Welcome to the Third Year!

Warren Newton, MD MPH

Vice Dean for Education

UNC School of Medicine

June 27, 2011

• Describe educational rationale for year III, with competencies we expect

• Describe what will be new this year, especially with respect to LCME issues

• Discuss learning environment• Give rules for living for third year;

start planning fourth year

Objectives

UNC Curriculum

• General Clinician• Active Learning

» Get involved in care» Read on individual patients

• Breadth of Experience» Varieties Patients/Specialties» AHEC

Educational Rationale—Year III

• See clerkship website• Clinical Evaluations• OSCE/Other Evaluations, either

formative or summative• Shelf Exam• End of Year (CPX, NBME II

MK/CS)

Grading

Competencies

• Practicing medicine requires more than medical knowledge

• In late 90’s, organized medicine committed to explicit training in six domains of competence in residencies

• All US residencies (and CME) focus training in medical knowledge, communication, clinical skills, professionalism, problem based learning, systems based practice

UNC School of MedicineCurriculum Renewal

• About 18 months ago, we began a review our medical school curriculum from a “competency” perspective…

• We started with outcomes and chose these core competencies and one other, managing the health of populations

• We define the UNC 96 and core procedures all students should learn

• We are now in the process of integrating the by each competency over all four years…

Medical Knowledge

• Tests of knowledge are foundation of our current system

• You will take tests for the rest of your life.

• Assessment: Clinical Evaluations, shelf exams

Clinical Skills

• History/Physical• Differential Diagnosis,

Management Plan, Procedures• Assessment: Clinical

Evaluation, OSCE, CPX

Communication Skills

• Not just patients, but peers and staff• Oral and Written; including cultural sensitivity• Guidelines, but specialty and situation

dependent• Your reputation, patient satisfaction, pay and

liabilility risk depend on communication skills • Assessment: Clerkship evaluations, OSCE’s,

CPX

Systems Based Practice

• WebCIS• CPOE• Care Management• Speech Therapy, etc• Referrals• Discharge Planning

Systems Based Practice

Problem Based LearningLearning from Experience

• Case by case• Critical appraisal of literature…• Quality Improvement

Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial.Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, Jackson RD, Beresford SA, Howard BV, Johnson KC, Kotchen JM, Ockene J; Writing Group for the Women's Health Initiative Investigators.

AbstractCONTEXT: Despite decades of accumulated observational evidence, the balance of risks and benefits for hormone use in healthy postmenopausal women remains uncertain.

Practice Based LearningQuality Improvement

Managing the Health of the Population

• Managing costs, quality and access• Both primary and subspecialty care

» ACOs and Bundled Payments for common major procedures

» Center of Excellence for Bariatric Surgery • Assessment: Projects

Professionalism

Harris Poll, September 8, 2005

The Prestige of Doctors

30

40

50

60

70

2000 2001 2002 2003 2004 2005

Doctor Nurse Police Officer Priest/Minister/Clergyman

• A Social Contract

ProfessionalismKey Issues for you

• Honesty/Integrity• Show up on time• Be Respectful of patients, peers, staff• Learn from feedback• Assessment: Clerkship evaluations

Competencies

• Competencies, mileposts, UNC 96 and procedure list available on SOM website—and by clerkships

• What is new is focus on outcomes of the curriculum and tracking over all four years; this year, clinical skills, professionalism and health of population

• Common asessment form and new CPX• Thanks for all your help…

What’s new this year…

Curriculum Improving Infrastructure

• At least two meetings of clerkship leaders• Regular review of duty hours, timeliness and

distribution or grades across clerkships/sites• Grading: 35-45% H, broaden assessments• Clinical log/One45 to track experience• Improved consistency of mid-course

feedback, direct observation of history and exam skills and common assessment form

Patricia White, MDCharlotte

Bert Fields, MDGreensboro

• Student Health Services

• Counseling Services

• Needlestick Protocols

• Housing • Orientation

John Perry, MDWake

Mark Darrow, MDWilmington

Campus Directors

Jeff Heck, MDAsheville

AHEC Infrastructure Improvements

LCME Review

• Every 8 years; a broad review (not just curriculum and student affairs)

• March 11-14, 2012• Student Self Study submitted 5/11,

with 90.5% response rate!• Student Steering Committee,

Whitehead • Opportunity to think how it ought to be!

Improving the Learning Environment

Mistreatment Incidence (LCME Student Report)

» 10% - 3rd year» 19% - 4th year» 31% report

Experience or observe

UNC vs. National

• All schools UNC• 2006 12.2 20.0• 2007 14.7 19.5• 2008 16.7 24.6• 2009 17.0 18.4• 2010 16.9 15.2

What is mistreatment?

• Not being asked questions or to do things for patients

• Not nurse vs. student• Occasional physical violence,

inappropriate sexual advances, or ethnic/racial slurs.

What is mistreatment? Specialty Bashing/Bigotry

• “I was interested in ------- until my third year rotations. EVERY single specialty talked trash about --- physicians stating how frustrating and incompetent most of them were.”

• “Because the residents knew that I did not plan to go into ---, they did not give me the opportunity to do many things in the OR despite my attempts to show enthusiasm and motivation.”

Disrespect forPatients or Students

• “There are patients that residents and attendings make fun of there is often judgment about whether they have had too many kids, shouldn't have kids, about their social situation, about whether they can afford kids, and most often that they are large.”

• Another student, seeing that the patient was being placed on the wrong side in the OR, made the resident aware of this and the resident said, “YOU’RE A MEDICAL STUDENT, YOU DON’T SPEAK! I DON’T EVEN WANT YOU TO THINK!!!!”

David Carl Charlotte

Michelle Kane, PsychDGreensboro

Gary Gala, MDUNC Chapel Hill

Alan Cross, MDUNC Chapel Hill

Dale Fell, MDAsheville

Joe Kertesz, MAWilmington

Ombudsmen

David Gittleman, DOWake

John Perry, MDWake

Rev. Barbara BullockCharlotte

What we are doing…

• Institutional policy about positive learning environment, with emphasis on respect, engagement in patient care, and student participation in care (pagers, Webcis, POE)

• Zero-tolerance approach, with close to real time monitoring through clerkship evaluations, clerkship directors, chairs, and ombudsmen

• Ensure safety of process for students, continue separation of grading from evaluation

Next Steps—What you can do?

• Get involved in patient care and your teams• If you have questions or concerns, contact

your clerkship director, the chair, the ombudsmen, Ms. Stone, Dr. Dent or me.

• Grades handed in before we evaluate; we will respond to every case, and report your name only with your permission

Surviving and Thriving as an MSIII

• Keep in touch: Advisors, Dean Dent, Student Affairs Staff; day backs

• Laptops—OIS walk, or email Jake Achey • Student Health – Waiver; take off for care• Physical Difficulties-- Communicate With

Course Directors • Excuses through local staff, tracked by

student affairs office

Rules for Living

• 5-10% of Students• Differential Diagnosis

» Test Taking» Clinical Skills» Professionalism Issues

• Get In Touch With Us!

Academic Difficulty

• 50% in July of third year (1/2 will later change)

• 75% by April Next Year• 5-10% will apply in 2 or more

specialties• 5% will change after internship• National: increasing students for

fixed number residency slots

Natural History of Specialty Choice

• January 3, 2012 Specialty Information Sessions• Career Advisors mandatory• 2012 Summer/Fall MS IV

» CPX, NBME Part II MK/CS» Audition Electives

• Dean’s Letter Deadline—October 1, 2012; College advisors will write most

• ***Identify writers of recommendations this year

Specialty Choice Timeline

• Specialty Choice/Applications• Advanced Skills (AI, Critical Care)• Schedule Flexibility/Choice

» For Boards and Interviewing» Student Choice: Advanced Practice

Selective, Medicine and Science• You will never be as free again: Keep in

mind special interests

Year IV Educational RationaleSpecialization