Minutes 04/02/08

Minutes 04/02/08

Joint Charlottesville, Fairfax, Roanoke & Salem
University of Virginia Clinical Medicine Meeting
04.02.08
Minutes

 

Introduction - Don Innes

The Claude Moore Medical Education building is now "5% done" and on schedule to open in May 2010. Construction began in January 2008 and is currently in month 3 of the 24-month contract duration. Construction completion is currently at 5%. Owner occupancy of the new Claude Moore Medical Education Building is scheduled for May 2010.

Current Activities: Excavation and shoring continues.   The electrical duct bank feeding the HS Library has been relocated outside of the excavation. Excavation has begun in Lane Road to for the installation of the chilled water loop connection for the South Chiller Plant.  The HS Library will be fed from this loop so the existing chilled water lines feeding that building can be removed from the building site.

Upcoming Activity: Main site excavation and shoring will continue this month. Chilled water work in Lane Road will continue this month.

SOM Planned Building

Defining the clerkship experience: A core clerkship is a required one to two-month academic period of instruction based in clinical experience in which the medical student learns and participates in patient care broadly, but is generally focused on a single medical discipline. The experience grows out of a set of knowledge, skills, and attitudes based on the Twelve Competencies Expected of the UVA Physician.

Elements Expected of All Clerkships

  1. Orientation
  2. Direct participation in and observation of patient care with resident/fellow/attending [including discussion of evaluation, differential diagnosis, treatment, and follow-up]. (daily)
  3. Daily medical student presentation of patient history & physical examination (or follow-up) to supervising resident/fellow/attending
  4. Patient-based formal teaching at least weekly, such as Clerkship Directors (or Designee) Rounds, student morning, report or Ethics Rounds
  5. Teaching conferences at least weekly, e.g. Grand Rounds, Clinical Pathologic Conferences
  6. Clinical Skills Passports
  7. Self-learning: student should review patient's medical history and physical examination, imaging and pathology laboratory studies, and read about the patient's disorder and read about diagnostic and treatment options. Reading may include relevant basic science, anatomy and procedures.
  8. Complete an on-line patient exposure log
  9. Direct teaching time with attending at least three days a week
  10. Evaluation of knowledge, skills, and attitudes relating to the clerkship

Other elements of clerkships (not required for all clerkships):

  1. Clerkship designated learning events, e.g. radiology rounds
  2. Exercises in Clinical Problem Solving, e.g. CLIPP Cases, Virtual Patient
  3. New patient admission opportunities, e.g. night call, night float
  4. In ward rotations, student should experience the life of a resident.
  5. Workshops for clinical skill learning.

Amendment to the Twelve Competencies Expected of the UVa Educated Physician: An addition was made to the first competency to include an attitude of "Cultural competency in clinical practice and professional relations."

  1. The development and practice of a set of personal and professional attributes that enable the independent performance of the responsibilities of a physician and the ability to adapt to the evolving practice of medicine. These include an attitude of: 

     a) Humanism, compassion and empathy, 
     b) Collegiality and interdisciplinary collaboration, 
     c) Continuing and lifelong self education, 
     d) Awareness of a Personal response to one's personal and profession limits, 
     e) Community and social service, 
     f) Ethical personal and professional conduct, 
     g) Legal standards and conduct, 
     h) Economic awareness in clinical practice,
     i) Cultural competency in clinical practice and professional relations

The PassPorts have been revised for the 2008 -2009 clerkship period and a new entry has been added to all PassPorts: "Student managed a patient effectively within the context of the patient's cultural beliefs, practices and needs."

Match Results 2008 - Allison Innes

127 members of the Class of 2008 matched to a wide range of highly competitive programs.   23 students will be doing all or part of their residency program training at the University of Virginia.  3 students have elected to defer their residency.  27 matched in Internal Medicine, 14 in Pediatrics, 12 in Emergency Medicine and 8 in Obstetrics-Gynecology.  Specialty counts and placement information can be found on the web at:

http://www.med-ed.virginia.edu/handbook/residency/Match/index-page

Electives and Selectives Assessment  - William Wilson, Allison Innes

Reminder that evaluations for Selectives and Electives are due no later than 2 weeks after the end of the rotation.  Selective evaluations can be printed from OASIS or downloaded from the web at:

http://www.med-ed.virginia.edu/handbook/electives/info/forms-page

Education Task Force - Melanie McCollum

Melanie McCollum and Bobby Chhabra co-chair the Education Task Force.  The task force charge was to determine how to best utilize the features of the new Medical Education Building for UME, GME, and CME with special emphasis on use of the Simulation Center and the new Learning Space. Suggestions for use of the Simulation and Standardized Patient Center by clerkship programs should be communicated to Don Innes dji@virginia.edu and Melanie McCollum mam7nk@Virginia.edu 

Clerkship Websites - A Common Format  - Veronica Michaelsen

What: Update all clerkship web sites to conform to common structure and required elements

When: Draft web site review: April 1, 2008. Final deadline April 28, 2008 (Start of first rotation of 2008-2009 year)

Where: //

How: Required Elements

All Clerkship websites must have clearly stated:
Overview and list of student expectations and responsibilities *
Goals and objectives *
Evaluation and grading standards *
Access to the online course evaluations - OASIS
Access to the clerkship patient log
Orientation materials for each site
Housing information for away sites
* Basic expectations and expectations, goals and objectives, and evaluation and grading standards must be common to all instructional sites within a discipline.
Access to clerkship specific resources, e.g. syllabus, clinical problem sets
A statement of the attending and resident physician's roles and expectations.

All Clerkship websites should have:
Access to clerkship site specific schedule information , e.g. lecture and workshop
schedules, rotation schedules

Site Layout:

Home page: overview, goals, and objectives

Menu Items:

Logistics: Orientation, Housing, Contacts, Guides for each site, Passports
Schedules: Attendance, Lecture Schedule, Workshops
Learning Materials: Textbooks, Workshops, Ward Conduct/Activities, Readings, Library link for away sites, Online Resources
Grading and Evaluation: Grading and Evaluation Policies, Problems and Feedback, Oasis, Patient logs,
For Educators: Expectations, Orientation Guide, Library Resources, Residents as Educators
Links: Your department, Student Source, Professional organizations

For Reference:

Medicine Clerkship draft web site at:

//internet/MedicineClerkship/


USMLE-2CS and the Clinical Practice Exam (CPX)
- Don Innes, Anne Chapin

Don Innes reviewed the format of the USMLE-2CS and circulated sample review books that explain the format and expectations of the examination. Anne Chapin reviewed the most recent CPX results pointing out the areas in which our student's performance was the weakest. Each clerkship should evaluate which of the following areas they are responsible for (or partially responsible) and focus efforts on improving them.  For a number of the clerkships the PassPorts address issues evaluated by the CPX.

Students continue to find the exam helpful in preparing for USMLE 2 CS. Circumstances that may contribute to poor student performance are:

  1. Student inexperience with performance exams--timed performance with Hx, focused PE and communicating possible diagnosis and next steps to patient
  2. Uncertainty about grading criteria (checklists)
  3. Students modeling doctors who inconsistently apply correct clinical skills
  4. Student attitude/impression that speed in making a diagnosis is more important than thoroughness of H&P for diagnosis.

Two remedial/practice sessions were offered first to the lowest 30 performing students and then to the entire class.   Seventeen students elected to receive additional practice and feedback on their performance with standardized patient cases.

List of topics where CPX performance was weak.

  • Anxiety: lungs 25%, heart 35%, thyroid 90%.
  • Appendicitis:  abdomen 23%, percussed 71%, heart 40%, lungs 50%, raise leg 75%.
  • Hypertension: BP one arm 52%, BP two arms 98%.
  • Chest pain:  BP 60%, lungs 35%, heart 58%, pulses 85%, one side of neck lying down 77%.

Additional comments

  • Students do not wash their hands before the PE 10-25% of the time.
  • SPs performing chest pain role noticed that students went through motion of listening to heart in 4 places, but not accurately in aortic, pulmonic, tricuspid and mitral areas.
  • Several cases reported that 30% of students did not drape them.
  • Lowest scoring case was contraceptive counseling.

What should be done?

  • Added practice sessions afterwards with SP feedback on checklist
  • Propose adding practice sessions beforehand with feedback so students understand nuance of performance exam
  • Urge faculty to more closely observe and monitor clerkship student PE skill development. 
  • Model excellence, students do what they see.

Clinical Skills Working Group - Gene Corbett

Enhancement of students' clinical skill performance education in the clerkship year

  1. Increase opportunities for skills learning and practice.  What skills?

    -In direct patient care
    -Specific skills workshops
    -Web-based exercises

  2. Increase clinical skill assessment and formative feedback. How?

    -Direct observation in patient care
    -Objective structured clinical examinations (OSCE)
    -In web-based instruction
  3. Increase the participation of faculty and residents in skills teaching and mentoring. How to encourage the clinical teacher?

    -barriers?
    -strategies to overcome barriers?

Luncheon Workshops on Clinical Skills - Gene Corbett

The clerkship directors broke into groups by discipline to address the questions "How can students' clinical skill development be enhanced in the clerkship year?" and  "How can we emphasize student's feeling of ownership of / responsibility for patient's care in order to enhance their participation and skill practice opportunities (currently estimated nationally to happen about 20% of the time in the clerkship year)."

Strategies to enhance student participation in clerkships

Identify tasks that the student on which the student can focus
Assign a learning objective (knowledge, skill, or attitude) and provide immediate feedback
It is quality, not quantity, of the feedback that is important
Use the PassPort system effectively to focus feedback.
Most PassPorts contain focused goals and objectives. Re-emphasize the PassPort and the OSCE checklists to students and resident and attending physicians.
Ask the student "What is your goal or objective for today?" Help the student identify an achievable objective, assist them in achieving that objective, and provide feedback.
Provide a long-term mentor within a clerkship [across clerkships?]
Establish continuity of the learning experience - the new plan for Surgery should increase the "participation" of students in surgery
Establish "mini-OSCEs" within clerkships - timing may be a problem -mid? - end? -formative? -summative? [The Objective Structured Clinical Examination is a modern type of examination often used in medicine to test skills such as communication, clinical examination, medical procedures, prescribing and interpretation of results.] 
Development of multimedia assessment tools, which would allow, for example, a student who had just examined a patient to look at pictures of various retinae to be asked to identify one with the same condition that he had just observed (e.g. hypotension).  Another possibility would be to develop audio examples of various murmurs or dysrhythmias, and ask the student what he or she had heard.

Other Areas of Concern

Finding the proper balance between didactic and skill teaching
How do we "incentivize teaching"

SMEC Focus - Animesh Jain

The new leader of Student Medical Education Committee, Animesh Jain, aj2v@virginia.edu  continued in the footsteps of Sixtine Valdelievre, focused on three issues pertaining to the clerkships:

a) Making better use of "downtime" on rotations.

Downtime usually occurs last hour of the morning or afternoons (sometimes as much as 3-hours) when the student has no specific assignment.

b) Define expectations.

Five minutes of dialogue between student and the attending and resident physicians to make explicit expectations, e.g. pre-rounding, time of rounds, presentation format, required student conferences, notes, etc. The attending and resident physicians should be aware of the student's learning stage - early 3rd year vs. late.

c) Increase supervision of physical examinations

Review findings reported at report/rounds at the patient bedside, e.g. go back to the patient to palpate the enlarged spleen reported as normal during rounds.

Salem - Mehdi Kazemi for Maureen McCarthy reviewed the Salem VA focus on quality enhancement and patient safety. VA wide the focus is on returning vets with mental health, GI, neurologic, and musculoskeletal conditions. At Salem the full leadership team is in place with Dr. Maureen McCarthy as Chief. The leadership stresses their ongoing commitment to education of trainees and hopes to expanded opportunities for medical student and resident training. There are opportunities to expand residency programs with funded positions and for "educational innovation" positions.

University of Virginia Students contribute significantly to the VA medical center, assist with the ability to recruit quality providers devoted to education, keep us in touch with the joy in the nuts and bolts of patient care, and contribute significantly to patient satisfaction. Concerns include adapting to the new curriculum, the amount of time available for teaching, given our distance and the need for our students to be in Charlottesville often, but with awareness that these issues will be worked out with innovative approaches to education.

Fairfax - Alicia Freedy reviewed the programs at Fairfax in Northern Virginia. There are some 186 pediatric beds of which 75 are NICU. As the 5th largest birthing center in the United States there is much work for pediatricians (~12,000 deliveries). Four UVa students, two Georgetown students, and two VCU students are present at any given time.

The date of the fall Joint Clerkship meeting was selected as Wednesday, October 29, 2008. The location will be the Salem Veterans Administration Hospital, room 74-232. Please forward topic suggestions for this meeting to Don Innes at dji@virginia.edu

 

Simulation Learning Center - Elisabeth Wright, Keith Littlewood

The University of Virginia Medical Simulation Center functions in an interdisciplinary, multi-specialty environment working to promote advances in simulation though the development of innovative research, education, and quality improvement initiatives. The Simulation Center is fundamental to the technologically enhanced collaborative learning model. 

The first simulator was purchased in 2002, with two additional patient simulators, a bronchoscopy simulator and various task trainers acquired the following year. Later pediatric and baby patient simulators were added. The Life Saving Techniques Workshop for third year medical students is a curriculum requirement and quickly became a medical student favorite. 

Elisabeth Wright and Keith Littlewood provided guided tours of the newly renovated 1200 ft2 space. The new Medical Education Building will contain a 13,500 ft2 simulation floor and is scheduled to open in 2010.

Clerkship directors are encouraged to bring ideas for using simulation in teaching medical students to Elisabeth Wright, Keith Littlewood, or Mark Kirk. Medical Simulation Center?, University of Virginia Health System, PO Box 800699, Charlottesville, Virginia 22908, (ph) 434.924.2566, (fax)  434.924.2877 ?medicalsimulationcenter@virginia.edu?

-DJI

University of Virginia School of Medicine
The Twelve Competencies Required of the Contemporary Physician