University of Virginia School of
Minutes – 12/12/13
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, Mary
Grace Baker (alternate), Derrick Thiel, Debra
Announcement: The Health Sciences Library MD Consult has been replaced by the vendor (Elsevier) with a new much more comprehensive product called Clinical Key. The Library has subscribed to this product and all the resources within Clinical Key are now available for your use. Please be aware that all MD Consult links will cease to work after the end of this month – December.
Many of these books enable chapter-level pdf downloads – a very nice feature. **In order to access the pdfs faculty and students must create personal accounts.**
A link to Clinical Key can be found on my Medical Student Web Portal: https://www.hsl.virginia.edu/portal/somedicine or from the Library’s main page under Databases – More Databases: https://www.hsl.virginia.edu/
Neurology Clerkship Review
Reviewers: Sabrina Nunez; Peter Ham, MD
Clerkship Director: Guillermo Solorzano, MD; Binit Shah, 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, a mid rotation quiz, and oral exams. Many other learning activities such as lectures have been replaced by online problem sets and reading materials so students can access them on their own time without disruption of other clinical learning and whether their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 also have a take-home exam, 2 H&P reviews, and an extra credit ethics essay. Students participate in other learning sessions with residents such as daily morning rounds and inter-disciplinary stroke patient team meetings.
Strengths of the Neurology Clerkship:
This is one of the strongest clerkships in terms of consistency and supervision. The clerkship directors do an excellent job creating a clerkship that sets clear expectations, provides resources, and assesses the objectives. The website is clear has resources that are helpful for topics and learning objectives for the core curriculum. The clerkship directors also supervise the clerkship extremely well by meeting regularly (twice monthly) with their faculty; and, clerkship directors evaluate the students to achieve consistency. Neurology has purchased a curriculum that includes validated questions and has a well thought through set of clinical skills and objectives. Many of the questions for the exam have been rewritten to assess the main points of the online resources; however, we did not review the exam questions.
Students rate the neurology clerkship highly overall in the Mulholland report (90% rate A or B), especially in quality of teaching from attending physicians and housestaff. Neurology faculty have received teaching awards from students, housestaff, and the hospital.
The standardized curriculum developed by the American Academy of Neurology Medical Student Consortium strengthens the clerkship. This allows students consistent exposure to common neurological problems, assessment that is tied to specific learning objectives, and feedback. The online cases and video series also ensure consistent teaching of clinical skills. Students seem well prepared for the exams and score in the 70-85 range (passing >59) although the comparative norms for the shelf were not available for this review.
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. Residents seem to receive lots of help with teaching during conference time and working with students on the wards.
Weaknesses of the Neurology Clerkship:
The Clerkship Directors identify a few areas of concern. Hospital wide pressure to decrease length of stay and shorten office visit times give students less time to practice their history and physical exam skills; although, students seem to still see 3-5 patients per day (outpatient) and meet course objectives. The online cases help ensure a broad exposure to topics. The course does not have a peer eval component (few do). And, although there is no formal self-evaluation, students provide an informal self-evaluation during the mid-month feedback meeting with the clerkship directors. There are no formal cultural competency objectives or sessions; however, students work in the hospital where use of interpreters, Cyracom phones, and discussions with patients are supervised by neurology attending physicians. Every student can’t guarantee exposure to patients from a different culture, but it likely happens regularly.
SMEC representatives compiled feedback from 2012 students. Their concerns were that it was confusing what lectures and problem sets were required. The schedules have been simplified with online material replacing lectures.
Low census of the inpatient services was also noted. The student’s assessment of the adequacy of their responsibility level seemed to correlate with the number of patients admitted to the service during their rotation. This is likely to remain an issue.
Outpatient Exposure: Some students used to have all inpatient rotations. Now all students have 2-week outpatient blocks.
Take-Home Exam: Many 2011 students felt that the take home exam was not a fair assessment of the knowledge and skills they acquired during the Neurology clerkship. This exam has been revamped to directly assess the material from the online presentations.
Stroke Codes: Students on the stroke service and on stroke call were frustrated that there was not a formal system in place to notify students when a stroke code was called.
Recommendations from 2012/13 review:
* Recruit a co-clerkship director when Dr. Potter retires. Done * Designate the stroke inter-disciplinary team meetings in which students participate as an example of inter-professional education (IPE). Done * Include use of Cyracom phone and translator services during student-patient interview as examples of cultural competency training. This would be better handled by a Universal Passport system. It is certainly occurring. It is currently not tracked by the Neurology Clerkship’s formal curriculum. * In planning for Dr. Login’s retirement, develop a strategy to support another faculty as a master teacher to continue teaching chief residents to assess medical students. Done. Other faculty and chief residents are assuming roles of teaching physical exam skill session. * Retain a Clerkship Coordinator that has intimate knowledge about the schedules within the Department of Neurology. Done.
Recommendations for 2014:
* The Neurology Clerkship is in excellent shape and should remain in its current organizational structure, rotations, assessment methods, and oversight. The recommendations below are really more for the SOM as a whole; however, these are areas where the Neurology Clerkship would have excellent input. * The SOM is considering how to incorporate clinical skills teaching in the SIM center into the 3rd year. The Neurology Clerkship could provide content expertise in developing a Lumbar Puncture simulator exercise. * Encourage the Neurology residency program to utilize the residents as teachers program (online) to enhance the already strong teaching from resident physicians. * Include use of Cyracom phone and translator services during student-patient interviews as examples of cultural competency training and encourage the school to include these experiences on a Universal Passport.
Recommendations for 2014 following discussion by the Curriculum Committee:
* Expand inpatient and outpatient sites to alleviate perceived over crowding and lack of specific patient types at some of the current sites if possible. * Refine exam and quiz questions using expertise of Casey White and Jim Martindale. * Exam questions used in Mind Brain and Behavior should be incorporated into the clerkship quizzes/exams (See Mary Kate Worden and Bart Nathan). * Consider use of a “stroke” pager system for students on the Neurology service. * Use the Simulation Center to reinforce instruction in LP – CPD-1 provides a LP simulation experience that should be repeated and enhanced during the Neurology clerkship. * Provide descriptions for both inpatient and outpatient services on the clerkship website so students can make an informed decision when selecting the sequence. * Keep Neurology physical exam as a separate item in combined clinical skills passport as neurologic exams in other services may not be of the same caliber. * Keep Ethics activity optional and encourage students to complete this earlier in the clerkship (before the end of the third week). * Improve the correlation between learning resources, learning objectives and exam questions on in-house exams/quizzes. * Ensure that students are aware of their progress (grades) during the clerkship especially items from the OSCE that need remediation. This would address an apparent lack of transparency in the OSCE grade.
A comment was made that the perception was that it was impossible to get an “A”, however review of the grade distribution from the Class of 2015 to date (106 students) showed 30% A/A-, 61% B+/B/B-, 4% C and 5% D.
Student duty hours. The SOM policy regarding student work hours has been unanimously approved by the Curriculum Committee with a change in the first sentence from “should” to “will.”
Medical students rotating on clinical services (clerkships, selectives and electives) will be subject to the same principles that govern the 80-hour work week for mid-level residents (a maximum of 80 hours of required clinical duties per week averaged over a four week period, no more than 24 consecutive on duty hours with at least 10 hours off between shifts, and on average one day in seven free from all required clinical duties). Four additional hours for the handover of patients (no new patients) after 24 hours is allowed for feedback on clinical decisions and for continuity. Clerkship, electives and selectives directors are responsible for monitoring and ensuring that duty hours are adjusted as necessary. Student duty hours should be set taking into account the effects of fatigue and sleep deprivation on learning and patient care. In general, medical students should not be required to work longer hours than mid-level residents*. (Curriculum Committee 9/9/2004; modified 12/13/13) http://www.med-ed.virginia.edu/handbook/policy/attendance.cfm#clerks
Clerkship/Course Evaluations. For future reviews, Elizabeth Bradley will provide evaluation data from Oasis to the subcommittees along with the self-evaluation documents prior to their clerkship/Course reviews.
Mulholland Report. A draft of the Mulholland report will be distributed at the 2/19/13 Joint Clerkship Committee meeting. The final report should be available for Curriculum Committee review in early March 2014.
Pagers. Linda Waggoner-Fountain is working on obtaining additional pagers for medical student use. The Clerkship/Post-Clerkship Committee will be asked to prioritize the specific areas that need the additional pagers.
Donald J. Innes, Jr., M.D.
Addendum: [Added 12.13.2013] Change in Minimum
Passing Requirements for Step 1 from 188 => 192
This announcement describes a change in the Step 1 examination minimum passing score that will affect examinees testing on or after January 1, 2014.
At its December 2013 meeting, the Step 1 Committee conducted a review of the USMLE Step 1 examination minimum passing score. During the meeting, the Committee considered information from multiple sources, including:
Recommendations from independent groups of physicians who participated in content-based standard-setting activities in 2013;
Results of surveys of various groups (e.g., state licensing representatives, medical school faculty, examinees) concerning the appropriateness of current passing requirements for the Step 1 examination;
Data on trends in examinee performance;
Data on precision of pass/fail classifications.
As a result of its review, the Step 1 Committee decided to raise the recommended Step 1 minimum passing score from 188 to 192.
This change will be applied to Step 1 examinees testing on or after January 1, 2014.
USMLE website: http://www.usmle.org/announcements/?ContentId=127