University of Virginia School of Medicine
Pediatric Conference Room, 4:00 p.m.
Present (underlined) were: Gretchen Arnold, Eve Bargmann, Megan Bray, Dan Becker, Robert Bloodgood, Thomas Gampper, Wendy Golden, Donald Innes (Chair), Howard Kutchai, Marcus Martin, Mohan Nadkarni, Chris Peterson, Jerry Short, Bill Wilson, Kira Mayo, Jason Franasiak, Guest: Anne Chapin, Debra Reed (secretary)
Announcements. The Committee welcomed Megan Bray, M.D., as a new member of the Curriculum Committee.
CSTAP (Clinical Skills Training and Assessment Program) Report. Anne Chapin met with the Committee to discuss the CPX program.
The CSTAP program has three components. During the PoM1 course, small groups participate in clinical exercises involving primarily history taking, physical examination, and cultural sensitivity. During the PoM2 course, H&Ps in the UTA and GTA portions of the course involve history taking, physical examination, patient note, and invasive procedures. The CPX during the clerkship year is a performance exam with a focused PE and patient note.
What is going well?
- Over past 10 years, case means and ranges have remained relatively consistent.
- Many students report that the CPX is a great learning experience.
- Students report that it is a good opportunity to practice the format of the USMLE Step 2
- Consistent with past years, physical exam scores are lowest.
- Done incorrectly because students listen to heart and lungs through gown.
- Many critical PE items overlooked.
- Students do not incorporate patient education smoothly.
When the PE was not done or done incorrectly, errors were made in the following:
- Anxiety Case: lungs 25%, heart 35%, thyroid 90%.
- Appendicitis Case: abdomen 23%, percussed 71%, heart 40%, lungs 50%, raise leg 75%.
- Hypertension Case: BP one arm 52%, BP two arms 98%.
- Chest pain Case: BP 60%, lungs 35%, heart 58%, pulses 85%, one side of neck lying down 77%.
Other problem areas:
- 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, tricspid and mitral areas.
- Several cases reported that 30% of students did not drape them.
- Lowest scoring case was contraceptive counseling.
In the 2007 USMLE CS examination 8 students did not pass. Possible reasons for this might be:
- Students casual: assumed showing up and speaking English = pass. (no review)
- In clerkships speed and diagnostic efficiency are valued ≠ quality focused PE + patient education of performance exam format.
- Students failing CS difficult to predict: Low performing CPX students generally pass CS exam. Students who fail CS exam perform just below average in CPX.
- Students have little practice or feedback in performance exam format.
What has the CSTAP Program done?
- Offered practice sessions after CPX with SP feedback on checklist.
- Invited low scoring students to practice sessions.
- Offered individual coaching to all CPX students.
- Advised all students to review First Aid book to prepare for CS exam
- Raised passing score for POM 2 H&P assessment.
- Remediated all POM 2 low-scoring students.
What should be done?
- Review checklist items for importance, revise if needed.
- Propose adding CPX type activity (2 cases) at beginning of clerkship with feedback so students understand nuance of performance exam (Hx, focused PE, patient ed.).
- Urge faculty to more closely observe and monitor clerkship student PE skill development.
- Model excellence, students do what they see.
- Preparation of a web video of the "ideal" H&P for student review prior to the CPX (an attending do a full or appropriate PE on a patient)
- Addition of one or two SP cases to the beginning of the clerkship year (providing the student with perspective as they go through the clerkships)
- Expand the CSE program to more clerkships
- Increase use of proctored simulated cases in the Simulation Center, e.g. breast exam
- Questions regarding time constraints of the CPX versus those of the USMLE-CS were raised. From student comments, time does not appear to be a major issue. Students who have been on the wards are already in the mindset of completing tasks in a time delineated fashion.
The Committee noted that if the Clerkship Passports were used as intended, many of the issues raised in the CPX would not be a problem. The CSTAP provides a detailed report to the Clerkship Directors on each year's CPX results.
- The Clinical Medicine Committee is asked to review the report and develop an "action plan" to address these issues. PoM1 and PoM2 directors should be involved in the Clinical Medicine Committee discussion.
- A short focused report (1-2 pages) should be provided to the Clerkship Directors with instructions that the information should be shared with all the Clerkship sites and teaching faculty and housestaff. This focused report should be broad and perhaps not clerkship specific.