CC Minutes 12.21.12

CC Minutes 12.21.12

University of Virginia School of Medicine
Curriculum Committee
Minutes – 12/21/12

Pediatric Conference Room, 4:00 p.m.

Present (underlined) were: Gretchen Arnold, Robert Bloodgood, Stephen Borowitz, Megan Bray,  Donna ChenPeter Ham, Donald Innes (Chair), John Jackson, Keith Littlewood, Nancy McDanielBart Nathan, Amita Sudhir,  Linda Waggoner-Fountain, Casey WhiteBill Wilson,  Mary Kate Worden,  Jeremiah GarrisonDebra Reed (secretary)

2011-12 Clerkship Reviews

Discussions of three reviews were conducted. 

1. Family Medicine Clerkship Review 2012  This  annual review was conducted by  Curriculum Committee members:  Theresa Schlager , Donald Innes, and Elizabeth Bradley and presented  for Curriculum Committee discussion.       

The Family Medicine clerkship goal is to provide students with the clinical skills, knowledge, problem solving skills, and professional attitudes necessary to access and care for patients in the family practice setting.

At the core of the Family Medicine setting is providing comprehensive care to the patient and their family. The reality of primary care is that it includes many varieties of care including acute and chronic medical care, prenatal care, obstetrical delivery care, pediatric care, basic preventive care, basic mental health care, inpatient care, nursing home care, etc. The experiences while varying from practice to practice are comparable and meet the core learning objectives for Family Medicine.

On the Family Medicine clerkship the student becomes an integral member of an active community practice seeing 80-120 patients from a diverse population of patients presenting with a wide variety of problems. The student experiences the diagnosis and treatment of common and undifferentiated medical problems, and experiences continuity of care by seeing patients at follow-up visits, patients with chronic medical problems and patients presenting for preventive health visits. The students also attend to patients presenting with a variety of psychosocial issues.

Clerkship Strengths

  • Students have a 1:1 mentoring relationship with a generalist physician for 4 weeks. The attending physician develops a close working relationship with the student, helping them to develop broad clinical skills by setting expectations, giving feedback, and assessing improvement.
  • Students are given first interview; independent access to patients in a real time clinical setting to try their clinical skills.
  • The clerkship has been the highest rated clerkship for 7 of 8 years in the Student Mulholland report.
  • Mid- and end of clerkship evaluations include history taking, physical exam, use and interpretation of diagnostic tests, clinical procedures, and professionalism. The mid-clerkship feedback requires written comments and face-to-face review by both the student and the attending physician.
  • Students are exposed to a wide variety of chief complaints and medical conditions many of which present as undifferentiated.
  • The EBM exam assessing the student’s understanding and application of principles of Information Mastery.
  • Cultural Competency Workshop and OSCE.
  • Family Medicine Morning Report Workshop - students present 3 self determined learning objectives; then teach a small group what they have learned on the rotation with attending physician feedback.

Clerkship Weaknesses

  • Office practice varies. Some practices are more procedure based, some include obstetrics, inpatient, or nursing home care, and some are independent of consultants while others refer more often. Students share their experiences in morning report presentations and workshops so that all students may understand that primary care delivery can vary depending on geography, culture, and resources.
  • Achieving grading consistency among solo preceptors and grade inflation is difficult.


Recommendations

  • Develop an Objective Clinical Skills Exam assessment component for Family Medicine clerkship learning objectives. Work with the OSCE Group to include Family Medicine in the quarterly “medicine” OSCE.
  • Explore with the Simulation Center the use of simulation for clinical skills learning.
  • Develop cultural competency learning objectives around military, rural, recent immigrants, etc. as well as clinical topics, e.g. obesity, dyspepsia, asthma.
  • Monitor the changing personnel in practices; court UVa Family Medicine graduates as a pipeline of new Family Medicine preceptors.
  • Pursue faculty development opportunities to further the consistency of grading and to focus on the core Family Medicine skill sets.

 

A progress report with detailed plans addressing each of the above recommendations is due to the Curriculum Committee by February 13, 2013.

In summary, the Family Medicine clerkship is well organized and operates smoothly thanks to the leadership of the director Peter Ham and coordinator Leslie Stewart. Our findings and those of the most recent April 2012 Mulholland Report were considered.

Additional discussion noted that the Family Medicine clerkship gave students

  • example, valuable experience in basic clinical H&P skills
  • increased responsibility and autonomy in interacting with patients
  • opportunities to form relationships with preceptors who are passionate about teaching
  • exposure to a wide variety of common medical issues
  • workshops covering essential skills and material

 

It was also noted that reimbursement, travel and site placement remain areas in need of constant monitoring, evaluation of current workshops – elimination of some and the creation of others as educational needs change and clerkships become increasingly integrated, define entrustable professional activities (EPAs) for Family Medicine both procedures and one-on-one experiences, and increasing pediatric and OB/GYN exposure and patient diversity.

It was noted that filling all the preceptorships locally for Family Medicine has proven impossible. It was suggested that recruitment be conducted during local Medical Society events. UVA outreach clinics should be used for preceptorships whenever possible.   Obtaining evaluations from preceptors at away sites has been problematic – suggestions to tie evaluations to funding. Stressing the importance of timely submission of evaluations (within 10 days) should be communicated. The Committee offered to provide assistance to the clerkship director if needed.

2.        A.  Perioperative and Acute Care Medicine Clerkship – EM Week Review 2012  This  annual review was conducted by  Curriculum Committee members,  Megan Bray and Keith Littlewood,  and presented  for Curriculum Committee discussion.      

Clerkship Director –Amitha Sudhir, MD

Strengths of Clerkship:

  • Dedicated Clinical faculty who are invested in teaching and accessible to students.
  • Exposure to simulation activities with real time feedback. 
  • Didactic Curriculum

Areas of Challenge for Clerkship:

Most challenges have been due to the constraints of the one week time frame.

  • Lack of continuity as perceived by students.
  • Inability to practice writing ER notes given EMR system.

Recommendations
** See proposal for expanded clerkship on the Curriculum website. 

  • The clerkship will expand from 1--> 3 weeks.  The above areas of concern will be adequately addressed by the additional time spent in the new clinical rotation.  There will be 9-11 students per block.
  • Clinical time will expand significantly.  Students will be paired with a resident for an entire 8-hour shift providing continuity for students.  Student will work night and weekend and day shifts to expose them to variety of patients and work hours.
  • Didactic time will expand.  Simulations will occur in am and workshops in pm.  There will be some web-based learning modules to complete.  All lectures will continue to be available to students on line.
  • First Day Orientation will expand.  Still will review expectations of course, but will also complete workshops on EKG -reading & performance, BLS, suturing and splinting.
  • Assign students the task of learning & writing acute care H&P’s and has identified faculty members who will consistently read, grade and provide feedback to students.
  • Begin mid clerkship feedback sessions and personally meet with students.
  • The mid-clerkship evaluation will have assigned readings with post reading quizzes weekly.
  • A separate clinical clerkship coordinator is needed to assist with scheduling, grading, and maintenance of web site, etc. 
  • Devise a mechanism for assessment of students - paper vs. electronic evaluations, grade components, and mechanism for getting feedback from faculty and residents.
  • Given the current scheduling with other clerkships - students every 4th block will have to take their medicine shelf and their EM test in back to back days. 

Dr. Sudhir has begun to design a thoughtful and organized expanded clerkship.  She is aware of some immediate needs moving forward and is savvy enough to recognize that as her clerkship rolls out there will be unanticipated, new challenges that arise.

A progress report with detailed plans addressing each of the above recommendations is due to the Curriculum Committee by February 13, 2013.

In summary, the Acute Care Medicine clerkship is well organized and operates smoothly thanks to the leadership of the director Amita Sudhir. Our findings and those of the most recent April 2012 Mulholland Report were considered.

B.  Perioperative and Acute Care Medicine Clerkship  – Anesthesia Week Review 2012  This  annual review was conducted by  Curriculum Committee members,  Megan Bray and Keith Littlewood,  and presented  for Curriculum Committee discussion.      
CPD-2 PACM- Anesth Portion
Clerkship Director- Ashley Shilling, MD

Strengths of Clerkship:

  • Core Faculty that participate and are responsible for Simulation and Didactics- Ashley Shilling, MD; Keith Littlewood, MD; Chris Stemland, MD ; and Sachin Mehta, MD.  Provides consistency and continuity to simulation experience for students.
  • Simulation Experience within the Clerkship. 
  • Resident Liaison Group that helps to facilitate learning and takes responsibility for the large majority of onsite clinical teaching.
     

Areas of Concern for the Clerkship:

  • Short duration of Clerkship. Students have voiced concerns that they cannot build relationships with clerkship director, other faculty or residents given the limited time in clinical setting.
  • Limited clinical exposure time.

Recommendations

  • Clerkship is expanding from 1à 2 weeks.  This will place 7 students on rotation per block.
  • Given the limitations of expense and faculty availability, Simulation time will remain constant but clinical time will greatly expand.  Students will be able to participate in a variety of areas including Pre-op/ Main OR/PACU/ Obstetrics/ Pain Service and OPSC.
  • Didactic Curriculum will expand.  The current plan is to utilize the Resident Liaison group to help give weekly lectures/group sessions.
  • Revamp goals and objectives [With Michelle Yoon in SOM Med Ed division], orientation schedule and clerkship handouts.
  • A dedicated coordinator is needed to make schedules for students every evening for the next day.  Other tasks that a coordinator could help with include grading, evaluation and maintenance of web site etc. 
  • Appoint  an assistant clerkship director to help share in responsibilities and not overburden one person makes sense.
  • Devise a mechanism for assessment of students - paper vs. electronic evaluations, grade components, and mechanism for getting feedback from faculty and residents.
  • Given new clerkship pairing and scheduling-  every so many blocks, student will have to take the surgery rotation shelf back to back with this exam.   
  • Midclerkship feedback is necessary.
  • Following the first iteration of this expanded clerkship, re-evaluation and possibly modification may be necessary.
  • The current lack of student notes in Epic will be addressed in the new clerkship schematic.  There is a methodology in Epic that student notes are part of the patient record and can have faculty/resident feedback attached but their notes are not used in patient care.   Epic training for both faculty and students should be completed by 3/1/12. 
  • An Assistant Clerkship director should also be found for these clerkships.
  • Following the first iteration of this expanded clerkship, re-evaluation and possibly modification may be necessary.
  • The current lack of student notes in Epic will be addressed in the new clerkship schematic.  There is a methodology in Epic that student notes are part of the patient record and can have faculty/resident feedback attached but their notes are not used in patient care.   Epic training for both faculty and students should be completed by 3/1/12. 
  • An Assistant Clerkship director should also be found for these clerkships.
  • The current lack of student notes in Epic will be addressed in the new clerkship schematic.  There is a methodology in Epic that student notes are part of the patient record and can have faculty/resident feedback attached but their notes are not used in patient care.   Epic training for both faculty and students should be completed by 3/1/12. 
  • An Assistant Clerkship director should also be found for these clerkships.

Additional EM and Anesthesiology Discussion 

Life Saving Techniques Workshop might be better incorporated into the new extended PACM-EM clerkship.

The most recent April 2012 Mulholland Report was reviewed and the major concerns will be addressed with the expansion of the Emergency Medicine (Acute Care Medicine) section to three weeks and the Peri-operative to two weeks.


In summary, the Acute Care Medicine clerkship is well organized and operates smoothly thanks to the devoted effort of Ashley Shilling, MD; Keith Littlewood, MD; Chris Stemland, MD; and Sachin Mehta, MD.

 

A progress report with detailed plans addressing each of the above recommendations is due to the Curriculum Committee by February 13, 2013.

 

3.  Neurology Clerkship Review 2012This  annual review was conducted by  Curriculum Committee members,  Megan Bray and Keith Littlewood,  and presented  for Curriculum Committee discussion.      

Clerkship Director: Guillermo Solorzano, MD, Priscilla Potter, MD

Summary of Neurology Clerkship

The Neurologic Clerkship is a 4 week experience completely at UVA.  Students rotate on two of the following services for two-week blocks:  general inpatient neurology service, stroke team, neurology consults, pediatric neurology, outpatient neurology clinics, or neurology specialty clinic.  During that time, students also have other learning activities such as neurology clinical skills training, 3 weekly quizzes, and oral exams.  Other learning activities such as lectures have been replaced by online problem sets and reading materials so students can access them on their own time without disruption of other clinical learning and whether their clinical service is located at the main hospital, west complex, or Fontaine.  Students have a take-home exam, and two H&P reviews. Students participate in other learning sessions with residents such as daily morning rounds and inter-disciplinary stroke patient team meetings. Students are assigned as observers in one of the multidisciplinary clinics of Huntington’s disease, ALS, Multiple Sclerosis, or Deep Brain Stimulation where they observe the interactions of the team members of neurology physicians, physical, occupational, and speech therapists, social worker, and disease specific agency workers to work to promote improved quality of life to the disease specific patients.

Strengths of the Neurology Clerkship:

Students rate the neurology clerkship highly overall (3.5/4.0: from the 2011 Mulholland report), especially in organization and quality of teaching from attending physicians and housestaff, many of whom have received teaching awards from students, housestaff, and  hospital wide. 

The standardized curriculum developed by the American Academy of Neurology Medical Student Consortium is a strength of the clerkship.  This allows students consistent exposure to common neurological problems, assessment that is tied to specific learning objectives, and feedback that prepares them for the exams and medical practice.

The Neurology Clerkship is organized to promote teacher-learner continuity.  Neurology attending physicians are on service the entire 2 weeks students are on their rotation.  Dr. Ivan Login, an attending physician who has received awards for teaching and is considered a master-educator, oversees the student clinical skills and physical exam training by teaching the students and training Chief Residents to assess and teach students in clinical skills during the rotation.  And, the Clerkship Directors review all take home tests and H&P write ups to provide feedback and consistent evaluation of student performance.

Weaknesses of the Neurology Clerkship:

Like many rotations, students cannot be guaranteed to see the full spectrum of real patients with problems to learn neurology sufficiently to prepare for the exam or for medical practice.  This is because of patient volumes and inability to control admission diagnoses.  The Neurology Clerkship does an excellent job with online materials, weekly quizzes and teacher-learner continuity to ensure that core clinical skills and topics are covered and strengthened when clinical experiences are available.

Recommendations:

The Neurology Clerkship is in excellent shape and should remain in its current organizational structure, rotations, assessment methods, and oversight.

  • Recruit a co-clerkship director when Dr. Potter retires.  Develop a job description for the clerkship directors with time estimates for orientation, grading take home exams, reviewing H&P exercises, overseeing clinical skills training, providing feedback to residents and faculty, and other teaching to be sure both clerkship directors have clear roles, adequate time and support.
  • Recommend that the intersession following or preceding neurology include an adult Lumbar Puncture simulator exercise (follow up to the CPD session in the first year) to ensure that every student can perform this core clinical skill.
  • Compile a list of teaching awards or positive comments from the Mulholland Report that faculty and house staff have received to showcase the excellent teaching this rotation provides. Awards given by residents to faculty (or vice versa) support the overall high caliber of teaching interactions when students work with this department.
  • Designate the stroke inter-disciplinary team meetings in which students participate as an example of inter-professional education (IPE).
  • Include use of cyracom phone and translator services during student-patient interview as examples of cultural competency training.
  • Formally recognize Dr. Ivan Login’s training of chief residents to assess students’ neurologic exam skills in a Resident as Teacher program. If and when Dr. Login wants to retire, develop a strategy to support another faculty as a master teacher to continue teaching chief residents to assess medical students.
  • Retain a Clerkship Coordinator that has intimate knowledge about the schedules within the Department of Neurology. The Clerkship Coordinator must retain the ability to coordinate resident and attending schedules to fit in the many learning activities described above. This is a complicated clerkship with seven clinical services, orientation that occurs during inpatient rounds, two formal end-of- clerkship exams, clinical quizzes, clinical skills assessment, and online resources that need to be coordinated with chief resident, regular housestaff and attending physician schedules.  Currently it is working well. The Medical Education Office should provide central oversight by approving of the clerkship coordinator’s job description; however, the coordinator should remain within the Department of Neurology.

 

In summary, the Neurology clerkship is well organized and has been improved and energized by Drs. Potter and Solorzano.

A progress report with detailed plans addressing each of the above recommendations is due to the Curriculum Committee by February 13, 2013.

Donald J. Innes
dmr