University of Virginia School of Medicine
Pediatric Conference Room, 4:00 p.m.
Present (underlined) were: Reid Adams, Gretchen Arnold, Eve Bargmann, Dan Becker, Robert Bloodgood, Gene Corbett, Thomas Gampper, Wendy Golden, Donald Innes (Chair), Howard Kutchai, Marcus Martin, Mohan Nadkarni, Chris Peterson, Jerry Short, Bill Wilson, Brad Bradenham, Emily Clarke, Sixtine Valdelievre, Debra Reed (secretary) Guests: Jeff Young, Darci Lieb
The Committee welcomed new member, Thomas Gampper. Dr. Mohan Nadkarni will also be joining the group later in 2008.
Anatomy Access Policy and Rules of Behavior. A policy for anatomy acess and rules of behavior has been finalized by the subcommittee. The policy has now been submitted to the Dean for final approval. When approved, it will be placed on the web along for students to read and sign electronically. [A NetLearning session has been devised to assure that all students have read and understand the policies. - 01.30.08 DJI]
Anatomy Curriculum Group. The group met this week to continue the discussion regarding the anatomy curriculum revision. Some progress has been made. Melanie McCollum, Anatomy Course Director, and Don Innes are to draft a curriculum proposal and circulate to the Anatomy Curriculum group for input.
Card Scanners in the Anatomy Labs. Card scanners have been installed on the doors to the Anatomy Labs. All students will have access to the labs. Faculty and others will need to be added to the list of allowed visitors.
Integrating War Games into Transition from 2nd Year to 3rd Year of Medical School. Jeff Young met with the Committee to outline his proposal for integrating war games into the School of Medicine curriculum.
The War Games program (low fidelity simulation) has been in place since 2003. Over 1000 case simulations have been completed in over 340 individual students and residents. Four peer reviewed publications and multiple presentations at national meetings [1-4] have come from this effort. The results have demonstrated that the cognitive performance of individuals can be improved in simulated clinical situations through deliberate practice as created by the War Games process.
The War Games take urgent clinical situations and break them into their component actions. The subjects is presented with data as they ask for it, and must stabilize the patient by describing what actions they would take, and what labs and studies they would obtain (please see email attachment for sample evaluation sheets). Feedback from students has been consistently positive, and has centered around the fact that this training is unique to their medical school experience.
We wish to use the War Games to prepare second year medical students for the realities of their ward rotations, and to provide them with a framework for the types of clinical decisions they will encounter. Many students relate that the ward experience is so different from their previous encounters that it is difficult for them to keep pace with the clinical work, and to know how to separate essential from frivolous information. We believe that a "curriculum" of War Games involving second year medical students that take place at the second half of their second year will enhance their clinical experience in their third year.
We have developed a curriculum of clinical encounters that we believe provides a continuum of care from the simplest to the most complex. Inherent in these simulations are condensation of information and patient presentations. In addition to helping them understand the process of clinical care, this will enhance the student's ability to put together concise and effective clinical presentations during their third year.
The proposed mandatory case curriculum includes:
Patient Risk Assessment
Simple pre-operative surgical patient screening
Simple medicine admissions screening
Cardiac, Pulmonary, Metabolic, Infectious
Routine Hospital Admission
Post-operative surgical patient, Routine medicine admission, Pediatric
Emergent Changes in Patient Condition and Stabilization
Somnolence - Drugs, CVA, Hypotension, Hypoxia,
Cardiovascular - Hemorrhagic shock, Cardiogenic shock, Congestive heart
failure, Rapid arrhythmia, Bradycardia
Pulmonary - Aspiration, Pneumonia, Pulmonary embolism,
Pulmonary contusion, Pain (atelectasis)
Renal - Oliguria--Preload, ATN
Metabolic - Hypoglycemia, Hyperkalemia
Infectious - Rigors and fever, UTI, Sepsis of unknown origin, Severe
Progression of Care - Medical discharge process, Surgical discharge process, Pediatric discharge process
Optional Critical Care Medicine Curriculum
Respiratory failure and ventilator management - ARDS, Pleural effusion,
Lost airway - Lost trache, Inability to ventilate
Cardiovascular - Severe MI, Hypotension, Hypertensive crisis
Sepsis - Routine therapy, Refractory hypotension with multiple organ
Erroneous data from equipment
CNS - Blown pupil, Severe agitation
We propose that groups of ten students are assigned two one-hour sessions weekly. At those sessions we will proceed through the cases in the curriculum. Every student will not perform each case, but they will encounter every case since they will be present at the session when the case is presented to another student and critiqued. Each student should attend six sessions at minimum. Our lab can accommodate six sessions weekly. Each student can track their performance if they wish through our evaluation scheme, but all records will be de-identified after the student has completed their sessions. All information is confidential unless the medical school administration wished to use it in some manner. At the termination of all sessions, we ask the students by email if they would allow us to use their anonymous responses for research purposes. If they decline their responses are deleted from our database. This work is approved by the SBS-IRB. The sessions are either conducted by myself or my lab coordinator who has witnessed or participated in every session since the inception of the project.
Obviously scheduling all of the students would be complex so we would need as much lead time, and help as possible from the administration of the second year class.
Dr. Young provided the following citations for published articles regarding War Games.
1. Young, J., et al., "The Use of "War Games" to Evaluate Performance of Students and Residents in Basic Clinical Scenarios: A Disturbing Analysis. Journal of Trauma, 2007. 63(3): p. 556-565.
2. Young, J., R. Smith, and S. Guerlain, Resident Cognitive Performance in Surgical Critical Care: The Basic Science of Medical Errors. American Surgeon, 2006. 73(6): p. 548-555.
3. Young, J., et al., Proactive versus reactive: the effect of experience on performance in a critical care simulator. American Journal of Surgery, 2007. 193(1): p. 100-104.
4. Young, J. and T. Hedrick, The Use of "War Games" to Enhance Clinical Decision Making in Students and Resident American Journal of Surgery, 2007. In press.
Sample grading sheets and transcripts from War Games completed by third year students in the past were also distributed.
The cases that have already been developed are divided into three levels of difficulty. Level 1 and even 2 may be appropriate for medical students. Level 3 is geared more toward the intern or resident.
The Committee discussed the "debriefing" session with Dr. Young. The Committee noted that the lack of discussion of the case with an attending or resident after the sessions was a major weakness. The Committee briefly discussed when and where in the curriculum these exercises might be valuable. Cases might be placed in PoM2 and even PoM1. Inclusion in the transition course, the Life Saving Techniques Workshop and the clerkships was also mentioned. The possibility of a pilot program was briefly discussed. It was suggested that this might also be useful as a computer based timed exercise. Dr. Young was asked to provide a video of a War Games session to the Committee and electronic copies of the publications.
The Committee will discuss this proposal at an upcoming meeting and respond to Dr. Young's proposal after that discussion.