it goes up hope you're following but I'm saying you need to catch a ride yeah and so how do you get that to the right this is important for traditional doctoring biomedical skills like yes but especially early on I came to the right because that's where the learning is happening so that's where these value-added roles are coming into place learners to the right and that's where we go first navigator program it's not highlight without glue we want the learner to get into the hub place them here in the position note a monk - we don't want to do that but we click place them here these are smart people so Harold Freeman was a breast cancer surgeon he's known as the founder of patient activation he practiced in Harlem he does not practice anymore he had female patients to his clinic but upholstering recitation you cannot take them to the other and out of frustration group here to journey into the community into their lives that I'm packed why why they coming to me so late and how can I help them and what he identified was the patience in education they need psychological and emotional support they need facilitation through a very fragmented healthcare system I mean there's a breast cancer screening trucks that are two blocks away but the female patient is two blocks away she's still coming in with advanced stage one so up spring the patient navigator not need a medical you start an oncology once hid primary care we took that model modified it and made a student program learners embedded with patients who are in need of help we don't link them up with patients who said yeah I'm one to talk I love doing events they come over I'm not saying that's not important but we're linking them up with a position who says you know I'm really worried about this patient because they have not shown up to their last two appointments or a physical medicine a rehab clinic that says we're discharging this patient home they're on crutches in a week and now they're in a wheelchair I need to make sure their home is safe learners can go in and do the safety assessment if we teach them they can add value to that they can do some of this this is conceptually hard for some people I'm just acknowledging that I've been around walk for seven years on and it's tricky but that's our program that's what we try to do and this is just a pictorial of our map this is south central Pennsylvania Hershey is where our our Medical Center medical school is we've got 16 sites there for in Harrisburg which is a remarkably underserved city and so is 11 and 40% of those patients in Lebanon and Lancaster [Music] all launch of 42 medicines is the nominal affair they get enrolled within a month to 8 to 12 hours a month from September who men and their lengths of the patients 96% of them are mentored by the non physician safety 6% of kovin position so we talked this morning about interprofessional education practice it's happening in the clinical site they're learning from the care coordinators socialization and here's a family they make about the time the clients reinvestment you notice that's right cetera I think these are up there in excites these are not community based organizations from a service army claim these are sites within the health system not so you walk in the excitement say here's an idea that we have they would get engaged with us everyone's saying yes I mean by Oh March everyone saying yes we see this as an extension of our clinic of providing value to our patients we will engage and it's remarkably tricky intrude if they see the alignment momentum all they want to do it so this is your six our students have navigated 25 at the basement 2500 I think the membership probably up 1,000 just really hard to track them with mmm ends and these are patients who need help so think about that population health determinants for Penn State Health these are the patient without merging not into things any thoughts on this reflection stuff but I'm sure that you have gone through and what scented you described a lot of time not only in place but for training I would imagine together what did you guys end up giving up yeah this was a paradigm shift for our med school weekend Kirkham demomen one on one so when partically a new education being start in 2013 and she believed in self-directed learning so we wanted a couple years earlier students were on classroom eight to four she did away with that it was it was a significant upheaval and said in the afternoons this is where the self-directed learning and experiences are going to having doctoring course patient nap so that's for the space came and the courses needed to pare down what they were teaching in lecture based formats big big change the classroom pieces because this is running in parallel with the course that runs two hours a week so that time we had a little bit of a two progenitor courses that existed before that was probably a quarter to a third of the time of the other two-thirds of the time we had the makeup and the other courses that unit to pare back this was a significant huge dose by the way I said it this morning Penn State we're at the we're at the far end because we are all in on believing in this but it is an investment talk about this but one thing to the my head we need to talk about city students with risk came out for the first year and a half and any kind of that figured out so it's more accessible to patients students go into a house with a patient and they're they're doing they're watching pornography the computer how do you deal with that they face occupation on the thumb and they suggested they're suicidal how do you deal with that the things that caused angst for me there windcliff members and if you're very clear just like a student who would go on a clerkship to the emergency room they tent and okay don't see that person they see that patient and they're worried about that ideally there was an evening arts there but if they're worried there's an untrusted that I'm supervising with you that we got to have communication same thing that if there's any issue teaching about the red flag scenarios go to your mentor immediately there's a pager there's a phone number there's a process I wait you have that figured out you cannot predict every minute it happens less than you think settings so I introduced them I was interested as a student so it's sort of what you know so they have a sense of responsibility and also a patient's they want them to grow into so yeah the attendant as a mannequin has been always tell students like you're pushing that forward and I just want to highlight this this is how some of the work is evolving this is some of the tension and also the opportunity this is the traditional sub for district the blowout effect I believe has we generally generally agree with that we know that there are 23 plus social determinants of health that are associated with poor health outcomes I know what you know - did you when she says 25th 2013 5 social times we hardwired into their assessments with patience and then they're in a doctoring course that is right at running in parallel with them and they're teaching everything in the pink box cause extension but what I think the program is doing what helps us design is doing and what we bag I have older than these are you climbing the social history and example out of Kaiser Permanente Kaiser Permanente does this right now they if you read the new six months ago they partnered up with this program called unite us these are physicians identifying the social determinants of health if whatever they say it's food insecurities there's only referral right in the EHRs in this program that outrages into the community fighting physicians are engaging in the blue box and I would argue that 95 percent of what we do right now in the clinical sphere is in that pink box you can disagree early this is what's so exciting we should this is patient senators you can make and I said that today it says that this patient center he can be but this is just some of the preliminary data and then the students are identifying so this is a portion of all those logs they're identifying what these gaps are in their patients which are working with the navigation and look at this learner there's a question about learning so if you ask a learner what they learn I don't know what they're gonna say when you look at their reflection in their blog I do know they're gonna say I'll show you slide but there are this is important points that this is what they're identified as our mantra professionals health care professionals identifying asthma patients like a spotter so it's trying to pound on the educational method each SS has opened up the door for us to begin to think about the learning agenda which is what's most exciting I highlighted the three pillars today if you have humanities as a fourth pillar it's a fourth pillar that would go there so where does the learning evaluate our old master so what are the students learning is the plane right back to your question it's gonna say that we just last year this is an evaluation from all their what they'll tell us from their reflections and all their deliverables clinical medicines at the bottom because it's variable but that's not the role or program you have a doctor course for history taking disability our goals are this that's exactly the point it the purpose of this program is to map for the system learning person we're not trying to tackle on cardiac auscultation different course UCSF blends it all together you know Catherine Lucy goes from Ohio to UCSF get a seven million dollar startup package you build a program we build a network of mentors and you blend all the roles together with one coach and a half half a day a week for your first time here and you're there and you're learning all the four colors it's mapping to the cosine cosine so there's a little vignette just because there's another piece of warning which I never anticipated I got back to your point about their learning so the first-year medical students the patient navigator in the PNR was assigned to perform a home safety assessment for a patient pending discharge he failed to attend the scheduled appointment with the patient which was uncovered after the social worker the next week talked to the patient I see some laughs in the crowd when confronted with this information the student communicated that was not clear to him about the expectation for the experience trust me it was very sweet and we saw these things serve to happen happen in the first year we weren't sure how to unpack that now we're six years in like we know how to present these events by placing them into that right side of the political community of practice that right side circle not on the left they can hide in classroom side and they just have to kind of show up to the small group and they there's an attendance piece when you place them into the critical community of practice here's what happens they get a little stressed can they wear a white coat when they're supposed to wear a white coat are they using the right language are they documented are they documented appropriately are they communicate limitations a student who reads a charter goes in to meet the patient for the first time it says view of a cancer diagnosis happened two weeks ago the patient was not told they had a cancer diagnosis they don't have a diagnosis of cancer there's an abnormal finding on a CT scan so there's this little bit on these many stresses that happens for many of the students within two months we our program can tell you who's going to perform poorly in your clerkships from this program you say the clinical chairs for the review the progress committee they love it because it's early detection and it's professional development and many students just need to be tweeted back on track and we help them pants it successfully certain other ones there they're having multiple blips and instead of seeing it and maybe not even seeing in the third or fourth or fifth rotation on a clerkship we're singing the senator so that force us to make these EPA's and trustful professional activities for patient navigation I know David and the report talked about transitioning the clerkships because this is why I think we'll see them learning at back to the point this is a blurter old accordion that our early immersion demonstrate to us it can do this developmental work continues document act profession thoughts reflections on most so that exam please escape that's a huge professional I just had a conversation this afternoon similar issue at the GME level you know that's petitioner powerful offense did show quark your assignment and he didn't show up to your identify that behavior here what's that leading to the remediation or is that leading to youth learn and this person's not professional you can't before I'm gonna be pointed for a second so let's fast forward three weeks it led to something really good no matter what the outcome is so I don't know if they're all different so it might be remediation you talk to them we put them through a professional learning plan and maybe they're not on the radar in any other courses and it's a one-time thing they talk about you know uncover it you know okay let's split monitor let's watch this there's some oh he he did this and he's other to course and it's an issue already I think medical school acting proactively monitoring professionals and issues and maybe not professionally developing when they do occur this is what's happening never anticipated this first year by the way I thought it would be all mapping the systems on communication everything you saw on another slide this is probably the biggest battle there's a national conversation about how to provide offer extra benefit students we poured the end of medical school before the comfortable it's a nice idea but it's really hard to do unless you make an early identification of whatever that might be so it may not lead to immediately firing but it'll lead to a student a quicker decision point and that decision point after some remediation efforts could can help identify the students to go on into that off-ramp status so yes you say I think I think whatever the outcome is it'll end up being better than not going on it that that's my point you may comment on this the future so what is the infrastructure required by which to roll this out and away from the mentorians new is going student going to call when rubber meets the road what is the support as far as cleaning up all these things [Music] I'll just give you a quick response of our doctoral program has 20 mentors to 20% FTE per minute and do the math 20% the math program the mentors really [Music] billing and pro bono work to get it launched now we have money $75,000 there's 1.2 million for the doctorate program 75,000 for this just to highlight some of the challenges that exist in a program like this empanada Jefferson modeler garrison Jimmy Kimmel Medical College model marker program for their program for twenty to sixty students and the first thing I said was you need an infrastructure they're doing is I'm pondering a monthly they got five times that amount they have huge hubs where they send out this challenge okay so this is your report that was submitted by the HSS task force I'm just highlighting that this is your turn now by the way this is about how to confed the navigation experiences allowing students to follow a patient family longitudinally and ideally would transition one of the courses this is a suggestion that's not getting too dated right so I guess the question for you is here a minute or two talk to your neighbor and maybe just talk about what are the potential opportunities everything you just learned about value-added roles in Roanoke so what did you need what what can be built here talk to your neighbor comment and of all guitar very exciting No what is here seventy there's a group in London called the healthy brunette Valley that is using community navigators already to kind of feed patients into a hub and to make them up with assessments I think that that which is kind of already a perfect situation words and therefore the students maxing out what's the clinical seven clinical sites like a lot of this is homes I mean these guys are community navigators they do have I think they're planning an FQHC and I just want to highlight that Florida International University School of Medicine has a program like a great program family program nodding the clinical community of practice and budgets it's based in the home so I'm not I'm not putting a formative judgment I'm just highlighting the community of practice model and the difference is living this here to argue to place rather than a food pantry versus gone for home business versus being a clinical community of practice we can do home business and go to the food pantry I would argue for this but these are some of the things that I'm trying to decipher out for you as you think more of the rules you're wonderin third are itching to get into a credible study period and they want to be able to interact with patients with interview skills or something school exam skills but by year two that may be a good natural to home on time because they there's two parallel programs and to me I would like to be more anyway so we're fighting them at least at one point two million dollar program six four years new program but how do we integrate the social history and that's just one bridge so we're trying to in fact have the assessment plans look different she's an early innovator here in life so I'm just saying that set a positive synergy because there's a lot of synergy so in your developing the patient navigator program I think one of the things that we were just talking about is did you did you do a means assessment from those clinical sites to see because I would think that we would have to start with what are the needs that students could fit first so what are the needs we have a student fitted and how are you know sure that that's the right match episodes but we wrote two papers on that ones in the American Journal of medical files what my learner's can do and then the other one is in a public health Journal primary care public health journal about what are the gaps in care for vulnerable patients those two papers directly address that the whole program is built upon those results because we're debt we're trying to align it's interesting because I would want any new places and there was a family medicine clinic minutes in soccer work because I'm on clinic that day I need to be right downtown Harrisburg they never have using my product five minutes absolutely I can see how students can add value so there's a paradigm shift some of this traditional mindset on how we think student wolves can go about that you kind of have to tackle a negotiation the patient and continue to talk to those folks who might not have that mental model as leadership where the things that came up like to stir things up a social history question and then identify those on those systems with restructure certain to find the resources to address those things it was that challenging I guess in terms of the system so you sort of identify it in the navigator program but where there are their definitive resources and identify all of those there are social determinants or different challenges it's interesting beyond five years at Penn State focus on social determinants of health and they're building platforms by which they are asking the question what's the incidence or what's the prevalence of these social determinants of health in our patients and somebody invited me to a meeting I showed them data is how do you have this data so let's talk we tell you about it our firm had it for six years where the only mechanism the Penn State Health on this scale is 4,000 2594 4000 that are identified and the system didn't even know about it so how to act on that it's on the agenda we're nowhere near KP this is a 2025 2030 agenda but we're trying to raise awareness and push the system and they want to go to it they're just not sure how to do I had some questions here about student gaming tomorrow 7:00 a.m. session it's all about the challenges of HSS and value-added goals it gets a whole session I just told her that I knew that I I never thought a good part of the papers that I would write six years ago which would be about the challenges but it was so thick I need it I felt the needs unpacking I was unpacking it anyway in the job like I said what I felt I didn't do it systematically it's that thick because there are challenge and it's a complicated thing but here's one of the theaters that wrote the key issues I'm doing that soon engagement is near the top I would say it's variable students many students elected some students don't you can have the best model primary care clinic great example primary care clinic great mentor so you need she actually gets paid to students work for thirds that it's the most amazing experience to students command and say this is a waste of my time so the curriculum committee doesn't mean whenever you should improve the site is a lot second its view the bowls let me show you the work that portfolio work they're doing here's two students who are in love with it so let's have a more do you come about what what kind of probably really wanted question there have you look at the impact of this the students perception these ones their preference no link yet down the road people have suggested that me then what's your hypothesis even for that one whether it profile or something completely here's my micro page I haven't thought about it one to ten seconds I've had I've talked to me this morning on a student company said I wish I was at Penn State College of Medicine surgery med school because it's is some stuff doesn't mean anything doesn't mean anything for surgery you don't I can check our educator most are surgeons because they are believers in a patient of a knee replacement they can't be wrong transportation or access difficult Erica we represent coverage so they care about that I don't think especially specific to me I don't I said this worked four or five times today this grills afaik the mindset I think that spans specialties but those with a growth mindset my dream would be that we were able to detect and identify people with both minds that before we accepted in America they're assisting citizens students who cannot and they are rock stars and there's certain other ones who have fixed mindset and some people would argue with that apply health care is aware that we have generations of physicians is a very points of common generations and physicians who are expensive and that's why we have important I'm totally not laying down positions but how do you improve that system you change their positions in the actually educate them and what the financial purposes and then we won't think a limit to the system I mean you can blame it on a fixed motor center you can blame it on the way that we have thought in this country to develop our workers and some of the other is canal to death on these young people to try to become physicians and you can't fault them for having a practical mindset and that I'm certainly not and please I'm not blaming anybody I'm trying to highlight the factors in this system of the issue that we haven't played anything so I think the fixed ice met plenty of students who have growth mindset you can engage and have jet dollars I'm just highlighting that they're not see they're not usually the same they're inherently different about you them I see system citizen searching system system memory card ox whoever likes it but it's a fascinating concept I think it's as I said today's need professionals in the health care system citizen those who want to care for the health care system that were in because it's part of our job we care about cost care a lot of movement so we co-create was isn't this thing I feel like I I feel like I might get preachy but this is what David her concept to think about any thought about it goals comes out of work this is over 10 years old care continuity an impertinent we try to do is navigate some time for but Cochrane they would care this is revolving to our patients you look around the patient that I don't have a follow-up but you're not seeing them enough times gotta have some continuity with the patient's illness course you got a continuity with the curriculum how does it map to the learning support stem acknowledge them incentivize them to do that work and if they're in that relationship that's where the trust is gonna point in the lining of habit today the International Association of medical science educators is going to have a five session series for those lines the system science directed by Mark said it starts at noon his biggest hoping to gather force with his comments on the country we have a institutional subscription so I'm going to take all of you on work early on are read from the sign-in sheet for the food and then we're going to make sure that you get the the series you become to the Mets go watch it with us please we have to walk before you can watch the office longer to watch it so it would be starting with March the how much did you miss it 11 Eric I've always been something out now.