University of Virginia School of Medicine
Curriculum Committee
Minutes – 05/12/11

Pediatric Conference Room, 4:00 p.m.

Present (underlined) were: Gretchen Arnold, Robert Bloodgood, Megan Bray, Troy Buer, Chris Burns, Donna Chen, Eugene Corbett, Thomas Gampper, Wendy Golden, Donald Innes (Chair), John Jackson, Keith Littlewood, Veronica Michaelsen, Mohan Nadkarni, Linda Waggoner-Fountain, Bill Wilson,  Mary Kate Worden, Thomas Jenkins, Long Vinh,  Sam Zhao,  Debra Reed (secretary)

1. Role of Medical Students in EPIC.  Sam Zhao presented student  recommendations to the Curriculum Committee for enhancing the role of medical students in Epic. 
   
   As stated in the document “Competencies Defined for the Degree of Doctor of Medicine at the University of Virginia” (http://www.medicine.virginia.edu/education/medical-students/UME/curriculum/Competencies-IIDR3.pdf/view?searchterm=competencies ), by the time of their graduation, medical students should demonstrate:
   
   The ability to engage and communicate with a patient, develop a student-
   patient relationship, and communicate with others in the professional setting, using interpersonal skills to build relationships for the purpose of information gathering, guidance, education, support, collaboration and the provision of individualized patient care.
   
   The ability to record, present, research, analyze and manage clinical information.
   
   Quality patient care is dependent on health care providers’ efficiently accessing and effectively communicating information about the patient.  Written notes and orders are the most important part of the patient chart.  Written notes and orders should be windows into the clinician’s thought processes – communicating to other care providers what is going on with the patient, why, and what the plan of care is.  For medical students to learn how to communicate in the patient record effectively, they must practice doing so.  Students develop competence by practicing and receiving feedback on their clinical skills, including the writing of notes that communicate their diagnostic reasoning and their therapeutic plan and its rationale, and operationalizing that therapeutic plan through the creation and entry of orders. 
   
   Both before and after the deployment of the EPIC electronic health record at the University of Virginia, faculty physicians and house-officers have had highly variable expectations of a medical student’s role and authority in documenting within the medical record and authoring medical orders.  We recommend the Curriculum Committee adopt the following universal recommendations around medical student documentation and order entry: 
   
   1.  In ALL clinical settings, Medical students should document all of their patient encounters within the electronic medical record at the University of Virginia.  
   
   

   a.	Medical students should write and publish their own H and P’s, consultation notes, and daily progress notes.  These notes will be part of the permanent medical record and should complement but not replace clinical documentation performed by resident physicians and/or attending physicians.
   b.	Supervising faculty and housestaff should read and comment on medical student documentation using the “addend” rather than “edit” function.   This will preserve the student’s authorship and make it easier for others to see that the student is the primary author of the documentation.
   c.	Faculty and housestaff must not ask or allow students to sign-in to the electronic medical record using a house-officer’s or faculty member’s username and password.  This is a direct violation of federal and UVA policies.

   
   2.     Medical students should be encouraged to enter patient orders for patients they are participating in the care of. 
   
   

   a.	All medical student orders will be entered in a “pended mode” meaning that the orders will not become active until they are reviewed and signed by a licensed independent practitioner who has ordering authority.
   b.	Whenever possible, if a student has entered a pended order, house officers and faculty physicians should review, revise and activate those orders and discuss corrections with the students.

   
   BILLING REGULATIONS AND THE ROLE OF STUDENT DOCUMENTION
   
   Current CMS regulations state "Students may document services in the medical record; however, the teaching physician may only refer to the student’s documentation of an E/M service that is related to the ROS and/or PFSH. The teaching physician may not refer to a student’s documentation of physical examination findings or medical decision making in his or her personal note. If the student documents E/M services, the teaching physician must verify and redocument the history of present illness and perform and redocument the physical examination and medical decision making activities of the service."
   
   This means that when documenting to support billing for E/M services, the attending physician may reference the student’s documentation of the patient’s problem list, medication list, allergy list, review of systems, past medical history, past surgical history, family history and social history.
   
   When documenting to support billing for E/M services, the attending physician MAY NOT reference a student’s documentation of the history of present illness, physical examination, and/or assessment and plan, and rather, must “redocument” these components.
   
   The Curriculum Committee endorses the students desire to have an active role in EPIC and deems this necessary to the students’ education.  The Clinical Medicine Committee will review the recommendations, possibly invite Dr. Stephen Borowitz to attend and prepare a response to be submitted to the Dean’s Office and Hospital Administration.
2. Clinical Performance Development.  Eugene Corbett outlined the progress of the Working Group on Clinical Skills Education.    The Group has developed a series of recommendations for CPD. The Committee discussed the progress of the Working Group and their recommendations.   
   
   The Committee was asked to read the recommendations carefully, consider how best to insure a longitudinal CPD experience for all students, and be prepared to discuss concrete steps at the June 2 Curriculum Committee meeting.
   
   RECOMMENDATIONS:
    

   1.	Establish a CPD leadership process in the School of Medicine:
   	A.  Create a CPD leadership committee in the SOM to provide centralized and integrated oversight of CPD design & implementation, administration, program evaluation and accountability.
   	Recommended CPD leadership committee members:
   	CPD I Co-Directors CPD II Co-Directors CPD III Director Clerkship Directors Student Medical Education Committee (SMEC) representation Clinical Performance Education Center representation Overall CPD Director
   	B.  Designate one overall CPD director who reports to the Associate Dean for Undergraduate Medical Education.
   	This reorganization (A & B) will help ensure that students’ clinical performance education is an integrated, longitudinal and developmental experience.
   	C.  Appoint CPD II co-directors who, working with clerkship directors, are directly responsible for oversight of CPD activities within clerkships. This will include providing for clerkship director input, standardized clerkship  design & implementation, coordinated administration, program evaluation and accountability.
   	The CPD II Co-Directors are also responsible for overseeing decision making and management as it relates to the following:
   	OASIS database utilization in the clerkships Financial support issues Clerkship accountability Faculty development and resident teaching skills programs Technical support (website, online cases, etc)
   	This leadership structure should replace the current Clinical Medicine Committee.
   2.	Standardize clerkship experiences.
   	The CPD II leadership should oversee the design and implementation of a standardized clerkship experience. Ultimately this should emphasize maximum patient care involvement and continuity of student-teacher mentoring. To this end the following should be implemented in this effort:
   	Administration: Develop clerkship-specific learning objectives Approve clerkship-specific student schedules Set expectations for the degree of student autonomy Limit orientation time/content  to maximum of  1 day Establish student on-call requirements
   	Clinical Performance Documentation : Provide guidelines/expectations for student note-writing, documentation and review by attending physicians and residents Review and coordinate clerkship passports, and establish uniform criteria for sign-off procedure. Specify guidelines for utilization of the Student Learning Portfolio for tracking clinical experiences, recording personal reflections, and documentation of student evaluation & feedback by clinical mentors (CPD I-II-III)
   	Patient Contact: Assure that  daily student-patient contact responsibilities occur from the beginning of and throughout the clerkship period Specify the number and kind of clinical case exposure (ED2) Require a specified number of independently performed student History and Physical Examinations including write-up (student autonomy issue) Set expectations for both inpatient and outpatient patient experiences in each clerkship discipline
   	Teaching Responsibilities: Designate  faculty who are available to students throughout each clerkship period who are responsible for individual student evaluation and feedback Designate responsibility for attending-student rounds in each clerkship Identify specific clinical skills to be learned and practiced throughout the year Develop clinical skills workshops in all clerkships. Offer Systems-Based Practice experiences in all clerkships (e.g., ethics, medico-legal, interprofessional, health system) Encourage teaching-by-student time and include evaluation & feedback on such student performance by attending physician, peers (also a CPD III goal) Advance attending expectations of students’ clinical performance as the year progresses (developmental principle) Maintain basic science learning/involvement in each clerkship Ensure continuity of CPD mentoring throughout four years (CPD I-II- III)
   	Standardize clerkship student assessment:
   	The CPD II leadership should design and implement a standard approach to student assessment. It is recommended that clinical performance evaluation should comprise the majority of any clerkship grading procedure, with written examinations contributing less than 50% to the overall grade:
   	Suggested elements to consider in clerkship grading procedures: Shelf/written examination OSCEs in all clerkships Preceptor evaluation (Uniform Clerkship/CPD III evaluation form) Mid clerkship evaluation and feedback process/form) Resident evaluation Peer evaluation Self evaluation The use of all 12 clinical competency objectives categories Proportionality of elements for grading to be determined
   	Design a longitudinal/continuity clinical experience
   	The Curriculum Committee should appoint a subcommittee to develop a plan for the design and implementation of a longitudinal clinical experience for all medical students within the four year curriculum.
   	Considerations should include any combination of outpatient or inpatient experiences. Multiple selective options should also be considered. For example: Weekly outpatient clinic attendance any time within the 4-year curriculum A longitudinal clerkship experience A longitudinal CPD III experience Longitudinal care of patients which includes transitional care opportunities (long-term care, nursing home, rehabilitation hospital care)
   	This longitudinal experience is required in order to ensure that student-patient continuity is contained in the School of Medicine curriculum. This is an essential underlying principle of both contemporary clinical practice as well as that required for clinical performance development education.
   3.	Student Testing Recommendations.  Bart Nathan, co-chair of the System Leaders, presented a list of testing recommendations developed by students for the Next Generation Curriculum. The recommendations were approved by the Curriculum Committee.

MCM/MIS/MSI/MBB Testing Recommendations

Most recommendations considered beginning for class 2015
Recommendation on summative exam open/close times

1. Summative exams should open for log-in on Friday at 12:00 noon and close for log-in Sunday at 1:00pm. There is a 4 hour window after log-in to take and finish the exam.
2. In order to make more vacation time, new material will be taught on Fridays before summative exams.
3. John Jackson’s office should ensure technical support is available to students over the weekend and particularly on Sunday near closing time.
4. Systems Leaders will not be designated contacts for technical problems.
   

Recommendations on exam/quiz score reporting and challenges
Exams (summative assessment)

1. The process should be implemented with the first summative exam in MCM for SMD15.
2. The process should be piloted before implementation. If possible, a non-graded anatomy quiz in GI could be the first trial.
3. Students may challenge a maximum of three questions per exam.
4. Challenges will be accepted through the online testing system.
5. Students will have 30 minutes after completing the exam to submit their challenges.
6. Students will not be given answers or scores before they submit their challenges.
7. Student review of exams will be done using printed copies that include any answer explanations in the Office of Medical Education until Friday at 5:00pm following the exam.
8. Exam grades will be posted through Oasis by Monday at 5:00pm the week following (7 days) the exam.
9. Preliminary grades will not be posted.
10. Scores will not be made available through the online testing system.
    

Quizzes (formative assessment)

1. As per summative assessments, except:
   a)      No challenges accepted (system leaders may always correct any problem questions of which they become aware).
   b)      Quiz grades will be posted by Wednesday at 5:00pm (or within three business days of the quiz closing).
   

Practice quizzes (ungraded formative assessment)

1. Students should be given periodic practice quizzes (e.g. weekly).
2. The questions should closely reflect the style and difficulty of those used in summative exams for that system.
3. Practice quizzes should be administered through the online system similarly to graded quizzes and exams using appropriate open/close times.
4. Practice quizzes should contain 15-20 questions for one typical week.
5. Students should receive immediate feedback for scores, correct answers, and explanations.
6. No challenges accepted.
7. Questions that do not reflect those used on summative exams may be made available to students, but to avoid confusion, these should be clearly labeled “Study Aids”, not “Practice Questions”.
   

Donald Innes
dmr