HOW TO REACH THE UNREACHABLE: HANDOUT
Transcription
HOW TO REACH THE UNREACHABLE: HANDOUT
HOW TO REACH THE UNREACHABLE: HANDOUT WHAT ARE OUR CREDENTIALS TO GIVE THIS LECTURE? o o o Drew Nyce – program director for 5 yrs, clerkship director for 6 yrs Sundip Patel – clerkship director for 4 yrs Required clerkship since 2007 Our program stats based on AAMC Medical Student Graduation Survey Year 2007 2008 2009 2010 2011 Our Clerkship National Avg Our Clerkship National Avg Our Clerkship National Avg Our Clerkship National Avg Our Clerkship National Avg Poor 0.0 6.0 3.8 6.1 3.6 4.5 0.0 4.3 0.0 4.3 Fair 25.0 13.9 11.5 13.7 3.6 11.5 2.3 11.3 12.0 11.1 Good 50.0 36.7 26.9 35.0 32.1 33.1 34.9 32.4 12.0 32.1 Excellent 25.0 43.4 57.7 45.2 60.7 51.0 62.8 51.9 76.0 52.6 What do these stats mean? We did not do well in our first year as a 4th year mandatory rotation in 2007 when you compare the excellent category However, we have steadily improved over the past few years surpassing the national average in the excellent category This is not to show off / brag, but to show that we have been able to utilize certain techniques and teaching methods that have reached all students rotating on the Emergency Medicine (EM) clerkship throughout the year WHY ARE YOU CURRENTLY (or will in the future) HAVE STUDENTS NOT INTERESTED IN EM ROTATING ON YOUR CLERKSHP? o LCME requirement ED-17 states that all students be exposed to Emergency Medicine ED-17. “Educational opportunities must be available in a medical education program in multidisciplinary content areas (e.g., emergency medicine, geriatrics)” Database question – “Describe where in the curriculum the following subject areas are covered and specify the amount of time devoted to each area” Self Study question – “Comment on how well all content areas required for accreditation are addressed in the curriculum. How CORD: How to Reach the Unreachable (Sundip Patel & Drew Nyce) Page 1 confident is the educational program leadership that these topics are appropriately addressed” o Having students do H&Ps in the ED on their Medicine rotation does not seem to meet this requirement o Other clerkships (OB, Surgery) have minimal EM experience and that experience does not provide students the ability to see a patient as the first healthcare provider o Schools meet the ED-17 requirement by making EM a required rotation 36% mandatory rotation in EM (14% selective) in 2007 (Wald Acad Emerg Med 20071) 65% clerkships have EM rotation only in 4th yr (Wald Acad Emerg Med 20071) where you are more likely to encounter students not interested in EM So if you’re not a mandatory EM rotation now, you just may become one soon to help meet this LCME requirement EM clerkship can help the medical school meet many other LCME requirements (McLaughlin Acad Emerg Med 20052) – Taking their article and using the most updated LCME requirements from the website – www.lcme.org ED-2. An institution that offers a medical education program must have in place a system with central oversight to ensure that the faculty define the types of patients and clinical conditions that medical students must encounter, the appropriate clinical setting for the educational experiences, and the expected level of medical student responsibility Translation o We see many different patients and disease processes in the ED o Medical schools have a hard time finding these patient encounters, especially initial presentations, in other clerkships so they turn to EM Examples – Anaphylaxis, Cardiac arrest, Ruptured ectopic o More reason for medical schools to drive their students to the EM clerkship, even ones not interested in EM as a career ED-6. The curriculum of a medical education program must incorporate the fundamental principles of medicine and its underlying scientific concepts; allow medical students to acquire skills of critical judgment based on evidence and experience; and develop medical students' ability to use principles and skills wisely in solving problems of health and disease CORD: How to Reach the Unreachable (Sundip Patel & Drew Nyce) Page 2 Translation o Evidenced Based Medicine (EBM) is required and no better way to teach it than at the bedside in ED o EM is a great way to show disease process, real patient, and evidence all tied together in real time o Med school recognizes this as well and will try to get students exposed to EBM in the ED All these LCME requirements show the following The EM clerkship can provide many solutions to the medical school LCME requirements This will lead to more students being required to rotate in the ED which means many of us will see students not going into EM rotating through our EDs from Jan to June WHY IS IT IMPORTANT TO REACH THOSE STUDENTS FROM JANUARY TO JUNE? o Need to answer to the Dean and your chairman Your clerkship stats on the rotation are analyzed VERY closely Organization of your rotation Patient care experience Educational experience Opinion on faculty & resident educators Professionalism Dreaded “Additional Comments” o Medical school administrators love to focus on these random comments about your clerkship o One disgruntled student writing bad “additional comments” can cause a lot of work for you All of these stats can be affected by dissatisfied students not going into EM It is imperative that you find a way to connect to those January to June students, otherwise your overall stats will be skewed towards lower evaluations o Showcase your EM program Visiting students, home program students will view treatment of their peers/friends not going into EM as a sign of a malignant program This bad treatment could cause you to lose out on a potential recruit o We’re educators, Damnit!! We in Emergency Medicine enjoy educating everyone Even those not going into EM We’ve never shown preferential treatment to students going into EM CORD: How to Reach the Unreachable (Sundip Patel & Drew Nyce) Page 3 o We want to create an image of a rotation that enjoys educating everyone This enhances our reputation Potential to sway a really good student to EM Give the student a fair chance to decide if EM is the right career for them Would not want to turn off someone who could really contribute to our field While Jan to June is very late in the game, a student who initially was not going into EM may decide to take the year off and then go through the EM match KEY MOTIVATIONAL FACTORS FOR STUDENTS ROTATING FROM JANUARY TO JUNE Need to fulfill this required rotation (and that may be the only motivation a student may have) Other students may recognize that they have a final chance to work on certain things before they become interns Some things that you need to remind all students about the EM rotation to motivate them o Procedures Fulfill medical school requirements Get practice with procedures they will be doing very soon as interns o Opportunity to see things, do things they may never do again Peds student seeing elderly patients Internal Medicine student seeing surgical abdomens Pathology student seeing living patients o “What are you going to do in 6 months” argument a.k.a “You will soon be an intern” Practice H&Ps, committing to plans that the students will soon need to do as interns Practice placing orders, calling consults, working on interpersonal skills o Handling sick patients Learn how to handle the situation at 2 am when a nurse tells you “Mrs. Smith is really short of breath and doesn’t look good….” Ability to run through ACLS protocols How do we remind the students from January to June of all of this o EM Clerkship Orientation Day o Our orientation is different depending on the time of year July – Nov orientation (geared for EM bound students) Focus on LORs Additional EM experiences If deciding late to pursue EM, how to go about the process, visiting rotations Jan – June orientation (geared for non-EM bound students) Focus on fulfilling procedures CORD: How to Reach the Unreachable (Sundip Patel & Drew Nyce) Page 4 Completing med school requirements Obtaining skills that will help when they are an intern METHODS TO REACH THE “UNREACHABLE” JAN TO JUNE STUDNETS 1. Simulation Experience o Not many other clerkships provide it o Those that do focus on small areas Anesthesia – intubations, difficult airway Critical Care – sepsis, shock pts o Practice procedures (more on that later) o Our simulations provide students the opportunity to practice things they never get to do ACLS protocols To run a code is something a student never gets to do In real life, they do compressions and that’s it Students always provide positive feedback/evaluations on this Broad approach to SICK pts o Will help when they are interns on the floors in a code o Can instill helpful algorithms in students Student really love running through ACLS protocols o Yeung Canadian study (CJEM 2010; 12: 212-219)3 o 2 x 2hr ACLS lectures with 8 hr skills session o Students ranked ACLS training with skill workshop over clinical shifts, supervised shifts (teaching shifts) o ACLS is a hands-on activity that they can apply clinically o Can tailor simulation experience to student’s interest For example Student going into derm – take septic shock case and tweak it to be a toxic epidermal necrolysis (TEN) or staph scalded skin syndrome Show images of TEN during sim and then go into septic shock sim Student has buy-in to sim and you still cover main points in shock simulation Other examples Optho – globe rupture into a trauma simulation Ortho – long bone fractures into a trauma simulation Radiology – pregnant trauma o Can have them discuss radiation exposures o Other imaging options in trauma and limitations (MRI, ultrasound) Family Medicine CORD: How to Reach the Unreachable (Sundip Patel & Drew Nyce) Page 5 o o Simulation about end of life o Breaking bad news Pathology o Nothing you can do for them o Send them to the anatomy lab More work on your part Doing the preparation to get images Tweak existing simulations However students have huge buy-in and great evals of the experience Simulation has been shown to increase med student satisfaction Ten Eyck article4 Randomized control study with crossover where one group starts with simulation and the other group discussion and then switches midrotation Simulation while more stressful was more enjoyable, more stimulating, and closer to actual clinical setting Small improvement in learning as well 2. Teaching shifts o We have employed teaching shifts for over 7 years o A dedicated faculty member teaches 2-3 students on a 6 hour shift o Dedicated faculty member Does not hear any other cases Generally does not see any pts primarily o Change in pace from regular shifts as more time spent on education o Opportunities to directly observe students do H&Ps o Can spend time going over concepts (acid/base, anion gaps, etc.) o Problems Need buy-in from faculty worried about RVUs Expensive shifts for department to finance o It has been proven to work (Cassidy-Smith5) Students were more satisfied with the quality of bedside teaching, preceptor experience, and usefulness of the rotation Faculty noted improvement in their availability to listen to student presentations, timeliness to initiate workups, and timeliness in pt disposition Residents noted improved availability of the other attendings working that day and improved faculty bedside teaching of residents 3. Evidence Based Medicine (EBM) o LCME requirement (ED-6) states we need to provide EBM to students o Real time scenarios / patient cases provide better retention of knowledge CORD: How to Reach the Unreachable (Sundip Patel & Drew Nyce) Page 6 o o o So many different aspects of EBM to focus on Gold standards, sensitivity, specificity, negative predictive value, number needed to treat, results applicable to your patient population Tailor the EBM to their future interests For student going into Ortho – do open distal tuft fxs need OR washout? Pediatrics – fever workup in the ED of children 8 weeks old? Surgery – Does morphine prevent an accurate abdominal exam? Pathology – Will you ever raise your hand in a plane if they ask for a doctor? Our ways to expose EBM to all students EBM stressed with students during patient care in the ED Wells Criteria for pulmonary embolism Ottawa ankle rules for ankle injuries Early Goal directed therapy for septic patients Centor criteria for sore throats On-line journal club Did not want to use up an hour of lecture time going over article no one has read We post an article online for students to read “CT should replace a 3 view radiographs in the initial screening test in patients at high, moderate, and low risk for blunt cervical spine injury: a prospective comparison” (Bailitz J Trauma 2009; 66: 1605-1609) Questions about article are also posted online o Design of study, sensitivity, specificity, likelihood ratio o Strengths, weaknesses o Applicability to our patient population We go over the articles and questions on day of test This requires students to read the article AND analyze it Student feedback has been very positive compared to traditional journal club 4. Optional Enrichment experience o All students have the option of meeting with an EM faculty member twice in 4 weeks Go over ECG module Clinical vignettes with ECGs Questions “Enrichment Case” Slow dissection of a case with students having to explain o Pertinent positives and negatives in H&P o Work-up and treatment plans o Interpretation of labs and xrays Go over an interesting case selected by the student CORD: How to Reach the Unreachable (Sundip Patel & Drew Nyce) Page 7 o o o o 10 min Evidence Based Medicine presentation Gives students more in depth experience on EM (could help that student unsure about EM) One-on-one interactions with faculty always viewed well by students Student particularly like ECG module Reinforces concepts learned Clears up confusion areas on ECGs Have ECG with clinical situation which provides more meaning to a student than just looking at ECG and interpreting it Problem Finding faculty who have the time to do this Pretty big investment in time and effort to set up the experience initially (gathering ECGs, creating the enrichment case, supporting documents) 5. Ultrasound o Literally no experience on other rotations o Radiology rotation – they read ultrasounds, they don’t do them o Perfect marriage of disease process, imaging, procedure, and patient contact ED provides wide variety of ultrasounds RUQ First trimester pregnancies Fast exams Peripheral IV placement Arthrocentesis Cooler stuff o Central line placement o Peritonsilar abscess drainage o FBs in eye o Could provide ultrasound experience Integrated into EM clerkship Pros o Every student gets exposed to it o Enhances the rotation Cons o Time taken away from other aspects of the clerkship o Hard enough in 4 weeks to get ultrasound competence, even Harder if only using small portion of 4 weeks for ultrasound Solutions o Separate ultrasound rotation More time to focus on ultrasound techniques, get proficient CORD: How to Reach the Unreachable (Sundip Patel & Drew Nyce) Page 8 o However students not going into EM won’t do it Another course you need to run which entails a lot of work Concentrate on one aspect of ultrasound during the EM rotation Pelvic ultrasound for first trimester pregnancies FAST exams in trauma Peripheral IV insertion 6. Mid-clerkship Feedback o Students appreciate feedback and it is not given well, if at all, in other clerkships o Can serve as a wake-up call to those students not interested o More detailed the better o Can give solutions to correct deficiencies a student may have o Also can give reminders about requirements Patient encounters that still need to be seen End of rotation presentation Meeting with advisor o Example of the feedback we give is in the back of this handout Focus on 3 areas Clinical work Have they seen required patient encounters Written patient notes o Example of student comments after this mid-clerkship feedback “Thanks a lot for the thorough feedback. I will continue to read and work on my data gathering skills” “Thank you for sending me my mid clerkship feedback. It is rare that I get that detailed a report, and I greatly appreciate the chance to know what I need to work on before the end of the clerkship” “I just want to let you know that this is the most thorough mid-clerkship evaluation I have gotten to date” 7. Procedures o Students are exposed to a wide variety of procedures on EM clerkship Just don’t get them in other clerkships Lumbar Puncture, suturing, arthrocentesis, joint reductions, splinting, ABGs Ability to be directly supervised by faculty From Jan to June, you will have residents give up procedures to students as they have become comfortable with them o Can fulfill any med school requirements Foleys, nasogastric tubes, IV lines, phlebotomy, etc CORD: How to Reach the Unreachable (Sundip Patel & Drew Nyce) Page 9 o o Stress importance of knowing mastery of certain procedures to help out in intern yr We can also run them through simulation to practice invasive procedures such as intubation, central lines, etc. DO’s AND DON’Ts OF DEALING WITH STUDENTS NOT GOING INTO EM o o Do’s Let them see cases in the field they are going into (on a limited basis) (Example – student going into ortho picking up ankle sprains, dislocations) If prevent them from seeing cases they’re interested in, you may have an unhappy student on your hands If you allow them to focus primarily on those cases o Miss out on the true EM experience o Not really an EM rotation o Faculty will be resentful Need a mix o Allow them to sometimes see those cases o Make sure to stress value in seeing wide variety For student going into peds complaining about seeing 80 yo pt, ask them what will they do when their grandmother gets sick? Parent gets sick in their office? Flexibility in scheduling Allow students to go to ortho conference, meet with advisor, etc. However students still need to make up shift, meet all requirements Make all schedules similar (same amount of nights, weekends, days on lecture days) Have the SAME expectations in seeing patients Don’t lower the bar for what is expected in clinical work If you lower the bar, students going into EM won’t be happy Short-changing the student who may think what they are doing is ok and will then transfer that practice to actual patient care as interns Make the objectives clear and unyielding for ALL students Don’ts Do NOT provide preferential treatment to students going into EM (with scheduling, more attention, more opportunities to do procedures) Easiest way to anger non-EM student Easy way to get bad reviews on the clerkship Easy way to draw the dean’s ire on you CORD: How to Reach the Unreachable (Sundip Patel & Drew Nyce) Page 10 Do NOT cut down shift number Jan-July Your faculty will pressure you into doing this A non-EM student who rotated in July working 16 shifts will not be happy about non-EM students rotating in Jan working 13 shifts Sends wrong message as well – that we don’t want to spend time with nonEM students Do NOT allow faculty to ignore or let non-EM students slide Don’t allow faculty members to send students home early Don’t allow faculty members to have students stop seeing patients early or shadow residents Your chairman should support you in preventing this CORD: How to Reach the Unreachable (Sundip Patel & Drew Nyce) Page 11 Journal articles 1. Wald DA, Manthey DE, Kruus L, et al. The state of the clerkship: a survey of Emergency Medicine clerkship directors. Acad Emerg Med. 2007; 14: 629-634. 2. McLaughlin SA, Hobgood C, Binder L, et al. Impact of the Liasion Committee of Medical Education requirements for Emergency Medicine education at US Schools of Medicine. Acad Emerg Med. 2005; 12: 1003-1009. 3. Yeung M, Beecker J, Marks M, et al. A new Emergency Medicine clerkship program: students’ perceptions of what works. Canadian Journal of Emergency Medicine. 2010; 12: 212-219. 4. Ten Eyck RP, Tews M, Ballester JM. Improved medical student satisfaction and test performance with a simulation-based Emergency Medicine curriculum: a randomized controlled trial. Ann Emerg Med. 2009; 54: 684-691. 5. Cassidy-Smith TN, Kilgannon JH, Nyce AL, et al. Impact of a teaching attending physician on medical student, resident, and faculty perceptions and satisfaction. Canadian Journal of Emergency Medicine. 2011; 13: 259-266. CORD: How to Reach the Unreachable (Sundip Patel & Drew Nyce) Page 12 MID-CLERKSHIP FEEDBACK EXAMPLE Mary, these were some of the comments from the evaluation cards for you over the past 2 weeks. Clinical Work Feedback “Enthusiastic, hard working” “Good histories, hard working, should read about differential diagnosis of back pain” “Oral presentation are organized and succinct. Would like to see her be confident with her differentials and treatment plans. Pleasure to work with” “Hard working, wrote good notes” “Does good job overall, should make sure to follow up on labs, xrays” Mary, please continue to work hard and keep up the enthusiasm. Please continue to work on ED appropriate differentials for the common complaints - chest pain, shortness of breath, abdominal pain. Remember to "rule out" the bad ones like abdominal aneurysm in an abdominal pain patient. Keep an eye out for any tests that were sent and do not just report the results, but interpret them in context with the pt’s disease process. Try to read up on a few case you saw in the ED concentrating on differentials and workup plans. One really good source is www.cdemcurriculum.org which has an approach to disease processes along with education on particular ones. By the way, it was commented that your patient notes are very good with regards to detailing the history, physical exam, and assessment and plan. Please continue your excellence in writing notes. Continue to hand out the blue evaluation cards over the remaining weeks to the attendings and senior residents. Remember, your grade is largely derived from these evaluation cards and it is your responsibility to hand them out. Attendings and senior residents may hand in eval cards if you forget, but they are not obliged to do so. If you run out of blue cards, make sure to ask Ms. Nancy Loperfido for more. Required Patient Encounter Feedback It is also your responsibility to make sure that you see all seven of the required patient encounters; chest pain, abdominal pain, shortness of breath, altered mental status, blunt trauma/fall, back pain, and management of a wound/suturing. Having reviewed your online patient logs, here are the following that you still need to see: Altered mental status, blunt trauma / fall Please make sure to see the required patient encounters. If the encounters are not seen, then you will have to do the remediation process as outlined online. You have until midnight Sunday following the end of the rotation to log all your patient encounters. Failure to do so will lead to your final grade being lowered by one grade. I have no desire to do this so please make sure you see and log all your required encounters. CORD: How to Reach the Unreachable (Sundip Patel & Drew Nyce) Page 13 Patient Notes Feedback I have also reviewed the notes you have written in EPIC. I am able to run a report to see notes written by students. Here is some feedback on your notes (Due to HIPAA privacy laws, I will not be providing the pt’s name or other identifying details): Patient Note Feedback: Back pain - Very good description of her pain, what caused pain, exacerbating and relieving factors - Really liked how you described what meds pt took and associated symptoms such as paresthesias - One suggestion is to give a small blurb on whether pt has had prior back pain episodes and if this episode is similar to past ones - I would also make sure to document if the pt has ever had any imaging such as an xray, CT scan, or MRI. - Excellent physical exam with concentration on neurovascular symptoms - For back pain pts, it is good to document their gait. If they can’t walk due to pain, that should be documented as well - Good Differential Diagnosis and plan. You stated what you thought was the most likely diagnosis, but also listed what else you considered and why you thought those were less likely. Let me know if you have any questions, comments, concerns, or want to meet to discuss these comments further. Dr. Patel CORD: How to Reach the Unreachable (Sundip Patel & Drew Nyce) Page 14
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