HAEI and HAEII course objective #16

HAEI and HAEII course objective #16

The following slides contain a template that illustrates the general format used for an On-Doctoring, Y3, or Y4 clerkship review. In the notes section of some slides there are further instructions to clarify what is needed for a particular section of the review. The components of the review are: Task Who Completes Revisit prior action plan and investigate progress Clin Ed Manager and Clerkship Director List course objectives and course content including essential skills and diagnoses Clerkship Coordinator and Clin Ed Manager (session objectives) Examine mapping of course objectives Clerkship Director Evaluate planned/unplanned redundancy Clerkship Director Look back for key concepts that need preparation and material in prior coursework Clerkship Director Look for Health and Values and other VIG content

Clerkship Director List Grading Criteria Clerkship Coordinator List how each course objective is assessed/evaluated Clerkship Coordinator Review measures of quality Grad Questionnaire, USMLE scores, Course Eval numbers Clin Ed Manager Review measures of quality---Student Evaluation Comments (Student MEC Representatives) Student MEC Representative The Deans of the appropriate year, or their agents, will serve as the team leader for each course review. The responsibilities of the team leader are: 1. 2. 3. 4. 5. 6. 7. Recruit members for the review team along with the MEC

Assign tasks to the clerkship director, clerkship coordinator, clin ed manager and student MEC reps, and convey deadlines for when the work needs to be done. Contact the clerkship director to inform them of the date the review will be presented at the MEC meeting so they can put it on their calendar/indicate availability. Ask clin ed manager to convene a Course Review meeting for the clerkship review team/committee Collect all the work completed by the clerkship director, clerkship coordinator, clin ed manager, and student MEC reps, and summarize the assessments and overall recommendations of the Course Review committee and collate into this PowerPoint presentation; Collect the action plan from the clerkship director and insert it at the end of the slides; send the slides to Rachel 2 weeks before the MEC meeting. Present the final recommendations of the subcommittee at the MEC meeting (last few slides) Review of Surgery clerkship Clerkship occurs in Year 3 Clerkship Director(s) Dr. Andrew Crockett, Dr. Meredith Sorenson Clerkship Coordinator Terri Nicholson Clerkship is 8 weeks long Clerkship was last reviewed in Feb 2016 Current Review: Nov 2017 Action Plan from Prior Review

Course Objectives Objective 1: Remove word critically DONE Objective 2: replace with Describe the etiologies, pathophysiology, clinical features, differential diagnosis, and related diagnostic testing and management of common surgical conditions to clarify expectation. DONE Objective 4: Change word different to various DONE Session Objectives Incorporate these well written objectives into CANVAS site along with sessions to better clarify expected learning goals NOT DONE Update 5, 8 and 9 (Remove DMEDS) DONE Essential Skills/Conditions Change Pain to Acute Pain; Change Acute Resp Failure to Acute Resp Distress NOT DONE Remove Inject Local Anesthetic NOT DONE Review Canvas site for accuracy and inclusion of objectives rather than links to Ilios Done Action Plan from Prior Review Pedagogy Will change scenarios used for the simulated Breaking Bad News session to be more surgery-centric to reduce redundancy with ICE and other clerkships DONE Didactic session will include a summary of main points, and a sample of MCQs to better prepare students for the shelf exam NOT DONE Will provide suture workshop schedule to residency coordinator in advance to promote resident involvement DONE Learning environment Continue annual retreat and monthly meetings with rotation directors DONE but moved to every other month Provide timely feedback from student evals to faculty and residents and their supervisors NOT DONE

Ask rotation directors to provide feedback on written patient notes consistently DONE Continue semi-annual grand rounds for faculty and resident professional development in education and resident as teacher seminars Planned Limit number of students on subspecialty rotations during sub-I months DONE Course Objectives 1. 2. Apply appropriate knowledge developed from relevant, consensus based literature to the delivery of surgical care. Describe the etiologies, pathophysiology, clinical features, differential diagnosis, and related diagnostic testing and management of common surgical conditions. 3. Recognize and define knowledge of surgical diseases that demand (change to deal with) risk factor modifications, end of life decisions, palliative care, pain management, medical legal issues and substance abuse. 4. Communicate effectively with patients and families of various social, economic and cultural backgrounds, or when special needs or barriers to communication exist, particularly in the areas of individual health, or factors that may impact health and informed consent. 5. Perform professional responsibilities by establishing respectful relationships; e.g. student-patient, student-family, colleagues, and all members of the health care team. Professionalism also includes respect for diverse patient concerns, opinions and cultural perspectives , with respect to the basis for the doctor-patient relationship. 6. Interview patients skillfully, perform a complete physical exam with attention to infection control, patient comfort and privacy in order to define and prioritize the patient's problems and organize a differential diagnosis. 7. Identify, define and perform the indications, complications and limitations of simple clinical procedures; e.g., suturing, foley placement, etc., and assist in common surgical interventions; e.g., laparoscopy, chest tube placement, abdominal exploration, etc. 8. Interpret without assistance common abnormalities and urgent findings on common diagnostic tests and studies; e.g., chest x-ray, abdominal series, CT scan, ECG, etc. 9. Demonstrate the ability to assist patients in understanding their treatment options and motivating them to make healthy behavioral and treatment choices. 10. Communicate effectively and collegially with physician colleagues and other members of the health-care team verbally, in writing and in the electronic medical record. 11. Demonstrate responsibility for his or her own medical education, develop the habits of mindfulness, reflection, and continuous learning by adhering to high ethical and moral standards, accepting responsibility for personal actions, incorporating constructive criticism and respecting patient confidentiality.

12. Identify and utilize appropriate resources to support patient care and collaborate with all members of the inter-professional team. Mapping of Course Objectives to Geisel Competencies Appropriately mapped. Course Objectives Comments Comments about objectives Appropriate number Describe course well Consider changes to the following; Remove 3: Recognize and define knowledge of surgical diseases that demand risk factor modifications, end of life decisions, palliative care, pain management, medical legal issues and substance abuse. Clerkship is not uniformly covering this for each student and not currently expected to. Change 5: Perform professional responsibilities by establishing respectful relationships with patients, families, colleagues and health care team members. Remove second sentence with this objective Professionalism also includes respect for diverse patient concerns, opinions and cultural perspectives, with respect to the basis for the doctor patient relationship. Course Objectives Comments Changes cont. Change 9: Demonstrate the ability to assist patients in understanding their treatment options. Remove the latter half of the sentence and motivating them to make healthy behavioral and treatment choices. Add the following: Demonstrate the adaptability necessary to function effectively in changing clinical environments. Format of Course & Session Objectives Course objectives are provided in the syllabus

Course objectives are written in the correct format Session objectives are mostly provided in the course Need to be in Canvas Missing on Ilios: Enculturation, Second Victim Session objectives are written in the correct format Issues of Redundancy Are there major issues of redundancy with other courses? Suture skills (OB and FM also have a knot tying workshop) We have introduced a suture skills exam We believe suturing and knot tying are integral parts of a surgical experience and the inherent redundancy is necessary as few students have actually mastered technical skills Breaking Bad News (ICE has a Communication skills workshop with responding to emotion after giving bad news, MED has an End of Life Discussion) Surgery session different because focus is on acuity and sometime unexpected nature of surgical M&M Additionally, we specifically address the issue of surgeon responsibility for complications/adverse outcomes Look back for preparation on key concepts Are there major issues that should be included with other courses? Preparation is adequate, recognizing that surgery is quite different from other specialties. Specific preparation for

the operating room, for example, is impossible without being immersed in it. Students should be reminded to review Surgical Scrub training modules prior to start of clerkship Vertical Integration/Preparation Rate training from Year 1 and 2 to prepare you this clerkship overall 4.5 4 3.5 3 2.5 14-15 15-16 16-17 2 1.5 1 0.5 0 FM MED OB PEDS PSYCH

SURG GAM NEURO Vertical Integration/Preparation Rate training from Year 1 and 2 to prepare you this clerkship communication: 5 4.5 4 3.5 3 14-15 15-16 16-17 2.5 2 1.5 1 0.5 0 FM MED OB PSYCH

SURG PEDS GAM NEURO Vertical Integration/Preparation Rate training from Year 1 and 2 to prepare you this clerkship Physical Exam: 4.5 4 3.5 3 2.5 14-15 15-16 16-17 2 1.5 1 0.5 0 FM MED OB PED PSYCH

SURG GAM NEURO Vertical Integration/Preparation Rate training from Year 1 and 2 to prepare you this clerkship Medical Knowledge: 5 4.5 4 3.5 3 14-15 15-16 16-17 2.5 2 1.5 1 0.5 0 FM MED OB PED

PSYCH SURG GAM NEURO Pre-clinical Preparation Rate training in Y1 and Y2 to prepare you for Clerkship Communication Skills PE Skill Med. Knowledge 2014-15 2015-16 2016-17 3.05 3.65 3.98 3.57 3.33 3.79 3.88 3.52 3.23

3.77 3.84 3.44 Issues: Scrub Training, IV Catheters and Trach Tubes Oral Presentations Health and Values Goals Ethics Identify key concepts in health care ethics and demonstrate an ability to recognize ethical issues arising in patient care and population health and to think critically and systematically in applying an ethical analysis Cultural Awareness Demonstrate an understanding and skill in managing patient care of people of diverse cultures, social, economic standing and belief systems Health Equity Identify the root causes and approaches for addressing health disparities locally and globally Resilience Demonstrate knowledge of skills and practices to prevent and address stress and maintain resilience in caring for patients and oneself Compassion and Empathy Demonstrate abilities to understand each patients experience of illness, adapt scientifically appropriate care to conform to that patients needs, and communicate in terms that each patient can understand There also are synergies to health law, communication skills, professionalism (as LCME requires). Health and Values Content What Health and Values Program material (healthcare ethics, cultural awareness, health equity, resilience, compassionate care) is presented in the course?

Informed consent session: ethics; cultural awareness Second victim phenomenon, Enculturation sessions: resilience Breaking bad news: compassion & empathy; cultural awareness Are the Health and Values topics noted in the course and session objectives? Action item: write session objectives for informed consent session Action item: specifically delineate health and values topics in objectives What do the student evaluations indicate regarding Health and Values teaching? Not assessed specifically Essential Skills Essential clinical skill performed in an inpatient setting: Are these appropriate for this clerkship? Yes Would you add or subtract any? No Are there major issues of redundancy with other clerkships? No Change Expected level of involvement on Trauma evaluation to ASSIST

rather than Perform with supervision Change Abd Exam to Perform independently Expected Level of Involvement Abdominal Surgery Assist Abdominal Exam Interpret CT scan of the abdomen/pelvis or chest Perform with Supervision Perform with Supervision

Insert Foley catheter HPI Inject a local anesthetic Perform with Supervision Place an NG tube Orally present patient admitted to hosp Perform with Supervision

Perform independently Suturing (simple, skin) Trauma evaluation Interpret Ultrasound of the abdomen Wound Evaluation Interpret X-ray (KUB) of the abdomen

Write an admission note Perform with Supervision Perform independently Perform with Supervision Perform with Supervision Perform with Supervision Perform with Supervision Perform with Supervision Perform independently Essential Conditions Are these appropriate for this clerkship? Yes Would you add or subtract any? No Are there major issues of redundancy with other clerkships? No

Remove Failure from Acute respiratory distress Essential clinical condition managed with assistance in an inpatient setting: Expected Level of Involvement Shock or SIRS Manage with Assistance Fever, post-op Manage with Assistance Acute Pain management Manage with Assistance Surgical evaluation of cancer patient

Manage with Assistance Post-operative care Manage with Assistance Abdominal pain Manage with Assistance Trauma Manage with Assistance Peritonitis or intra-abdominal abscess

Manage with Assistance Bowel obstruction, large or small bowel Manage with Assistance Acute respiratory distress/failure Manage with Assistance Nutrition Content What Nutrition content is presented in the course? Nutrition support (enteral, parenteral) surgical metabolism, nutrition in critical illness, post-operative nutrition, malnutrition in the surgical patient Fluids, Electrolytes, acid-base balance Are Nutrition topics noted in the course and session objectives?

No course objectives specific to nutrition Session 6: Fluids, Electrolytes, and acid-base case studies (session objectives 1-7) Session 21: Surgical Metabolism and Nutrition Case Studies (Session Objectives 1 through 4) Student comments: N/A Recommendations for Nutrition Integration Recommendations for Nutrition Education: 1. Utilize available resources (Nutrition in Medical Education Program, Rima Al-Nimr) for development, teaching/dissemination of course nutrition content as needed, and continue to work with nutrition program to meet goals and develop new content 2. Develop a nutrition-specific course or session objective to highlight content already being taught in the course 3. Review case studies with Rima Al-Nimr to ascertain no unplanned redundancy with year 2 Themes nutrition support lecture Summary regarding Objectives Course Learning Opportunities

Clinical experiences Ward, OR, Clinic, Overnight call x 4 Split between General Surgery and either a second Gen Surg or Specialty Surgery Orientation Suture Skills Workshop Small Group Case Based Discussions Abd Pain, Post-op Oliguria, Fluids/Lytes/Acid/Base, Post-op Fever, Wound Healing, Metabolism and Nutrition, Inflammation, Informed Consent Formal Case Presentations Enculturation Session 1 hr Path Conference x 2 Second Victim Discussion 1 hr Skills Workshop Delivering Bad News SP Session CORE Radiology cases (3 required) Summary regarding Pedagogy Consider Skills workshop at the beginning NGT, Foley with assigned NEJM videos

Assessment Clinical Performance Evaluations 44% NBME Shelf Exam 22% OSCE 11% (new 2017-18) Participation 11% Service Case Presentation 6% (new 2017-18) Suture Skills Exam 6% (new 2017-18) Assessment for Course Objectives Number Course Objective 1 Apply appropriate knowledge developed from relevant, consensus based literature to the delivery of surgical care. How Assessed Learning Activity 2 Describe the etiologies, pathophysiology, clinical features, differential diagnosis, and related diagnostic testing and management of common surgical conditions. NBME shelf, Ward

Evaluation, Case Present, OSCE 3 Recognize and define knowledge of surgical diseases that demand risk factor modifications, end of life decisions, palliative care, pain management, medical legal issues and substance abuse. NBME shelf exam, Ward Patient Care; Weekly Sessions Evaluation 4 Communicate effectively with patients and families of various social, Ward Evaluation, OSCE economic and cultural backgrounds, or when special needs or barriers to communication exist, particularly in the areas of individual health, or factors that may impact health and informed consent. Patient Care, Breaking Bad News Session 5 Perform professional responsibilities by establishing respectful relationships; e.g. student-patient, student-family, colleagues, and all members of the health care team. Professionalism also includes respect for diverse patient concerns, opinions and cultural perspectives, with respect to the basis for the doctor-patient relationship. Ward Evaluation, OSCE Patient Care

6 Interview patients skillfully, perform a focused physical exam with attention to infection control, patient comfort and privacy in order define and prioritize the patient's problems and organize a differential diagnosis. Ward Evaluation, OSCE Patient Care NBME shelf exam, Ward Patient Care; Weekly sessions Evaluation Patient Care; Weekly sessions Assessment for Course Objectives Numb Course Objective er How Assessed Learning Activity 7 Identify, define and perform the indications, complications and limitations of simple clinical procedures; e.g., suturing, foley placement, etc., and assist in common surgical interventions; e.g., laparoscopy, chest tube placement, abdominal exploration, etc. Ward Evaluation, Suture Patient Care, Knot tying session, Skills Session exam, Passport

8 Interpret without assistance common abnormalities and urgent findings on common diagnostic tests and studies; e.g., chest x-ray, abdominal series, CT scan, ECG, etc. Ward Evaluation, Passport Patient Care, CORE cases; Weekly Sessions 9 Demonstrate the ability to assist patients in understanding their treatment options and motivating them to make healthy behavioral and treatment choices. Ward Eval, OSCE Patient Care 10 Communicate effectively and collegially with physician colleagues and other members of the health-care team verbally, in writing and in the electronic medical record. Ward Evaluation, OSCE Patient Care, Write Ups 11

Demonstrate responsibility for his or her own medical education, develop the habits of mindfulness, reflection, and continuous learning by adhering to high ethical and moral standards, accepting responsibility for personal actions, incorporating constructive criticism and respecting patient confidentiality. Ward Evaluation, Self Assessment Patient Care; Weekly Sessions, Enculturation; Second Victim Phenomenon Session 12 Identify and utilize appropriate resources to support patient care and collaborate with all members of the inter-professional team. Ward Evaluation Patient Care Measures of Quality AAMC GQ Rate the quality of your educational experiences in the following clinical clerkships. Likert Range: Poor, Fair, Good, Excellent. Reporting % in top two categories (Good or Excellent) below. Geisel mean 2013 Geisel mean 2014

Geisel mean 2015 Geisel mean 2016 CFM 70.3 77.4 93.2 83.8 MED 91.4 96.5 85.9 92.6 NEURO 58.0 82.7

78.9 72.9 OBGYN 72.3 73.8 75.4 PEDS 86.2 96.2 PSYCH 90.5 SURG 63.8 Clerkship Measure s of Quality AAMC GQ

Geisel mean 2017 All schools means 2017 90.5 85.7 92.0 91.2 71.1 76.7 73.5 68.2 79.4 95.9 75.0 85.7 86.3

97.6 94.6 91.2 95.2 87.3 79.8 81.6 79.4 82.0 82.4 Measures of Quality AAMC GQ Percent answering Yes to question (goal is 100%) Measure s of Quality AAMC GQ Geisel 2015 Geisel 2016 Geisel 2017

All Schools 2017 Observed taking relevant portions of pt history? 69.9 61.8 77.8 74.4 Observed performing relevant portions of physical or MSE? 91.8 74.6 84.1 80.4 Provided with mid clerkship feedback? 98.6 91.2 95.2

92.0 SURG Measures of Quality AAMC GQ Scale: Strongly Disagree 1 to Strongly Agree 5; Reporting % in top two categories below Measure s of Quality AAMC GQ Geisel 2015 Geisel 2016 Geisel 2017 All Schools 2017 Faculty provided effective teaching 76.3 75.0 77.7 73.9

Residents provided effective teaching 84.9 81.8 85.7 79.6 SURG Measures of Quality Step II CK *values depicted are SD above the US/Can mean for Geisel mean scores NBME Shelf Score Percentiles 90 80 70 MED SURG OBGYN NEURO PSYCH FM AVERAGE 60 50 40 30 20

10 0 2011 2012 2013 2014 2015 2016 2017 Measures of Quality Course Evaluation Overall Satisfaction AY 2014-2015 Overall Satisfaction AY 2015-16 PEDS 4.5 4.1 MED 4.5

4.5 CFM 4.5 4.3 PSYCH 4.3 4.3 SURG 4.2 4 GAM 4.2 4.1 OBGYN 4.2 4 NEURO

4.0 4.2 Clerkships scale [1=poor; 2=fair; 3=good; 4=very good; 5=excellent] Overall Measure Satisfaction AY 2016-17 s of Quality AAMC GQ 4.2 4.3 4.4 4.4 4.3 4.2 4.1 4 Measures of Quality Course Evaluation scale [1=poor; 2=fair; 3=good; 4=very good; 5=excellent] FM 2014-15 2015-16

2016-17 Overall Experience 4.2 4.0 4.3 Objectives well defined and clearly presented 4.2 4.3 4.1 Expectations well defined and clear 4.0 4.1 4.1 4.5 / 4.4 4.7 / 4.5 4.6/4.3 Volume adequate for learning

4.3 4.2 4.2 Variety of dx adequate for learning 4.3 4.2 4.1 Quality of teaching by attendings 4.3 4.4 4.3 Methods used to eval student learning made clear 3.9 3.9 3.9 Quality of mid-clerkship feedback 3.8

3.7 3.9 Quality of teaching by residents 4.2 4.2 4.1 Directors /Site Directors responsive to concerns Measures of Quality Student Comments Strengths Didactics (PBL), minimal busy work, breadth of exposure, appreciation for Death and Dying session Very understanding leadership that makes it a joy to go through the rotation. Rotation is centered around clinical experiences rather than unhelpful "busy" assignments making the clinical experiences very meaningful and educational yield very high quality. Measures of Quality Student Comments Suggestions for Improvement: More orientation around Shelf preparation (resources, assign presentation topics around core material), clearer expectations, less call, more PBL format, preload skills in orientation (camera skills, scrubbing, writing orders) Administrative: better canvas organization (use calendar feature of canvas to show deadlines), change evaluation section so that comments arent required

The online Canvas site was very difficult to navigate. It was difficult to know when assignments were due. It would be helpful if there was a calendar on the front page of the canvas site with all the due dates available. Measures of Quality Student Comments Other issues from student comments The VA: It seems that there is an expectation to constantly be at clinic when not in a caseit feels as though the VA prioritizes this for students not because it is a great learning opportunity, but rather because it decreases the work that the attendings and PA's have on their plate. I also felt frustrated about the minimal feedback I received during this clerkship, both during the rotation and after its completion. Very little opportunity to be involved in OR cases because of heavy PA involvement. Give opportunities for students to demonstrate knowledge, and give feedback that allows students a definitive way to improve. It felt like there were very few ways to demonstrate competency or engagement. There are not enough surgeries to support 3-4 students. Measures of Quality Student Comments Other issues from student comments Trauma Consult: Structure of clerkship was fine. My experience wasn't great on the Trauma service bc the resident seemed uninterested in student learning. My experiences in the OR was good when I was involved with the surgery, but this was seldom. My experience on rounds on both services was decent, but half the time I felt like I had little opportunity to articulate my assessment and plan because we were in such a rush. Measures of Quality Student Comments

Other issues from student comments Plastics: Overall the faculty on this rotation were much less enthusiastic and engaged in teaching than the faculty I experienced on my second rotation Recommendations Course Objectives Remove 3: Recognize and define knowledge of surgical diseases that demand risk factor modifications, end of life decisions, palliative care, pain management, medical legal issues and substance abuse. Clerkship is not uniformly covering this for each student and not currently expected to. Change 5: Perform professional responsibilities by establishing respectful relationships with patients, families, colleagues and health care team members. Remove second sentence with this objective Professionalism also includes respect for diverse patient concerns, opinions and cultural perspectives, with respect to the basis for the doctor patient relationship. Change 9: Demonstrate the ability to assist patients in understanding their treatment options. Remove the latter half of the sentence and motivating them to make healthy behavioral and treatment choices. Add the following: Demonstrate the adaptability necessary to function effectively in changing clinical environments. Recommendations Session Objectives Include specific session objectives with session materials on CANVAS Provide objectives for the following sessions: Enculturation and Second Victim Essential Skills and Conditions

Change Expected level of involvement on Trauma evaluation to ASSIST rather than Perform with supervision Change Expected level of involvement on Abd Exam to Perform independently Remove Failure from Acute Respiratory Distress Keep Inject Local Anesthetic Assessment of Learning Objectives Review tables on slides 28 and 29 to assure accuracy of assessment measures for each learning objective Recommendations Pedagogy Include Surgical Scrub video modules on CANVAS and require viewing prior to day 1 in the OR Continue to coordinate with On-Doctoring Directors (Drs. Weinstein and PintoPowell) on surgical note writing and presentation skills during Years 1 and 2 Include NEJM video links on CANVAS for NGT, and Foley Placement and request students watch prior to Day 1 in OR Provide brief summary of main learning points for each of your case based teaching sessions and a few NBME style MCQs (this was requested on the last review and the request still stands*) Learning Environment Develop plan to give annual feedback to faculty and residents (this was requested on the last review and the request still stands*) Continue to monitor VA site for student concerns regarding light OR caseload and lack of feedback Review and edit CANVAS for accuracy, readability and usefulness Action Plan

Course Objectives Wording/phrasing changes will be made as outlined Session Objectives Session objectives will be written for Enculturation and Second Victim Phenomenon sessions All session objectives will be included on CANVAS Essential Skills and Conditions All changes will be made as outlined Assessment of Learning Objectives Recommendation: Review tables on slides 28 and 29 to assure accuracy of assessment measures for each learning objective This has already been done (saved in this version of the presentation) Action Plan Pedagogy Will include surgical scrub video modules on CANVAS and require viewing prior to first day in the OR Will set up a meeting with Dr. Pinto-Powell and/or Dr. Weinstein to add surgery-specific content to On Doctoring as appropriate Will add relevant NEJM skills videos to CANVAS Will create learning points for each didactic session and introduce a short NBME-style MCQ quiz each week Learning Environment Coordinator will compile student feedback on faculty and residents, and this will be distributed

VA site being actively monitored (as are all rotations) for equity of student experience and evaluation Improve CANVAS site, to include the additions noted above, as well as using the calendar feature and condensing content where possible to make the site more user-friendly

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