University of Virginia

Joint Clinical Medicine Meeting: Charlottesville, Fairfax, Roanoke & Salem

Wednesday, October 20, 2010

NexGen Curriculum:  The First Ten Weeks – Donald Innes, Veronica Michaelsen, Elizabeth Bradley, Megan Keeley

The Claude Moore Medical Education Building was completed on time and under budget.  It has a learning studio and a lecture hall as well as two entire floors devoted to the Clinical Performance Education Center with a variety of simulation and patient exam rooms.

The First Ten Weeks’:  Molecular and Cellular Medicine.  The curriculum was designed to include a large amount of student interaction versus lecture with study directed by clinicians, basic scientists and other faculty.  Each Monday a patient is presented with conditions related to the week’s science and clinical topics with a wrap-up session on Friday. These activities are integrated with the Clinical Performance Development activities held one afternoon each week.  Every other week students have formative or summative assessments.

Thus far student assessment scores are comparable to previous classes.  Upcoming revisions to the curriculum will include putting more emphasis on diagnosis, having more integration between topics, and incorporating more student interaction.

A winter break following completion of the Systems will allow for vacation and USMLE-1 study time.  The two weeks of Basic Patient Care Skills will include in addition to a clinical skills booster and evaluation, Epic training, mask-fit testing, PPD updates, professionalism, and medical careers.

The current second year class will start clerkships on May 2, 2011.

Curriculum Evaluation:  This is the first opportunity to evaluate the curriculum and implement new ideas.

5 goals

1. Assure all students demonstrate mastery of UVa’s12 competencies
   a. Professionalism: the ability to demonstrate professional behavior in the act of medical care;
   b  Competence in the human sciences;
   c.  The ability to engage and involve any patient in a relationship for the purpose of clinical problem solving and care throughout the duration of the relationship; 
   d.  The ability to take a clinical history;
   e.  The ability to perform a mental and physical examination;
   f.   The ability to select, justify, and interpret clinical tests and imaging;
   g.  The ability to perform basic clinical procedures;
   h.  The ability to record, present, research, critique and manage clinical information;
   i.   The ability to diagnose clinical problems including differential diagnosis, clinical reasoning and
   problem identification;
   j.   The ability to intervene in the natural history of disease through preventive, curative and palliative strategies, including the utilization of appropriate health care system resources;
   k.  The ability to formulate a prognosis about the future events of an individual’s health and illness based upon an understanding of the patient, the general natural history of disease, and upon known intervention alternatives. Each of these are essential for planning for individual health care outcomes;
   l.   The ability to provide clinical care within the practical context of the individual patient-physician relationship. This includes the patient’s age, gender, personal and cultural preferences. It also includes adapting their clinical care to practical encounter-time constraints, economic limitations, individual and family considerations, and to the availability of health care system resources. This also includes ethical and legal perspectives.
2. Integrate content around organ systems
3. Integrate clinical and basic science content across the 4 years and within systems
4. Utilize more active learning methodologies and provide learner-centered curriculum
5. Provide frequent and developmental opportunities for clinical skill learning throughout the curriculum
   
   

 It’s critical to evaluate how objectives relate to content and were or were not accomplished.  There are weekly evaluations by students and faculty, daily observations of the morning hours, and debriefing meetings by all involved to discuss the effectiveness of the curriculum and changes that need to be made.

Other evaluations

Perioperative and Acute Care Medicine Clerkship Skills Project

Clerkship Preparedness Study

Emphasize knowledge acquisition and clinical performance development and get the student to experience the skill.

Feedback from students provide lessons for clerkships

Clerkship Transition:  March/April 2012 – Dr. Wilson

Dr. Wilson discussed the overlap period between period 6 for the Class of 2013 and period 1 for the Class of 2014. All clerkship directors are aware of the overlap and are asked to make plans to address this issue as soon as possible. 

Culturally Competent Care of Vulnerable Populations - Elizabeth Bradley

LCME Standards 21 and 22 require medical schools to provide training in cultural competency in dealing with vulnerable populations.  The 2007 accreditation cited UVa because, while it provided education on cultural sensitivity, it did not provide opportunities to evaluate how effectively students applied that knowledge in a practical setting.

To address the need, UVa’s General Medicine, Geriatric, Palliative, Family, and Pediatric Medicine Divisions wrote a pre-doctoral training grant “Enhancing the Culturally Competent Care of Vulnerable Populations:  Global Health in Your Own Back Yard.”  The goal is to develop culturally competent care of vulnerable populations such as the elderly, children,  immigrants and refugees, HIV/AIDS patients.

Learning opportunities:

Dark Humor – Elizabeth Bradley

Dark humor (derogatory and demeaning physician comments both to and about patients) is common.  The impact on medical students is that during their first and second year, they begin to adopt some of the behaviors modeled by their preceptors even though those values conflict with their own values.  By their third year, they feel powerless to break out of the trap created by the desire and need for a good evaluation and being part of the “team.” As a result they experience stress and guilt for behavior incongruent with their own consciences such as such as misleading patients, behaving unethically, or not intervening when they witness unethical behavior in team members.

The impact will lead to one of the following:

1. The clarification and strengthening of the student’s values
2. The confusion of the student’s values and, therefore, stress
3. The erosion of the student’s values

It is the student’s response to the conflict that shapes the student’s moral and professional maturation, and not necessarily the conflict itself.  The goal is self-authorship and not imitation or conformation to unethical group norms.

UVa reinforces high moral and ethical values

1. through the covenant at White Coat Ceremony
2. during CPD
3. through the covenant at Becoming a Clinician

UVa students report that derogatory comments occur in all settings but not often; it does occur, however, more on some services than on others.  Some third-year students choose to go into some fields of medicine because of the faculty response.

UVa meets with students 4 times a year to get feedback about unethical behavior and what can be done to help students and is considering using simulation exercises to provide students an opportunity to learn and practice skills in addressing dark humor in a safe environment.

Clerkship Director survey results

	67% heard a member of the health-care team make a derogatory comment about a patient, colleague, or student in a clinical setting.
	58% reported feeling comfortable with how they handled the situation
	42% reported feeling uncomfortable with how they handled it.
	89% believed it was important to respond.
	66% had not had training in handling dark humor or were uncertain if they had had training
	56% had never trained students in handling dark humor, 33% have trained students
	28% report that during the last year students have come to them with concerns about inappropriate comments made by a member of the health care team.
	33% have a formal process of review within the clerkship if these situations arise.
	56% report having training in providing culturally competent care to paitents.

  

Strategies for Addressing Discriminatory Remarks

1. Use “I” statements  (When you say ___, I feel ___.)
2. Specify the discriminatory comment (I think it is derogatory when you say ___.)
3. Suggest alternative ways of perceiving the situation (You may not think that statement is offensive, but from my perspective it is.)
4. Focus on the action and not the individual (That statement you made offended me because ___.)

Luncheon Workshops on Culturally Competent Care and Dark Humor – Elizabeth Bradley

 The clerkship directors broke into groups by discipline to consider ways to address Dark Humor and Culturally Competent Care with medical students.  

Acting Internships at Carilion Clinic – Mark Greenawald

 Informal survey of Student Affairs Deans and FM Chairs indicates that all require some form of AI or ACE and many require as many as 3.

 Purpose for AI’s or ACE’s

	To prepare students for transition to internship/residency
	To prepare students for specific internship/residency
	To remediate weak PGY-3 performance
	To build upon PGY-3 skills

 

Structure

	Four weeks in duration
	Require greater autonomy from student
	Involve increased responsibility and workload
	Include increased intensity
	Provide more upper level resident and attending contact

 
Objectives/Outcomes

	Variable and often vague
	Should they be competency driven?  Competencies are challenging to create, implement, and measure.
	It’s hard to get procedures for residents.  Is it possible to do so for MS4’s on AI’s?
	Subjective long term outcomes
	How will AI’s involve increased responsibility and autonomy in an age of increased regulation and decreased autonomy?

 

Conclusions

	Fourth-year AI’s are a long-standing tradition with many positive attributes.
	The structure and outcomes vary greatly within and among schools.
	There is a question as to whether or not they are competency driven.
	It is unknown how they will be impacted by changes in the health care structure.
	National criteria should be developed such as that given by the ACS.

 

Comments from Joint Clerkship Faculty

	All sites give medical students the opportunity to write notes, but UVa and Salem VA give students the ability to write orders.
	UVa is providing Epic Ambulatory training and Carilion is providing ambulatory and inpatient training.
	Autonomy is good but sometimes patients in the past might have gone through more than necessary.
	There is a need for senior oversight for quality reasons and for redefining “autonomy” to include more collaboration.
	While ownership reflects one’s commitment, it sometimes requires going to others for input.
	Change “hand off of care” to “transition of care”

Patient Safety in the Clerkships: Follow up - Innes

Core curriculum for effective experiential QI and safety education should include didactics on background KSA acquisition and team learning of experiential QI/safety.  Including learning in the clerkships would help the students be a more active part of the team.

Didactic elements should include the following:

	QI and safety epidemiology/background, principles of population-based medicine Systems science
	Human factors, systems thinking, complexity theory
	QI and safety skills
	PDSA cycles, root cause analysis, variation, process mapping
	Data collection ,analysis, presentation skills (run & control charts)
	Team participation & leadership (focus on interprofessional teams)
	Change theory & implementation

 

Requirements should include the following:

 

	Supportive institutional culture & infrastructure
	Faculty skilled and interested in QI/safety methods
	Residents interested in improving processes of care
	Functioning inter-professional teams who accept medical students as active participants
	Clinically relevant and educationally meaningful medical student role
	Near real-time relevant population-based data available

  

Currently QI/Safety education is contained in the AIM clerkship via CHESS simulation and the RxDx course.

Possible Options for the future

	Online modules for didactics and to demonstrate skill familiarity
	Reflective exercises/portfolio entries on clinical encounters
	CDR analysis:  Population level analysis or use CDR to build a cognitive simulation
	Create QI proposal:  practice skills, OSCE
	ACGME Vanderbilt matrix exercise
	Team training/CRM
	Participate in longitudinal QI – This is the best option but has many challenges.

Input from Joint Clerkship Faculty regarding ways to incorporate QI in clerkships 

	Include powerPoint slides that include patient safety issues specific to your clerkship (patient ID, side rails, patient dosing, etc.).
	Encourage faculty to address the issues when speaking to the students.
	Carilion OB changed SOAP note to SOAPS note with the last “s” to trigger students to think about safety     Carilion Peds developed a patient module centered on communication with the family from start-to-finish
	UVa Surgery orientation includes segments on the following:       Contamination, sterility, needle sticks (both patient’s and student’s safety).        OR activities that can compromise safety       Restrictions on what students can do that put patients at higher risks

Assignment for Joint Clerkship Faculty is to develop short list of safety issues that are clerkship-specific.

Update on Carilion Clinic – Dan Harrington

 The Clinic’s mission is to provide continually improving patient care supported by medical education and research.  Toward that end, the Clinic has hired approximately 150 new physicians over the past 36 months and will develop an integrated multi-specialty clinic over the next 5-7 years.

A few residency applications are pending but EM will begin in July, 2011, and the Clinic has ACGME approval for fellowships in Pulmonary/Critical Care, Cardiology, Infectious Disease, Palliative Care, and Addiction. 

The new Carilion Clinic Medical Office Building opened September 2010.

The Virginia Tech Carilion SOM and Research Institute complex was completed this year.  The first class of 42 students just completed the first block of a PBL curriculum with 4 domains:  basic sciences, clinical sciences, research, and interprofessionalism.  As founding Director of the VTCRI, Dr. Michael Friedlander will focus on neuroscience but will recruit cardiovascular, obesity, and infectious disease researchers.

Salem VA Update – Mehdi Kazemi

The Salem VA Learning Center is being modeled after the Cleveland Clinic and should be live within six months.  The VA is one of only 5 VA hospitals with funding of .5 million for patient-centered education, and is in the process of developing a 2,200 square foot simulation center.

Business Meeting

The date of the spring Joint Clerkship meeting will be Wednesday, March 30, 2011.  The location will be the UVa School of Medicine.  Details and directions will follow.

Please forward topic suggestions for this meeting to Don Innes at dji@virginia.edu