MEDICAL EDUCATION COMMITTEE MINUTES: MEETING OF JANUARY 6, 2010

Transcription

1 MEDICAL EDUCATION COMMITTEE MINUTES: MEETING OF JANUARY 6, 2010 Members Present: Dr. Wendy Coates Dr. Jan Tillisch Dr. Margaret Stuber (co-chair) Dr. Jonathan Hiatt (co-chair) Dr. Shelley Metten Dr. Gregory Brent Dr. Michael Gorin Students: Amanda Chi Liv Leuthold Paul Rabedeaux Guests: Dr. Neveen El-Farra Dr. Carl Stevens Dr. Anita Nelson Rikke Ogawa Dr. Neil Parker Dr. Peter Chee Dr. Jimmy Hara Dr. Shirin Towfigh Staff: Gezelle Miller Margaret Govea Zachary Terrell Time Called to Order: Time Adjourned: 4:35pm 6:30pm AGENDA/NAME DISCUSSION/RECOMMENDATION ACTION Cedars-Sinai Continuity Proposal Dr. Shirin Continuity in Clinical Education Cedars Sinai Medical Center Why we want to do this: Informational Towfigh To provide Institutional Continuity To provide an integrated inpatient & outpatient experience To demonstrate collaboration between specialties to provide patient care To provide faculty mentorship to students during the continuum To improve quality of surgical clinical experience To objectively study the quality and outcome of such a program Track A Structure: 18-weeks, 6 weeks per rotation: Ob-Gyn, General Surgery, Surgical Specialties (no change from current structure). 18 students per track, 6 students per rotation, 36 students per year. Curriculum: Four equal rotations from: Day OB, Night OB, Gynecology, Gynecology Oncology, Ambulatory Service. Two 3-week rotations from General Surgery (2 students), Acute Care Surgery, Minimally-Invasive Surgery, Surgical Oncology,

2 Colorectal Surgery. Six 1-week rotations from Anesthesiology, Urology, Head & Neck Surgery, Orthopedic Surgery, Pediatric Surgery, Transplant & Hepatobiliary Surgery, Breast Surgery, Plastic & Reconstructive Surgery, Ophthalmology Clinical Experiences offer a balanced mix: Inpatient care to private patients Inpatient care to indigent/uninsured patients Ambulatory surgery Clinic care in private office setting Clinic care to indigent/uninsured patients Electively treated diseases Emergent/Urgently treated diseases Collaborative care across specialties, both surgical and non-surgical Educational Conferences Ob-Gyn Case presentation rounds 1 hour/week Student(s) present case, discussion topic exploded by faculty preceptor At least one session/3-weeks to include an integrative topic E.g., with General Surgery, Colorectal Surgery, Pediatric Surgery, etc. General/Subspecialty Surgery students to attend this integrative session Grand Rounds 1 hour/week Resident Educational Conference 2 hours/week General Surgery Bedside rounds 1 hour/week. Student(s) present their patient, discussion topic exploded by faculty preceptor with bedside exam, review of films, etc. Trauma Case Presentation Conference 1 hour/week Grand Rounds

3 AGENDA/NAME DISCUSSI ON/ RECOMMENDATION ACTION 1 hour/week Resident Educational Conferences 2 hours/week. Includes interactive audience-response testing of the students, Visiting Professor small groups, Journal club (students critique evidence-based surgical articles). Matrix Morbidity/Mortality Conference 1 hour/week Skills Lab 2 hours/week Surgery Sub-specialties Service-specific educational conferences Attending rounds, Journal clubs, M&M conferences, Case conferences, tumor board, etc. Many are interactive with other specialties Grand Rounds 1 hour/week Resident Educational Conferences 2 hours/week. Includes interactive audience-response testing of the students, Visiting Professor small groups, Journal club (students critique evidence-based surgical articles). Matrix Morbidity/Mortality Conference 1 hour/week Skills Lab 2 hours/week What s New Comprehensive Integrated Orientation Session Week 1 of 18-week session In the Surgical Simulation Skills Center and Ob-Gyn Simulation Unit: Scrub, prep, OR etiquette, sterile precautions Suturing, knot-tying, instruments Labor & Delivery simulation, pelvic exam, fetal heart rate patterns Airway management Laparoscopic navigation IVs, A-lines, Central lines, Foley catheter, NGTube, Chest tube EMR for inpatient and outpatient, surgical/obstetric H&P, Operative Note, Progress Note, ICU note, etc.

4 AGENDA/NAME DISCUSSION/RECOMMENDATION ACTION Faculty Mentor For the entire 18-week session Faculty to undergo orientation and training prior to their involvement Pre-approved faculty, assigned based partially on student preference E.g., gender, specialty To provide: Feedback regarding performance Role modeling Career advice, planning Psychological support and to promote a healthy, balanced lifestyle Meet every other week Mid-session and Final progress note to the Site Director Integration/Continuity Students will be acclimated to the Medical Center s environment, reducing stress, concentrating on patient care Familiarity with residents Familiarity with attendings Familiarity with nurses, techs, ER physicians, consultants in other specialties (e.g., GI, ID, etc.) Improved team interaction and sense of belonging Increased opportunities to be involved in hands-on care in the OR, ward, and ICU Improved satisfaction with surgical clerkship experience Integration/Continuity Students will be acclimated to the Medical Center s environment, reducing stress, concentrating on patient care Familiarity with residents Familiarity with attendings Familiarity with nurses, techs, ER physicians, consultants in other specialties (e.g., GI, ID, etc.) Improved team interaction and sense of belonging Increased opportunities to be involved in hands-on care in the OR, ward, and ICU Improved satisfaction with surgical clerkship experience

5 Kaiser Continuity Proposal - Drs. Peter Chee and Jimmy Hara Project Aims: Project goals for this 12-week continuity experience at our site will be to increase the medical students understanding of illness management and patient experience across the continuum of inpatient, outpatient, primary and specialty care within the Kaiser health care system. In this setting, medical students can follow patients in the acute hospital setting or the observation unit setting, and upon discharge, even the clinic setting when patients present for follow-up after their acute hospitalization. Informational The students will be able to learn about and interface with the many ancillary support services currently in place in the medical center. They will learn how to partner with health care managers and other health care providers to assess, coordinate and to improve the care of their patients, thus learning about the complexities of these systems and how these services can affect system performance. Ideally, they will learn how to practice cost-effective health care and resource allocation without compromising the quality of patient care, while still being good patient advocates. While the inpatient and Ambulatory Internal Medicine clerkships will focus primarily on Adult and Geriatric medicine, along with exposure to the subspecialty services, the Ambulatory Family Medicine rotation will expose students to Pediatric and Adolescent Medicine, along with some Obstetrics. The other goal of this project would be to optimize the continuity of contact between medical students and key faculty attending physicians. This 12 week block would allow key faculty members to be more familiar with the student s educational needs, progress, and achievements, thus allowing the faculty to better evaluate and mentor the students during their experience at the Kaiser Los Angeles Medical Center. Description and Rationale: We propose that the current 3rd year medical student clerkship be reconfigured so that 2 interested junior medical students can be based at the Kaiser Los Angeles Medical Center for a 12-week continuity experience in Internal Medicine and Family Medicine. Currently, they have 4 UCLA medical students rotating here for their core inpatient clerkship in Internal Medicine, along with 2 UCLA medical students for their core Ambulatory Internal Medicine clerkship and another 2 UCLA medical students for their Family Medicine clerkship. These clerkships are currently all a part of the Track B, 24-week track. However, this is currently not being done in a continuous 12-week

6 block, and it is not uncommon to see the same medical student do their Internal Medicine rotation here returning several months later for their Ambulatory Family Medicine rotation. As a pilot, we propose that 2 selected UCLA Medical Students spend 4 weeks in the inpatient setting, followed by 4 weeks in the Ambulatory Internal Medicine setting, (2 weeks in the medical office and 2 weeks in the stepdown ED 2). This in turn will be followed by a 4 week rotation in Ambulatory Family Medicine, resulting in a continuous 12 week experience at our site. The learning objectives would essentially remain unchanged from the specific learning objectives already set forth by each of the individual clerkships. The continuum would emphasize primary care and will expose interested medical students with a comprehensive primary care clinical experience. However, it can be added that medical students will learn more about the workings of health care systems and systems of care as outlined above in the Project Aims. The 2 medical students will be mentored by an assigned key faculty member on a weekly during the course of their 12-week rotation. Key Faculty and Staff: Dr. Thomas Tom, Dr. Jimmy Hara, Dr. Monica Quezada, Dr. John Su, Dr. Peter Chee, Dr. James Evans, Dr. Raymond Doh, 3rd and 4th year Chief Residents (and their designees). Evaluation Plan: Current survey through UCLA CoursEval online evaluation system as is already being done. Dedicated survey to be developed looking at specific aspects of the pilot, ie: Medical student satisfaction regarding the learning objectives. Key faculty satisfaction with the pilot. Patient/member satisfaction. Budget: Cost and patient access neutral. It should remain budget neutral since Kaiser is not adding or taking away students or staffing. They are proposing that the current clerkship program be modified such that a select number of interested medical students are allowed to spend 12 consecutive weeks for their clerkship at our medical center.

7 Reagan Continuity I. Premise Informational Proposal Drs. Neveen El-Farra and Jan Tillisch MSIII s have 8 weeks of Medicine Clerkship, 4 weeks of Ambulatory Medicine, with 4 weeks of Family Medicine as a 2 month block and 8 weeks of Psych/Neurology combined for a 6 month total in Track B. Track A is 12 weeks Surgery and 12 weeks of Women/Children s Health (6 weeks Peds, 6 weeks of Ob/Gyn. The major efforts in continuity should be 1) Continuity of Teaching continuous observation over at least 6 months by a single teacher in a preceptor mode. 2) Continuity of patient exposure. Where possible, the same patients would be followed through an episode of illness including outpatient follow-up care. 3) Continuity of discipline to permit development of a specific knowledge/experience base. 4) Continuity of site while less important improves logistics of other continuities and develops system familiarity. These are listed in priority of importance. Continuity of teaching is critical to develop an individualized curriculum for each student by their preceptor(s) and for the critical regular, immediate and relevant feedback necessary for learning. Continuity of patient care is important but very complex to organize. Where possible, the institution should provide the opportunity for cross-disciplinary follow-up (i.e. patient transferred from one service to another or from inpatient to outpatient setting. Initial exposure would be largely inpatient for logistic reasons but outpatients with specific diagnoses could be assigned to students with planned subsequent inpatient work up. (es. breast mass, colonic mass, worsening CHF/transplant eval.) Continuity of discipline is the traditional inpatient model but with current structure of care delivery, it fails to achieve continuity in the other two domains. Nonetheless, the knowledge base is well transmitted in this model and thus mandates its continuance in some fashion. The team rounding experience is less valuable than in the past and should not be preserved at the expense of other experiences but can still be the skeleton on which certain rotations are built. Continuity of site is often necessary for logistic reasons but multiple site learning has major disadvantages in time wasted learning new systems: the much-cited advantage of different types of patients should be dealt with by initial site selection.

8 II. Logistic Considerations Currently 10 students per 8 week block are on Inpatient Internal Medicine and variable lesser numbers on Psych, Neuro, Ambulatory and Family Medicine. There are 48 weeks of Clerkships plus 1 week of Clinical Foundations in year III. Approximately 160 students need the experience. Currently multiple sites are used for a variety of reasons but fewer sites could be used and still handle this number of students. III. Proposal All 6 months of Track B would be combined for a continuity experience. Clerkships would continue but priorities given for patient continuity experience (patients followed from assignment or prior rotation on transfers to another department from clerkship assignment). A. Teaching/preceptor continuity Six Track B preceptors would be assigned 5 students each with expectation of 1 ½ hour sessions twice per week throughout Track B (exception below). Individual meetings with preceptor would occur monthly and patient workup (Hx and PEx) observation would occur monthly (2 students at a time). During Ambulatory Medicine/Family Medicine and Psych/Neurology Clerkships, one of the weekly sessions would be conducted by representatives of those disciplines for the duration of that particular rotation. These preceptor sessions would be aimed at developing individual curriculae for each student based on their cumulative experience over the track. Didactic teaching would be conducted in a case-based fashion, the cases provided by the students but with an overall framework of diseases/issues felt to be critical learning issues for the Track B curriculum. Specific issues raised by the students or the preceptor related to physician behavior, team building/leadership, physician patient interaction, professionalism will be woven through these sessions.

9 B. Patient continuity Relying only on patient exposure during clerkships does not adequately provide continuity experience. Systems to provide medicine team patient post-discharge follow-up are being developed at RRMC but not elsewhere. Students will be assigned cases over the first 4 weeks of Track B. These cases will be selected from ambulatory, neurological, co-existent psychologic/medical illness and inpatient settings. The cases will be under the care of an attending faculty physician and the involvement with the student will be in a nested practice setting that is, the patient will be scheduled to be seen by both primary physician (of whatever subspecialty) and student. This will require planning to interact with the student s schedule as well as attending s. Attendings for the selected continuity patients will be selected rather than determined by patient/doctor; that is, the patient will be chosen from the panel or referrals of the selected attendings (different from preceptors). C. Site continuity This is perceived as a logistic consequence of the above, not a goal. The bulk of the student experience will have to be at a single or proximate site with exceptions possible for Family Medicine or Westwood/VA Medicine clerkships. IV. Resources and Schedule A. Student capacity determined by preceptor capacity first, site capacity second. RR-UCLA Medical Center can take IM Clinical Clerks on General Medicine ideal 2 per service x 5 services. (See attached block schedule.) Preceptors would be assigned 5 students which would require 6 preceptors per 48 week block (12 per year).

10 Family Medicine, Ambulatory IM, Neuro and Psych would require an additional 6 preceptors per block but because continuity of preceptor would only last 4 weeks, multiple preceptors could do 2 or 3 one month rotations of 5 students per year. This would permit 60 students to rotate through this Track B experience based at RRUCLA Medical Center. B. Patient continuity 12 patients would be identified over the first 4 weeks of the Track from a list of approximately 20 diagnoses ranging from chronic conditions managed by either Family Medicine or IM such as hypertension, Type 2 Diabetes, relatively stable COPD; psychiatric diagnoses managed/consulted by psychiatry such as bipolar disorder, chronic depression, somatization disorder (preferably those patients would have some associated medical disease) to allow exposure to interaction of psychiatric and medical diseases; neurologic diagnoses such as seizure disorder, Parkinson s, multiple sclerosis, again preferably with some other medical diagnosis and then acute workups of patients with COPD exacerbation, stroke, acute MI, renal failure, lung mass, w/u for lymphoma or other malignancy. These patients could be worked up as an outpatient but many would be initially seen as inpatient but would be followed in a once/week ambulatory setting with the patient s primary physician. These physicians and their patients would be chosen from a list of committed physicians willing to coordinate patient visits with the medical students scheduled clinic day. No more than 1 new or 2-3 follow-up patients would be scheduled per clinic day in that other activities, ambulatory or inpatient, would compete for their time. C. Evaluation self assessment exams including physical exams would be coordinated at the end of each block in the Track. Didactic evaluative exams could be substituted for this but with active feedback on exam. Preceptors would perform ongoing evaluations with formal assessment monthly with each student.

11 AGENDA/NAME DISCUSSION/ RECOMMENDATION ACTION V. Issues A. Having 60 students at 1 institution (RRMC) would diminish exposure to other institutions/patient populations However, 2 months of IM at one institution allows better continuity of preceptor, patient and institutional experience. RRMC has a vast variety of diseases on the IM service, a great opportunity to be involved in ancillary service of Radiology, Nuclear Medicine, Surgery and its subspecialties and Psychology/Neurology. The Family Medicine experience would be ambulatory and therefore could use multiple sites as currently employed. B. Availability of preceptors This would need to be explored but including senior established faculty practitioners in a variety of fields of IM including voluntary clinical faculty who are no longer involved in IM inpatient attending should provide an adequate number. C. Conflict with Doctoring and longitudinal preceptor these activities could be incorporated into the preceptor-developed curriculum with didactic issues addressed in limited lectures during the Track no more than 1 per month. D. Role of Major Disease Lectures These would be supplanted by preceptor teaching, noon lecture attendance with housestaff during clerkship, selected lectures as above. E. Potential elimination in affiliate role in 3 rd year teaching. This is a complex political, logistic and pedagogic issue. However, the tradition of using multiple affiliates was largely based on capacity for students rather than pedagogic considerations.

12 The expansion in patient and physician number and therefore breadth of experience has increased enormously in the past 15 years. The Westwood campus is the center of the medical student experience. Appropriate selection of patients and setting can now ensure exposure to a sufficient variety of clinical experience with the proposal outlined. Ambulatory experiences in the 25 different clinical sites in the Department of Medicine include primary care of community patients and the indigent, secondary, tertiary and quaternary care of subspecialty patients all within close proximity to Westwood. Inpatient experiences at RRMC as well as Santa Monica-UCLA Hospital provide an all encompassing breadth of patients. Exposure to County Hospital systems can continue for those in the class unable to fit into the initially proposed experience or in Track A. Close affiliation between the Westwood campus and Olive View Medical Center would be an excellent opportunity for a modified extension of this proposals core themes into a different form of health care system VI. Evaluation of proposal Olive View Continuity Proposal Drs. Carl Stevens and Margaret Stuber (on behalf of Dr. Soma Wali) Quasi-comparative groups from other sites with same track structure could be compared in both shelf exam scores, average clerkship evaluations and ward attending surveys. Student Track Evaluations should be undertaken with a tool to be developed as should preceptor opinion re Track structure. Introduction Currently, medical students are randomly assigned to preceptors at different locations during their medical training. First year students spend a year with a faculty preceptor, which consists mainly of shadowing the clinician. During the second year, the student is assigned to a different preceptor, where again, their clinical experience consists of shadowing the preceptor. Given that most of the preceptors are in private practice with very busy schedules. As a result, the faculty preceptors are unable to adequately get to know the students well and thus it makes it challenging for them to assess the student s needs and/or follow their progress. Informational

13 Program Description The goal of the Olive View-UCLA Medical Center Continuity Preceptorship Program is to provide a continuity experience over three years. The program will start during the first year of medical training. We propose a program that consists of 20 first year medical students who would be assigned to Olive View-UCLA Medical Center with a designated faculty member for their entire preceptorship experience and to continue the mentorship during the third year. The students will be divided into two groups of 10 students per group and they will be assigned to come to Olive view either on a Monday afternoon or a Wednesday afternoon. At Olive View, they will start with a formal orientation to the program and expectations will be reviewed with the students. The students will be assigned in groups of two for different experiences. There will be 5 different clinical settings, which include General Medicine Clinic, Urgent Care setting, Procedure Clinic, Inpatient Hospitalist experience and rounds and Physical Diagnosis rounds. Each student will be experiencing each setting multiple times during the two years. Students will have an opportunity to learn and practice how to take vitals and shadow the faculty preceptor during the first few visits. As the student becomes more comfortable with taking a history, he/she will be given an opportunity to practice history taking. Once they master their history taking skills, they will begin to practice performing physical exams on the scheduled patients. Students will spend 4-5 sessions in a General Medicine Clinic; they will also spend 2-3 sessions in our urgent care, as well as participate on inpatient rounds, physical diagnosis rounds and observe some procedures including a procedure clinic. They will be exposed to both inpatient as well as outpatient Medicine. At the end of the day, the students will return to a conference room where they share their most interesting patient with the rest of the group. The faculty preceptors will use these cases to teach important topics to the entire group. This will allow them to participate in discussions and learn from each other s cases. The faculty preceptors will also try to covert the topics covered in class during the week with actual patients and cases to help improve learning process After two years of completing a preceptorship at Olive View-UCLA Medical Center, we hope to have the same students assigned to Olive View-UCLA Medical Center for their third year inpatient as well as out patient Medicine Clerkships. They will

14 continue to work closely with their preceptors. These students will have the exact same experience as other students assigned to Olive View who have not done their preceptorship at Olive View. This will allow for continued monitoring of their performance, provide guidance and improve their clinical experiences. We believe that the three-year continuity experience will make the transition from second year to third year very smooth. Students will be ready to start their clinical years with much more confidence, as they will get to know their faculty preceptors very well and feel confident in their history taking skills and physical examinations skills. They will also be confident in their presentation skills. I am positive that this experience will improve long-term learning, retention and recall and help students perform at a much higher level during the clinical years. Key Faculty Soma Wali, MD: As the Site Director (Clerkship Director and Residency Program Director), Dr. Wali will oversee the implementation and day-to-day success of the program. She will ensure that all faculty mentor/preceptors meet the program criteria and fulfill the program s mission/objectives. She will have feedback session with the students on a regular basis to monitor the success of the program, thus ensuring a quality continuity experience for the students as well as providing the best possible clinical experience. The following people have been carefully selected to participate in the Olive View- UCLA Medical Center Continuity Preceptorship Program based on the following criteria: 1. Outstanding teaching skills 2. Commitment to Medical Student teaching 3. Enthusiasm 4. Team player 5. Program, facility and patient population knowledge 6. Teaching awards Scott Lundberg, MD: Board certified in Medicine and Emergency Medicine, as Associate Program Director he will participate as an faculty preceptor/mentor and he will also be required to cover in Dr. Wali s absence. Michael Rotblatt, MD, Pharm D: As the Associate Program Director, Dr. Rotblatt will serve as faculty advisor and he will also serve as backup in Dr. Wali or Dr. Lundberg s

15 absence. In addition, the following faculty will serve as faculty preceptors: 1. Elijah Wasson, MD (Director of General Medicine Clinic) 2. Peter Balingit, MD (Director of the Hospitalist Program) 3. Mark Richman MD ( Ambulatory Medicine site director) Evaluation Plan The site director will meet with the students bimonthly to obtain feedback on quality of teaching received, clinical experience, and exposure to diseases, strength and weakness of the program. A list will be generated and their recommendations for improvement will be taken into serious consideration. All data collected will be reviewed, tabulated and shared with the school of medicine. Continuous improvement will be implemented as needed. Students will complete formal evaluation forms. The performance of students will be monitored during the clinical rotations as well as on the shelf exams and USMLE to see if there is any correlation between a 3-year continuity experience and enhanced learning and performance. First Year Budget Student Affairs Officer $10,000 Computer, Laptop & Printer/Copier $ 4,000 Office Supplies $ 500 Faculty Incentives $10,500 Total $25,000 Harbor-UCLA Continuity Proposal Dr. Anita Nelson Project Objectives 1. To provide individual third year medical students with one-to-one protected time with motivated and trained faculty to help develop all aspects of their professional skills. 2. To provide interested third year medical students a sense of stability and continuity as they rotate through the various subspecialties in this 12-week clinical block. Informational

16 AGENDA/NAME DISCUSSION/RECOMMENDATION ACTION 3. To provide the medical student with more insightful and detailed information about the progress being made by individual students and the remaining education needs of some students, as requested. 4. To help students clarify their career goals based on a better understanding of their strengths, weaknesses and personal preferences. 5. To provide third year medical students with potential role models. Candidates Students who elect to do both OB/GYN and Pediatric rotations at Harbor- UCLA o Five students per 12 week cycle Assign one mentor to meet with one participating student for at least one hour every other week Proposed Activites Will vary by mentor and time of year o Advise on time management o Observe student: history taking o Observe student: physical examination o Review charting o Counsel on presentation skills o Develop more extensive differential diagnoses o Provide remedial support for those in need o Discuss different career paths Help student clarify his strengths/weakness in selecting specialties and residences Evaluation Tools Monitor student enrollment over time Survey student pre-program perceptions Student exit evaluations Compare overall clerkship evaluations of program participants to those of non participants Faculty evaluations Co-directors summary evaluations UCLA: frequency of student complaints

17 AGENDA/NAME DISCUSSION/RECOMMENDATION ACTION Implementation Issues Method of invoicing? o Suggest Pediatrics as lead Arranging training and further recruiting Advertising to students identifying candidates Insuring uniform quality Maintaining communication with other programs for benchmarking o UCLA to coordinate?