According to Schillinger, “Health system science has become the essential third pillar of medical education, along with basic science and clinical science. It means everything that anticipates, surrounds, and forms the context for health care.”

The course was designed to “prepare students for a 21st-century health system in which they will be leading health care,” says Schillinger. Specifically, she continues, “we asked the patient-student pairs to meet a minimum of one hour per month to explore the patient’s and caregiver’s experiences of the health care system, focusing on the topic of the month with the goal of providing rigor and structure and accountability to their partnership. The result has been a magical, game-changing experience that puts patients and families front and center in medical education from the very beginning.”

Motivated to integrate the science and art of medicine, incoming medical students at most institutions arrive on campus anticipating opportunities to engage with real patients and their families — at some point in the future. Medical students at Stanford, on the other hand, have an unusual opportunity to interact with patients in their very first month, even as they pursue the critical study of the basic sciences in their first two years.

The Walk with Me class, one offering of Stanford’s Patient and Family Engaged Medical Education program, is a student-patient-caregiver partnership experience that offers early, authentic engagement with patients and their families.

Students in the Walk with Me class are the beneficiaries of a key outcome of the Transforming Medical Education Initiative, according to Erika Schillinger, MD, professor of medicine and vice chief for education in the division of primary care and population health. That key outcome suggested that authentic early experiences with patients would put patients and their caregivers center stage from the very start of medical education, establishing the patient’s perspective and experience of health and the health care system as vitally important to being excellent clinicians.

The first practical step in putting early patient experiences in place was to create a curriculum in health systems science and deliver it monthly with didactic workshops, patient perspectives and practical skills building. According to Schillinger, “Health system science has become the essential third pillar of medical education, along with basic science and clinical science. It means everything that anticipates, surrounds, and forms the context for health care.”

The course was designed to “prepare students for a 21st-century health system in which they will be leading health care,” says Schillinger. Specifically, she continues, “we asked the patient-student pairs to meet a minimum of one hour per month to explore the patient’s and caregiver’s experiences of the health care system, focusing on the topic of the month with the goal of providing rigor and structure and accountability to their partnership. The result has been a magical, game-changing experience that puts patients and families front and center in medical education from the very beginning.”

Three students who enrolled in the course share their experiences.

Crocheting Together
Marija Kamceva switched her major at Yale from English to premed following a biology class she took as a junior. Once she got to Stanford and learned about the Walk with Me class, she jumped at the chance to take part because “it seemed like a really good opportunity to understand the role I was about to play either as a primary care physician or a psychiatrist. I thought it would contextualize the rest of my education.”

When she learned her patient’s name, she says, “I called her, and we met for coffee the first time near Stanford. We bonded really well.” Meeting her patient two or three times a month, Kamceva found that they shared many of the same interests, and they even learned to crochet together. “My patient’s story was long and interesting,” she says, “and this was the first time she had the opportunity to really tell it because it’s hard with something so personal to even talk with your friends about it. I feel like I will always have her story with me as I go on and work with patients.”

The primary objective was to see if lay health worker intervention encouraged patients to discuss their personal goals of care with their medical professionals.

Patel split the patients into two groups. While both groups received the standard of care for their disease, one group (the intervention arm) was also paired with lay health workers who were trained to assist patients with establishing end-of-life care preferences.

Can someone with no medical training improve the quality of life for a terminally ill cancer patient? And will that have any impact on health care costs?

That’s what Manali Patel, MD, an assistant professor of oncology, wanted to find out.

During her undergraduate and medical school studies Patel spent time in rural areas overseas where medical technology is scarce, and she noticed how community members without formal medical skills can be effective health workers.

She wondered if it were possible to counteract the U.S. tendency to over-depend on technology by using lay health workers (nonclinical, nonprofessional personnel with no prior experience in the medical field who are trained in specific skills to help deliver various services, including end-of-life care).

That led her to design a randomized clinical trial of 213 patients with late-stage or recurrent cancer at Palo Alto Veterans Affairs.

The primary objective was to see if lay health worker intervention encouraged patients to discuss their personal goals of care with their medical professionals.

Patel split the patients into two groups. While both groups received the standard of care for their disease, one group (the intervention arm) was also paired with lay health workers who were trained to assist patients with establishing end-of-life care preferences.

Patients in the intervention arm could talk about their worries and concerns with their assigned lay health worker on a regular basis and especially during “trigger points” (for example, after receiving results from a medical exam or imaging test that might cause unease). The workers also encouraged their patients to share with their medical professional or team what they were discussing with the worker.

Patel’s study, “Effect of a Lay Health Worker Intervention on Goals-of-Care Documentation and on Health Care Use, Costs, and Satisfaction Among Patients With Cancer,” was published in the July 26, 2018 issue of JAMA Oncology.

The study’s results exceeded Patel’s expectations. More than 90 percent of the patients who were assigned a lay health worker had the types of discussions described above, while less than 25 percent of the patients without lay health workers had them. The discussions also made patients feel more satisfied with their medical decision making and oncology care.

A startling result of the study was how the lay health worker involvement affected health care costs and use.

“In the last month of life we saw a 95 percent reduction in patients’ health care spending, which was largely because patients did not use the emergency department or the hospital,” Patel notes.

The drop in spending is consistent with patients feeling more empowered to decline those interventions after clarifying their wishes with their lay health worker.

“In my own practice I can get tunnel vision and focus solely on wanting to eradicate or decrease the size of the cancer in hopes that I can make my patients experience less suffering. But sometimes the treatments may make the patient feel worse, and I need a reminder from the patient that the therapies themselves may not necessarily be achieving the gain,” Patel admits.

“The big takeaway from this study is that lay health workers can serve as support for patients to formulate their care preferences and feel encouraged to openly communicate with physicians like myself. Especially when our focus may narrow, our patients allow us to take a step back and think about the big picture,” she adds.

A startling result of the study was how the lay health worker involvement affected health care costs and use.

“In the last month of life we saw a 95 percent reduction in patients’ health care spending, which was largely because patients did not use the emergency department or the hospital,” Patel notes.

The drop in spending is consistent with patients feeling more empowered to decline those interventions after clarifying their wishes with their lay health worker.

“In my own practice I can get tunnel vision and focus solely on wanting to eradicate or decrease the size of the cancer in hopes that I can make my patients experience less suffering. But sometimes the treatments may make the patient feel worse, and I need a reminder from the patient that the therapies themselves may not necessarily be achieving the gain,” Patel admits.

“The big takeaway from this study is that lay health workers can serve as support for patients to formulate their care preferences and feel encouraged to openly communicate with physicians like myself. Especially when our focus may narrow, our patients allow us to take a step back and think about the big picture,” she adds.

They encouraged and supported her ethics work. David Magnus, PhD, professor of medicine and biomedical ethics, and director of the Stanford Center for Biomedical Ethics, helped deepen her understanding of ethics and philosophy. In 2016 she was a summer fellow at the University of Chicago’s MacLean Center for Clinical Medical Ethics, and she’s been a clinical ethicist and consultant at Stanford ever since.

Luenprakansit’s work varies on a day-to-day basis. She fulfills her clinical duties as a hospitalist; conducts research; teaches students, residents, and fellows; and co-teaches two ethics courses — all on top of her ethics consulting work. This past year, she was also one of the ACES (Advancing Communication Excellence at Stanford) facilitators.

Bioethics is a rapidly evolving, more-relevant-every-day kind of field. And for Kate Luenprakansit, MD, clinical assistant professor of hospital medicine and clinical bioethicist, it has become a major part of her life’s work.

Luenprakansit’s interest in ethics was sparked when she studied molecular cell developmental biology as an undergraduate at UCLA. “I always felt there was something more to becoming a physician than just knowing the biology, the physiology, the math, and the science. There was even more fundamental knowledge I needed to gain in order to be the best physician I could be,” she says.

Her first ethics course during a study abroad program in medical practice and policy in Denmark provided the framework for her higher calling. Questions started to materialize for her about autonomy, beneficence, non-maleficence, and justice and how they play into the doctor-patient relationship. “How do I actually strive to uphold those ideals and principles in medicine?” she asked herself. That first ethics course became the “compass” for her career.

When Luenprakansit started at Stanford as part of the surgical co-management hospitalist group, she brought her interest in ethics with her. “I needed a way to figure out how I could effect change on a larger level,” she explains, “and I think Stanford is a phenomenal institution for that work.”

Her leaders were Mark Cullen, MD, director of the Center for Population Health Sciences and professor of primary care and population health, and Neera Ahuja, MD, clinical associate professor and division chief of hospital medicine. They encouraged and supported her ethics work. David Magnus, PhD, professor of medicine and biomedical ethics, and director of the Stanford Center for Biomedical Ethics, helped deepen her understanding of ethics and philosophy. In 2016 she was a summer fellow at the University of Chicago’s MacLean Center for Clinical Medical Ethics, and she’s been a clinical ethicist and consultant at Stanford ever since.

Luenprakansit’s work varies on a day-to-day basis. She fulfills her clinical duties as a hospitalist; conducts research; teaches students, residents, and fellows; and co-teaches two ethics courses — all on top of her ethics consulting work. This past year, she was also one of the ACES (Advancing Communication Excellence at Stanford) facilitators.

Luenprakansit was formally trained in mediation and conflict resolution, both at Stanford and during her summer in Chicago. She now takes part in clinical ethics consults at Stanford Hospital. She helps patients, doctors and families “reconcile the many ethical concerns and dilemmas that arise in a patient care setting.”

Often this means sitting in a room with physicians and patients, trying to work out an “optimal” solution. “Conflict often arises because of a misunderstanding,” she says. “And how we are all communicating with one another can lead to the misalignment of goals and expectations.”

“We strive to elicit each party’s perspective so that we can achieve some level of mutual understanding,” she says.

Mutual understanding is important, but the next step, consensus, may be harder to achieve. Ethics consultants help facilitate a plan and a resolution. “Decisions still need to be made,” Luenprakansit states. “At the end of this, there’s a patient at the center of all of these discussions.”

One of only a few physician ethicists at Stanford, her ultimate goal is to make ethics a part of the larger medical conversation. She wants to engage people, starting as early as medical school, to discuss “the practicality of understanding ethics, and how that affects our decision making: the what, why, and how of medical decision making as clinicians.” She concludes,  “Through my practice, I have come to appreciate how fundamental ethics is in my role as a physician.”

Luenprakansit was formally trained in mediation and conflict resolution, both at Stanford and during her summer in Chicago. She now takes part in clinical ethics consults at Stanford Hospital. She helps patients, doctors and families “reconcile the many ethical concerns and dilemmas that arise in a patient care setting.”

Often this means sitting in a room with physicians and patients, trying to work out an “optimal” solution. “Conflict often arises because of a misunderstanding,” she says. “And how we are all communicating with one another can lead to the misalignment of goals and expectations.”

“We strive to elicit each party’s perspective so that we can achieve some level of mutual understanding,” she says.

Mutual understanding is important, but the next step, consensus, may be harder to achieve. Ethics consultants help facilitate a plan and a resolution. “Decisions still need to be made,” Luenprakansit states. “At the end of this, there’s a patient at the center of all of these discussions.”

One of only a few physician ethicists at Stanford, her ultimate goal is to make ethics a part of the larger medical conversation. She wants to engage people, starting as early as medical school, to discuss “the practicality of understanding ethics, and how that affects our decision making: the what, why, and how of medical decision making as clinicians.” She concludes,  “Through my practice, I have come to appreciate how fundamental ethics is in my role as a physician.”