ace: transition to residency: osu clinical tracks

Transition to Residency: Who'sResponsible?Using Clinical Tracks to Assess Preparedness for Internship

Nicholas E. Kman, MD FACEPAssociate Professor-Clinical Emergency MedicineDirector, Part 3/Med 4 Academic Program

Objectives

Describe how a clinical track based on ACGME competencies could bridge the chasm between UGME and GME.

Demonstrate how Clinical Tracks are improving the 4th year at our institution.

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Medical Knowledge and

Skills

Practice and Lifelong Learning

Interpersonal Communications

Systems Based Practice

Professionalism

Patient Care

Medical Knowledge and Skills

Curricular Reform at OSUOld Curriculum 2 + 2 Approach

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Part ThreeAdvanced

Clinical Management

4 Years18 months 12 months 13 months

Longitudinal ProjectsLife-Long Learning/Reflection

LongitudinalHealth Coach

CommunityHealth

EducationPatientSafety

Hallmarksof L.S.I. Curriculum Reinforce foundational science throughout curriculum Early clinical service-learning experiences Faculty coaching Mastery based evaluations Building Entrustment on all 13 EPA’s Preparing for residency through increased patient care and

working toward Milestones with Clinical Tracks5

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Lyss-Lerman P, et al. What training is needed in the fourth year of medical school? Views of residency program directors. Acad Med. 2009 Jul;84(7):823-9.

“Organizing the curriculum with specialty-specific tracks could be explored by looking at specialty-specific data and expanding the interviews to include more PDs.”

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Walling A, Merando A. The fourth year of medical education: a literature review. Acad Med. 2010 Nov;85(11):1698-704.

ACGME policies and practices will increasingly influence medical student education

4th year as capstone for medical school versus preparation year for residency Turned in favor of the pre-residency viewpoint

Other factors that increase pressure towards using 4th year to prepare for residency are student debt and growing specter of unmatched US graduates

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Reddy ST, et al. ACE perspective paper: recommendations for redesigning the "final year" of medical school. Teach Learn Med. 2014;26(4):420-7.

Demonstrate that they have mastered objectives (based on 6 ACGME Core Clinical Competencies)

Complete a required capstone course prepares students for residency.

Structure their 4th year schedules to accomplish specialty-specific objectives that prepare them for their intended specialty.

Engage in thoughtful inventory of training. Identified gaps should be addressed through deliberate participation in rotations that address identified areas.

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Demonstrate that they have mastered objectives (based on 6 ACGME Core Clinical Competencies)

Complete a required capstone course prepares students for residency.

Structure their 4th year schedules to accomplish specialty-specific objectives that prepare them for their intended specialty.

Engage in thoughtful inventory of their medical school training. Identified gaps should be addressed through the deliberate participation in rotations that address the identified areas.

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4th year is a bridge between medical school and Residency: ACGME Competencies and AAMC Core Entrustable

Professional Activities (EPAs) should be used to guide curriculum development.

These competencies and specialty-specific milestones and EPAs provide guidance to medical schools for the minimum level of competency for starting intern and can be used to design 4th-year curricula.

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Chen HC, van den Broek WE, ten Cate O. The case for use of entrustable professional activities in undergraduate medical education. Acad Med. 2015 Apr;90(4):431-6

Specialty-specific EPAs could guide student selection of senior year electives as well as help program directors ensure a baseline competency level of their entering residents.

If operationalized properly, these specialty-specific EPAs could ease advising during the fourth year, ensure more adequately prepared entering residents, and obviate the need for extracurricular “boot camps”

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Solution: Clinical Tracks!

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College structure – 6 UCLA collegesAcute Care: time-based decision-making specialties(Anesthesia, critical care EM)

Applied Anatomy: structure-oriented fields (Surgery, radiology, pathology)

Medical Leadership: dual-degree programs in public health or business administration

Medical Subspecialties: subspecialties focused on clinical reasoning and advance fellowship training

Primary Care: longitudinal care specialties (FM, IM, pediatrics)

Urban Underserved: focuses on care of underserved communities

PARTAdvanced Management inHospital Based Care

Advanced Management in Relationship Centered Care

Advanced Competency Elective Clinical Tracks: A longitudinal experience in a specialty or subspecialty designed to prepare students to be an intern/incoming resident by meeting entry level milestones in that field.

Other Electives (4 total required including Advanced Competency)

Flex

Gateway Activities

Part ThreeAdvanced

Clinical Management

HSIQ Project

Clinical Track

Framework for 4th year medical school “curriculum” that aligns UGME and GME such that student is working toward entry level milestones (ACGME milestones) to prepare them for their intern year in specialty of choice.

Conglomeration of experiences (required courses, electives, advanced competencies, bootcamps) during 4th year to prepare them for internship.

List of current tracks Anesthesia Emergency Medicine Family Medicine Internal Medicine

(Preliminary medicine, IM-Peds included) Obstetrics/Gynecology Pediatrics Psychiatry Neurology Radiology Surgery/Surgical Subspecialties

(Preliminary Surgery included)

How long should a track be?

A clinical track is not a set number of rotations but a combination of different rotations/experiences that will allow the student to develop skills to become a proficient intern in that field Recommendations for rotations for the

required components of part 3 Recommendations for electives Required rotations

Advanced topics courses

What is required?

Each department/division decided what is required in order for students to complete the track Specialty specific scheduling guide (SSSG)-

recommendations for required and elective rotations put together by departments/divisions to guide students on what to take during fourth year to prepare them for a particular field

Specialty Specific Scheduling Guide (SSSG)2. Emergency Medicine Clinical Track (Revised 2/9/2015)

AMHBC: EMERGENCY MEDICINE: Emergency Med at OSU.AMRCC: CHRONIC CARE COMPONENT Geriatrics, HIV Patient Care, Congestive Heart Failure, Adult Kidney Disease, Child Abuse/Child Advocacy, Alcohol and other Drug Abuse.AMHBC: MINI INTERNSHIP: MICU, Cardiology, Pulmonary. Electives: Advanced Topics in Emergency Medicine (ATEM: Honors Longitudinal EM Elective), Advanced Competency in Ultrasound, Advanced Competency in Emergency Preparedness, Radiology, Anesthesia, Sports Medicine, Dermatology, Surgical specialties in general, including Plastics, ENT/Ophtho (two 2-week electives if possible), Hand Surgery, Orthopedics.

Special Requirements: Away Electives in EM only at places where you may want to match. Students interested in Emergency Medicine should schedule their AMHBC: EMERGENCY MEDICINE at OSU in July, August or September.

Busiest interview months to consider for flex months are November through January

Residency Directors: Sorabh Khandelwal (Director), Jillian McGrath, Sarah Greenberger, Laura Thompson, Andy King.Faculty Advisors: Dan Martin, David Bahner, Nick Kman, Mark DeBard, Ash Panchal, Creagh Boulger, Cynthia Leung.

How are students evaluated?

Competency based assessments

Ideally- the departments/divisions who created the tracks would select a subset of the ACGME milestones for that field that students would be evaluated on

Students would have “completed” the track if they achieve the selected milestones

This could be determined by one person or Clinical Competence Committee (CCC)

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Description of the EM Clinical Track

1. Patient Care 1. Emergency Stabilization (PC1) Prioritizes critical initial stabilization action and mobilizes hospital support services in the resuscitation of a critically ill or injured patient and reassesses after stabilizing intervention.

Level 1 Feedback/Assessment 1.1

Part 3 Curricular Component

1.1

Recognizes abnormal vital signs

Assessment week simulation

AMHBC1, ATEM

Level 2 1.2 1.2

1.2

Recognizes when a patient is unstable requiring immediate intervention Performs a primary assessment on a critically ill or injured patient Discerns relevant data to formulate a diagnostic impression and plan

Assessment week simulation

2. Performance of Focused History and Physical Exam(PC2) Abstracts current findings in a patient with multiple chronic medical problems and, when appropriate, compares with a prior medical record and identifies significant differences between the current presentation and past presentations. Level 1 Feedback/Assessment

2.1 Part 3 Curricular Component

2.1

Performs and communicates a reliable, comprehensive history and physical exam

.

Clinical Performance Evaluation (CPE), DOC, Assessment week simulation

AMHBC1, AMRCC, ATEM

Level 2 2.2 2.2

2.2 Performs and communicates a focused history and physical exam which effectively addresses the chief complaint and urgent patient issues

CPE, DOC, Assessment week simulation

3. Diagnostic Studies (PC3) Applies the results of diagnostic testing based on the probability of disease and the likelihood of test results altering management.



3.1

Determines the necessity of diagnostic studies


AMHBC1, AMRCC, ATEM

Level 2 3.2 3.2

Orders appropriate diagnostic studies Performs appropriate bedside diagnostic studies and procedures


4. Diagnosis (PC4) Based on all of the available data, narrows and prioritizes the list of weighted differential diagnoses to determine appropriate management.



Assessments

Required to complete 3 assessment shifts. Faculty member will perform a Direct Observation of Competence

(DOC) on each shift. A formal standardized assessment will be performed and feedback provided.

Perform common ED procedures under supervision and faculty will perform a checklist assessment. Procedure workshops scheduled throughout the year. Students

who are not able to perform procedures on real patients will perform required procedures on a simulator or task trainer under supervision.

Complete a comprehensive assessment with simulated patient during the Assessment week to be scheduled March 2016. Students will be scored on a standardized checklist.

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List of medical student milestones assessed during Professor Rounds

Milestone DescriptionRecognizes abnormal vital signs.Recognizes when a patient is unstable requiring immediate intervention.Performs and communicates a reliable, comprehensive history and physical exam.Performs and communicates a focused H&P which effectively addresses the chief complaint and urgent patient issues. Constructs a list of potential diagnoses based on chief complaint and initial assessment.Formulates basic diagnostic and therapeutic plans based on a differential diagnosis.Establishes rapport with and demonstrates empathy toward patients and their families.Demonstrates behavior that conveys caring, honesty, patient confidentiality, genuine interest and tolerance when interacting with a diverse population of patients and families.

Demonstrates basic professional responsibilities such as timely reporting for duty, appropriate dress, conference attendance, and timely completion of clerkship documents.

Effectively listens and communicates with patients and their families.

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Simulation

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Simulation

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Questions and Comments

References

Wolf, S J (02/19/2014). "Students' Perspectives on the Fourth Year of Medical School: A Mixed-Methods Analysis". Academic medicine (1040-2446), p. 1.

Cosgrove, E M (02/19/2014). "Empowering Fourth-Year Medical Students: The Value of the Senior Year". Academic medicine (1040-2446), p. 1.

Reddy ST, Chao J, Carter JL, Drucker R, Katz NT, Nesbit R, Roman B, Wallenstein J, Beck GL. Alliance for clinical education perspective paper: recommendations for redesigning the "final year" of medical school. Teach Learn Med. 2014;26(4):420-7. doi: 10.1080/10401334.2014.945027. PubMed PMID: 25318040.

Chen HC, van den Broek WE, ten Cate O. The case for use of entrustable professional activities in undergraduate medical education. Acad Med. 2015 Apr;90(4):431-6. doi: 10.1097/ACM.0000000000000586. PubMed PMID: 25470310.

Elnicki, et al for the CDIM/Association of Program Directors in Internal Medicine Committee on Transition to Internship. Course Offerings in the Fourth Year of Medical School: How U.S. Medical Schools Are Preparing Students for Internship. Academic Medicine 2015.

Lyss-Lerman P, Teherani A, Aagaard E, Loeser H, Cooke M, Harper GM. What training is needed in the fourth year of medical school? Views of residency program directors. Acad Med. 2009 Jul;84(7):823-9. doi: 10.1097/ACM.0b013e3181a82426. PubMed PMID: 19550170.

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References

Chen HC, van den Broek WE, ten Cate O. The case for use of entrustable professional activities in undergraduate medical education. Acad Med. 2015 Apr;90(4):431-6. doi: 10.1097/ACM.0000000000000586. PubMed PMID: 25470310.

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Thank You

ace: transition to residency: osu clinical tracks

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