University of Virginia School of
Minutes – 11/21/13
Pediatric Conference Room, 4:00 p.m.
Present (underlined) were: Gretchen Arnold, Stephen
Borowitz, Megan Bray, Donna Chen, Peter Ham,
Donald Innes (Chair), Sean Jackson, Keith
Littlewood, Nancy McDaniel, Bart Nathan,
Sabrina Nunez, Theresa Schlager, Neeral Shah, Amita
Sudhir, Linda Waggoner-Fountain, Casey White,
Bill Wilson, Mary Kate Worden, Elizabeth
Bradley, Lee Eschenroeder, Jean-Baptiste Maitre, Derrick
Thiel, Debra Reed (secretary)
2013 Annual Family Medicine Clerkship Review This annual review was conducted by Curriculum Committee members: Theresa Schlager and Elizabeth Bradley and presented for Curriculum Committee discussion by Elizabeth Bradley.
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.
· 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 9 years in the Student Mulholland report. · One attending provides both mid- and end of clerkship evaluations which 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. · Family Medicine Morning Report Workshop - students present 3 self determined learning objectives; then teach a small group what they have learned on the rotation and they receive peer and attending physician feedback. Additionally, they self assess this activity.
· 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. Starting in 2014 however, the clerkship will be pass/fail. · The Family Medicine assessments focus on knowledge, but not skills. A Family Medicine OSCE is being planned to address this.
· Continue to work with the OSCE Committee to develop a Family Medicine OSCE. Dr. Ham has ideas for appropriate content areas for this new assessment.
· Work with the Curriculum Committee to develop a Universal Passport. Although not Family Medicine specific, this could help address some of the concerns regarding variation of student experience in Family Medicine. · Continue monitoring the changing personnel in practices; court UVa Family Medicine graduates as a pipeline of new Family Medicine preceptors. · Continue to pursue new faculty development opportunities to further the consistency of grading and to focus on the core Family Medicine skill sets. These could include virtual learning or tele-faculty development sessions. Will work with the new Director of Educational Technology when s/he arrives. · Evaluate the change from A, B, C, D grading to Pass/Fail.
As reported in 2012, the Family Medicine clerkship is well organized and operates smoothly thanks to the leadership of the director Peter Ham and coordinator Leslie Stewart. Keep up the good work.
Dr. Ham relayed that one of his greatest challenges currently is accessing instructional design, assessment and curriculum development resources which he feels would improve the quality of the educational experience. This is likely not unique to Dr. Ham, thus a discussion with the Curriculum Committee about how to best harness the resources we have in the Office of Medical Education would be useful.
Casey White will outline resources in the Office of Medical Education that are available to the Clerkship Directors at a Clerkship/PostClerkship meeting.
The Committee discussed how best to make sure threads such as “military culture” are covered appropriately in the appropriate clerkships. Coordination amongst the clerkship directors will be necessary. Nancy McDaniel will add this to the agenda of an upcoming Clerkship/PostClerkship Committee meeting.
How to address perceived “unevenness” across the clerkship sites was discussed. The workshops all take place in-house help alleviate the variability of experience due to multiple clerkship sites. The Committee recommends that an OSCE be developed to assess student progress. This OSCE should be done after the midpoint of the clerkship but allowing time at the end of the clerkship if remediation is necessary. An OSCE would help to determine whether deficiencies exist in certain clerkship sites.
2013 Annual Surgery Clerkship Review. This annual review was conducted by Curriculum Committee members: Bart Nathan and Mary Kate Worden and presented for Curriculum Committee discussion.
After reviewing submitted self study, the Curriculum Committee reviewers met with Clerkship Director, Eugene McGahren, Associate Clerkship Director, Anneke Schroen, and Clerkship Coordinator Sylvie Moore on 11!313.
The current rotation is 6 weeks long and students are located in a wide variety of locations and surgical specialties. The clerkship directors feel the current length of the clerkship is sufficient, but would prefer to increase to 8 to 12 weeks.
Recommendations made in 2012-2013:
· Develop a consistent written (H&P) note policy. This should be a complete written note structured with a synthesis of information, differential diagnosis and action plan, e.g. SOAP note. Note review and timely feedback to the student is essential.
Outcome: Students are asked to write notes. Students do get feedback, but this is inconsistent in terms of frequency and number of opportunities to receive feedback on their notes. We recommend that a specific policy be developed to ensure that all students receive feedback on a minimum number of notes.
· Work with Michelle Yoon to improve the learning objectives, resources; formative and summative assessments for the Surgery clerkship.
Outcome: Review of learning objectives with Michelle Yoon has been completed. Review of assessments with Jim Martindale is planned.
· Develop online materials, quizzes to ensure that core clinical skills and topics are covered and strengthened.
Outcome: A new scrubbing video has been created; all online materials have been linked to learning objectives. The surgery clerkship is also using cases associated with virtual patients developed at Southwestern University. All clerkship students take a 30 item online quiz during the rotation for which students receive 100% credit if they have 75% or more correct answers. Students who have less than a score of 75% are required to meet with clerkship director to discuss answers to missed questions (although none have yet scored less than 75%).
· All Surgery clerkship sites must have the same learning objectives and these learning objectives are to be closely monitored by the central (primary) UVA clerkship directors.
Outcome: this has been achieved, all locations have the same learning objectives and standard instructions are given at the beginning of each rotation.
· Develop consistency in the learning of procedural skills across all surgery clerkship sites.
Outcome: There are more procedures to practice currently, because the students are now doing the procedure of Foley catheter placement in the OR. The clerkship directors encourage students to actively pursue practice with any and all procedures. The clerkship has added Red service and Acute care surgery as rotations for students to increase opportunities to learn procedural skills. Students on the surgery clerkship do not use the Sim center, because surgery has their own training rooms for practicing procedures and the clerkship directors consider this sufficient. The number of students going to Salem for the clerkship will decrease from 5 to 3 in the year 2015-2016.
· Consider a “night float” requirement to increase exposure of students to more procedural skills; exercises in the SIM center.
Outcome: Considered and rejected. The problem with night float system is that it would have to take students away from other services. The clerkship directors feel that the call schedule should be sufficient to give students a wide range of educational opportunities.
Recommendations made for 2013-2014:
· We recommend that a specific policy be developed to ensure that all students receive feedback from faculty on a minimum number of written notes. · Consider an elective that would have a night float component. · Consider whether specialized surgery should move to selectives in the 4th year. · Remind students that it is important to review anatomy before selectives/surgery rotations. This could also be emphasized during the transitions course.
The Surgery Clerkship Directors were asked to develop a “night float” elective since there is no night float experience available in the clerkship.
Jim Martindale has met with the Surgery Clerkship Directors to review the midclerkship quiz items for variety, links to learning objectives and quality of the questions. Additional work is needed to improve the quality of the questions and number to enlarge the pool of questions.
Surgery Clerkship Directors noted that student competence with anatomy principles has not changed from previous years. The Committee noted that some difficulties with anatomy have been reported by the Surgical Subspecialties, i.e. orthopedic surgery.
Clerkship Directors did report increased mispronunciation of medical terms. There is speculation that this may be due to decreased attendance at lectures where students hear the correct pronunciation. CPD mentors are encouraged to always correct student mispronunciations during their sessions.
Enhancing the pool of quiz questions and developing appropriate feedback for the quizzes will be recommended.
Keith Littlewood noted that the “practice room” is no longer available in the OR so the Surgery practice sessions may move to the Simulation Center.
2013 Annual Peri-Operative/Anesthesiology Clerkship Review
2013 Peri-Operative (Anesthesia) Clerkship Review This annual review was conducted October 25, 2013 by Curriculum Committee members, Donald Innes and Steve Borowitz, and resented to the Curriculum Committee.
Clerkship Director, Ashley Shilling, MD, and Associate Director, Stephen Collins, M.D.
The Peri-Operative clerkship introduces basic skills and important concepts within the environment of the operating rooms, pre-operative and post-operative setting. Interactive group didactic sessions augment individual rotations, incorporating basic science principles with clinical practice; including interprofessional education. The clerkship focuses on skills, concepts and tasks related to: pre- and post-operative evaluation (informed consent, patient education, optimization and risk-stratification), patient monitoring, pain management, airway and ventilation management, and fluid and intravenous management. Shock recognition and management, cardiac and respiratory physiology, and pharmacology of anesthetics, narcotics, neuromuscular blockers, vasopressors and ionotropes are reviewed. Perioperative patient safety and general principles of quality care are key components.
Strengths of the Peri-Operative Clerkship:
· Core faculty are responsible for the simulation and didactics allowing for consistency and continuity to the simulation experience for students - Ashley Shilling, MD; Keith Littlewood, MD; Chris Stemland, MD; and Sachin Mehta, MD. · Resident Liaison Group that helps to facilitate learning and takes responsibility for the large majority of onsite clinical teaching. · The two-week duration of the clerkship has been a great improvement allowing more clinical time and for a better paced simulation experience. · The addition of an Associate Director has been a great help to lessen the stress of daily assignment matching of students and allows for increased contact time between the directors and the students. · The 26 Learning Objectives make clear the expectations for the student. · The Resident Liaison group assistance with weekly lectures and group sessions. · Mid-clerkship feedback is provided in part based on a short on-line quiz by the directors and faculty feedback. · The self-directed learning project due the Friday of week two in which the student determines an area of personal interest related to the field of Anesthesia and then develops a brief written report sent to the clerkship directors. · Review of the student evaluations shows that the clerkship is given “A and B grades” with a score of 3.65/4.0
Comments by students were nearly all positive. Some typical comments follow:
o This was a terrific clerkship. Dr. Shilling and Dr. Collins were both really great at teaching and really worked to get us good opportunities to learn. I thought it was a very helpful experience that will really be useful in the future.
o This was an excellent 2 weeks! Learned so much about anesthesia, as we aren't really exposed to many of these concepts otherwise. The clerkship directors were absolutely fantastic, it was very evident that they cared about the students having a great and interesting experience. I gained a lot from this rotation.
o I think this is a good med student rotation even if you are not interested in anesthesiology. I didn't know much about the field before this rotation, so it was good to get exposure. I also learned A LOT for the amount of time I was there, not just about anesthesia but medicine in general. The residents I worked with were good at teaching, and even CA0s jumped right in and taught me a lot and let me do a lot of things. I have to say it was a little difficult to work with someone new every day, but it was good that we were indicated our preferences for where or with whom we wanted to work.
o Excellent clerkship - I loved the flexibility to pursue what interested me. I felt the residents were superb in this department - very interested in teaching students and allowing us to be as involved as possible in cases. The clerkship exceeded my expectations, and I felt I learned so much more because of the clerkship's flexibility than I would have if it were more regimented. The experience provided tons of diverse learning opportunities, I also felt I improved technically quite as bit as a result of being allowed to actively participate in cases.
Although not perfect:
o I thoroughly enjoyed this rotation and really feel that I learned a lot. I also got to practice numerous skills, including mask ventilating, intubating, placing IVs, and performing pre-op evaluations. The only concern I have was the end of rotation exam. Even though I learned a lot these last two weeks, I don't feel that is very well reflected in the test. I think that most of what we spent time talking about during the clerkship were the drugs and airway concepts, but these topics were not very heavily represented on the exam. o I think that this clerkship could greatly benefit from more structure. If quizzes are to remain a part of the rotation, then required reading and structured lectures should be included as well.
· Patient Quality & Safety learning objective(s) are missing from the Learning Objective list. · Resources · Daily feedback from attending/resident physicians may need to be more direct as the number of students answering “Did you receive feedback on your performance during the clerkship?
· The Learning Objectives should include Patient Quality & Safety learning objective(s). A reference to the general Patient Quality & Safety learning objectives should be made. · Explore creation of a handout or recommended resource material. · Consider having the student write a note on the clerkship, e.g. summary of the pre-operative interview. Another consideration is to have the student conduct the pre-operative interview under supervision.
The required Life Saving Techniques Workshop is now incorporated into the start of the Peri-operative-Surgical Specialty clerkship section of the 12-week Surgery block.
The most recent April 2013 Mulholland Report does not take in to consideration the expansion of the Peri-operative clerkship to two weeks.
In summary, the Peri-Operative clerkship is well organized and operates smoothly thanks to the devoted effort of Ashley Shilling, MD and Stephen Collins, MD.
XCredit Update - Sean Jackson updated the Committee on X-Credit and the AAMC database.
Stage 1: Prepare AAMC CI report for school year 2012-2013, which doesn't include our clerkship, selective and electives because the related courses were not in CXCREDiT yet. Originally, AAMC's deadline for the report submission was on 11/30/2013. Because of all kinds of unexpected problem, they have postponed the deadline to February, 2014.
John Jackson and John Voss have finished the work on converting old keywords to new keywords for 2012-2013 related contents. The report requires program description and med level description, John Jackson helped on that. We were able to generate the report from XCREDiT. We submitted it to AAMC and the report was checked by AAMC system and passed the business rules. However AAMC has technical problem on the server side, the system could not save our report. They are fixing it. We are not the only school that encounters the problem and we have not heard back from them. At this point, we can not do anything.
If they fix their problem and are able to save our report (in xml format), they will generate a report which should be viewed and verified by school Dean (Dr. Innes), if the Dean doesn't approve it, we need to work on any updates required by Dean and resubmit the report, if Dean approves it, it is done. Since John Jackson has been working on this project and knows very well about our curriculum, Dr. Innes may ask John to review the report and tell us if any changes need to be made and resubmit.
To make it simple, our status is that we've submitted the report, because of AAMC server problem they can not save the report to generate readable report for school to review, we can not go forward now.
Stage 2: Get XCREDiT ready for AAMC CI report for future years.
1. John Jackson has given few training sessions to our clerkship coordinators to tell them how to enter data into XCREDiT. And also gave trainings to our ISCs about how to deal with assessment only events in OASIS and XCREDiT in order to have data in XCREDiT for future report.
2. John also worked with Ye to modify XCREDiT to handle selective and electives. We had the design already. Ye is programming it in XCREDiT. John talked to related parties about learning objectives for selective and electives and we can plan how to enter them into XCREDiT.
3. John Voss and John Jackson also worked on new keywords system. The keywords are finalized. John Voss and John Jackson still needs to work together to map old keywords to new additional keywords since last time they finished the mapping.
4. John Voss and John Jackson has worked together to build our competency maps. The work is done. Once Ye uploads them into XCREDiT and they may work together later to map learning objectives to competency.
5. Ye (Chen) plans to upgrade XCREDiT in the week of DEC 16 when there is less traffic on XCREDiT. The upgrade will have new keywords system, convert old keywords to new keywords automatically, have the function to handle selective, elective courses and clerkship data for future AAMC CI report.
6. After the upgrade, John Jackson and John Voss may need to involve in further improvement since they are going to use the system to map learning objectives to competencies.
Donald J. Innes, Jr., M.D.