ThefollowingslidescontainatemplatethatillustratesthegeneralformatusedforaY3orY4clerkshipreview.Inthe“notes”sectionofsomeslidestherearefurtherinstructionstoclarifywhatisneededforaparticularsectionofthereview.
Thecomponentsoftherevieware:1. revisitprioractionplanandinvestigateprogress2. assesscourseobjectivesincludingessentialskills/diagnoses3. evaluateplanned/unplannedredundancy4. assesspedagogy5. evaluateassessmentofcourseobjectives6. reviewmeasuresofquality(e.g.courseevaluations)
TheDeansoftheappropriateyear,ortheiragents,willserveastheteamleaderforeachcoursereview.Theresponsibilitiesoftheteamleaderare:
1. Assigntaskstothefacultyandstudentteammembersandconveydeadlinesforwhentheworkneedstobedone.
2. Recruitmembersforthereviewteamifnecessary(typicallyteammemberswillbeassignedbytheMEC).
3. Contacttheclerkshipdirectortoarrangeameetingwiththeteamtodiscusstheclerkship;informtheclerkshipdirectorofthedatethereviewwillbepresentedattheMECmeetingsotheycanputitontheircalendar/indicateavailability.
4. CollectalltheworkcompletedbytheteammembersandcollateintoonePowerPointpresentation;collecttheactionplanfromtheclerkshipdirectorandinsertitattheendoftheslides;sendtheslidestoRachel2weeksbeforetheMECmeeting.
5. PresentthefinalrecommendationsofthesubcommitteeattheMECmeeting(lastfewslides)
ReviewofNeurologyClerkship
• ClerkshipoccursinYear4(somestudentsonYear3)• ClerkshipDirector
– JustinMowchun,MD• ClerkshipCoordinator
– MaghanPorter• ClerkshipLength– 4weeks,12cycles• Sitesused
– DH,DHpeds,VA,DH-Manchester,CPMC,MayoJacksonville
• ClerkshipwaslastreviewedinJune2014• ReviewDate/Team:6/28/16:JohnDick(MEC,GAME),NormSnow(MEC),Glenda
Shoop(OME),LynnSymonds(4th yearstudent– MEC),AlisonRicker(OCE)
ActionPlanfromPriorReview
• NeurologicExam:ThesubcommitteeexpressedinterestinbetterunderstandinghowthistopicwascoveredacrosstheGeiselcurriculum.– Response:willmakeaconcertedefforttomeetandiscusspreparationduringOnDoctoringwiththeOnDoctoring
Directorstoprovideoversightandfeedback.Inparticular,wewillshareourneuroexam checklist.- DONE• CourseObjectives – thesubcommitteerecommendedchangingasfollows:
• Delete#15“meetprofessionalresponsibilitiesfully”asthisseemsmuchtoobroadandiscoveredinmoredetailinsubsequentobjectives
• Delete#18“Describebarrierstoaccesstobasichealthservicesanditseffectonvulnerablepopulations”asthisisnotafocusoftheclerkshipyouarenotuniformlyorformallyassessingorteachingthisobjective.
• Delete#19“Contributeconstructivefeedbackduringpeerreview”asyouarenotdoingthisatthistime.• Delete#24“Identifytheroleofthephysicianinaddressingthemedicalconsequencesofcommonsocialand
publichealthfactors,andtoadvocateforoptimalcareinneurologicallyillpatients”asyouarenotuniformlyassessingorteachingthis.
– Response – willmakeallchanges- DONE
• Werecommendthatyouintegratecosteffectiveapproachofbrainimagingintoyourexistingmoduleonbrainimaging.– Response – willincludeaclearmoduleconcerningcostandbenefitduringtheHeadachelectureofthemedstudent
series.ThiswillbeavailableinPPTformforCPMC,VAandManchesterstudentswhodonotattendlecturesatDHMC.- DONE
ActionPlanfromPriorReview• Decreasenumberofgradedwriteupsfrom4to2andaddcomponentofreportingonthe
evidencebasefordiagnosticortreatmentorprognosis.Committeefeltthat4gradedwriteupswasexcessiveforthis4weekclerkshipandthatevidencebasecouldreceivegreaterweight.– Response – willmakeallchanges- DONE
• Adjustscheduletobetterallowstudentstomorefullyparticipatewhileonoutpatientclinics.
• Discussissueoftardyorabsentlecturerswithyourstaffandchair– Response – willinstituteregularscheduledpatientsforstudentstobediscussedwith
clinicattending.Chairtomakecleartheimportanceoftimelinessoflecturerstoallfacultyinvolved. - DONE
• Pleasemakesuretoemphasizetheinterprofessional natureofroundssothatstudentsnotonlywitnessandparticipatein,butalsoappreciatetherolesofthevariousteammembers.AssigningPT/OTcoordinationofcareasanessentialskillmayhelpwiththis.– Response – willmakeconcertedefforttoincludeweeklyOT/PTroundswithstudents
residentsattendings nursingandOT/PTstaff.Willalsomakestrongeffortstoincludenursingstaffinmultidisciplinarycasediscussions. - DONE
CourseObjectivesLearningObjective Assessment LearningActivity
1 Apply current clinical and translational sciences to diagnosis and treatment questions in patient care.
PerformanceEvaluationsWriteUpsCaseDiscussionsNBMEexam
Wards/ClinicsWriteUpsCaseDiscussions
2 Apply current knowledge of disease prevention, risk factor modification, end-of-life and palliative care, substance abuse, pain management, medical ethics, and medical-legal issues to clinical problems in neurology.
PerformanceEvaluationsWriteUpsCaseDiscussionsNBMEexam
Wards/ClinicsWriteUpsCaseDiscussions
3 Apply knowledge about the impact of social, economic, cultural, and personal factors on health to clinical problems in neurology.
PerformanceEvaluationsWriteUpsCaseDiscussionsNBMEexam
Wards/ClinicsWriteUpsCaseDiscussions
4 Establish comfortable and mutually respectful student-patient and student-family relationships with diverse patients and families and establishing a respectful basis for the doctor-patient relationship. (redundant, would strike words in red)
PerformanceEvaluationsSkillsForm
Wards/clinic
CourseObjectivesLearningObjective Assessment Learning
Activity5 Interview patients skillfully, utilizing a neurologically focused history. Performance
EvaluationsSkillsForm
Wards/clinic
6 Examine neurologic patients skillfully and respectfully, with appropriate attention to student cleanliness, infection control, and patient comfort and privacy.
PerformanceEvalSkillsFormFormalNeuroExamAssessement
Wards/clinic
7 Define and prioritize the patient’s problems accurately and generate an appropriate differential diagnosis for patients with disorders of the nervous system.
PerformanceEvaluationsCaseDiscussionsNBMEexam
Wards/ClinicsCasePresentationsDiscussions
8 Explain the indications, complications, limitations, and performance of a CT scan, MRI, electrodiagnostic studies (EMG, NCV, evoked potentials and EEG) and lumbar puncture.
PerformanceEvalsNBMEExam
Wards/ClinicsCaseDiscussions
9 Correctly identify, and prioritize, common abnormalities on CT, MRI and spinal fluid analysis.
PerformanceEvalsNBMEexam
Wards/ClinicsCaseDiscussions
CourseObjectivesCourse Objectives Assessments Learning
Activities
10
Communicate effectively with patients and families especiallywhen special barriers to communication exist, including cultural, linguistic or those based on a neurologic disorder (e.g. aphasia).
PerformanceEvalsSkillsForm
Wards/ClinicsCaseDiscussions
11
Assist patients appropriately in understanding their treatment options. To assist patients appropriately in understanding their prognosis. (would change to make a single sentence…”Assist patients appropriately in understanding their treatment options and prognosis.”)
PerformanceEvals Wards/Clinics
12
Communicateeffectivelyandcollegiallywithphysiciancolleaguesandothermembersofthehealth-careteamverbally,inwritingandintheelectronicmedicalrecord.
PerformanceEvalsWriteUpsSkillsForm
Wards/ClinicsWriteUpsCaseDiscussions
13
Behaverespectfullyandresponsiblytowardspatients,families,colleagues,andallmembersofthehealth-careteamandempathizeandberespectfulofeachpatient
PerformanceEvalsCasediscussions
Wards/Clinics
CourseObjectivesCourse objectives Assessments Learning Activities
14
Adheretohighethicalandmoralstandards,acceptresponsibilityforpersonalactions,acceptconstructivecriticismandrespectpatientconfidentiality.
PerformanceEvals,WriteUps
Wards/Clinics
15
Take responsibility for his or her own medical education, and develop the habits of mindfulness and reflection.
PerformanceEvals,WriteUps
Wards/Clinics
16
Identifyandcriticallyevaluaterelevantinformationaboutevidence-based,cost-consciousstrategiesinthecareofpatientsandpopulationsandtoapplythistopatientcareandtocontinuousupdatingofskills.
PerformanceEvalsCaseDiscussionsWriteUps
Wards/ClinicCaseDiscussionsWriteUps
17
Assess the effect of social environment on clinical care and outcomes and apply the concepts of improving quality of care, patient safety, and value of care in neurologically ill patients.
PerformanceEvalStudentCaseDiscussions
Wards/Clinics
CourseObjectivesCourse objectives Assessments Learning Activities
18
Identify appropriate resources to support patient care and to collaborate effectively with all members of the inter-professional team.
PerformanceEvals Wards/Clinics
19
Describe how healthcare is currently organized, financed, and delivered, and the larger environment in which healthcare occurs and the impact on neurologically ill patients.
CourseObjectives– Comments• Appropriatenumber,understandable• Coversover-archingGeiselcompetencies
FormatofCourse&SessionObjectives• Courseobjectivesareprovidedinthesyllabus• Courseobjectivesarewritteninthecorrectformat• Sessionobjectivesareprovidedinthecoursematerialsand
areprovidedinIlios• Sessionobjectivesarewritteninthecorrectformat
HowdoY1/2coursesprepareforY3• Questionsaskedatendofclerkship– 1=poorand5=excellent
Results:Overall
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
FM MED OB PEDS PSYCH SURG GAM NEURO
13-14
14-15
15-16
Results:Communication
00.51
1.52
2.53
3.54
4.55
FM MED OB PSYCH SURG PEDS GAM NEURO
13-14
14-15
15-16
Results:PE
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
FM MED OB PED PSYCH SURG GAM NEURO
13-14
14-15
15-16
Results:MedicalKnowledge
00.51
1.52
2.53
3.54
4.55
FM MED OB PED PSYCH SURG GAM NEURO
13-14
14-15
15-16
IssuesofRedundancy• Aretheremajorissuesofredundancywithothercourses?– Ilios searchforneurologicaltopics(neurologicexam,stroke,dementia,HeadCT)showoverlapwithYear1Neuroscience,Year2SBM(NeuroandPsychandPBL)aswellasYear1andYear2On-Doctoring.Alloftheseseemedlikeappropriateprimingand/orrepetition.
– DementiaisasharedEssentialConditionwithGeriatricsbutthisseemsappropriate.
EssentialSkills
• Aretheseappropriateforthisclerkship?Yes• Wouldyouaddorsubtractany?No• Aretheremajorissuesofredundancywithotherclerkships?Appropriate.
Skill Duplication LevelofPerformanceCoordinatecarewithPT/OT Withsupervision
Counseling:Medications Medicine;GAM
CThead
HPI
MentalStatusExam Psych
MRIhead
NeurologicExam
Oralpresentation,ambulatoryencounter
Oralpresentation,initialinpt encounter
Writtennote,initialinpt encounter
EssentialConditions
• Aretheseappropriateforthisclerkship?Yes
• Wouldyouaddorsubtractany?No
• Aretheremajorissuesofredundancywithotherclerkships?Appropriate
Condition Duplicationwithotherclerkship Level ofEngagement
BrainTumor ManagewithAssistance
CerebralorSAhemorrhage ManagewithAssistance
Coma,stupororalteredMS ManagewithAssistance
Dementia yes(GAM) ManagewithAssistance
Headache Yes(PEDI) ManagewithAssistance
MultipleSclerosis ManagewithAssistance
Paralysis(ALS,GBS,etc) ManagewithAssistance
PeripheralNeuropathy ManagewithAssistance
Seizure,epilepsy ManagewithAssistance
TIAorstroke ManagewithAssistance
Vertigo ManagewithAssistance
ExplorationofEthicsandCulturalCompetencies
• SessiononBrainDeathethicsbeingplannedwithDr.Bernat– Dr.MowchuntonotifyBillNelson
CourseLearningOpportunities• Clinicalexperiences
– 4weeksinpt andoutpt mix;2callnights(until10pmatDH)
• SmallGroupSessions– Orientation:LecturesonExamandLocalization;IntrotoNeuro-Imaging;handsonLPsession
– Topicseries– casebased• DeliriumAndComa,Epilepsy,Headache,InfectiousAndInflammatoryDisorders,MovementDisordersandAtaxia,NeuromuscularDisorders,Stroke
• Mini-CEXs• 2WriteUps
Assessment
• Midclerkshipfeedback– selfassess,reviewskills/conditions• Studentperformanceevaluationform(Filledoutbypreceptors)• Skillsform• OASISlog• WriteUps(2)• NBMEShelfExam• Mini-CEX
• Grading(2015-16)– PreceptorEval – 60%ofGrade– Shelfexam– 30%ofGrade– WriteUps– 10%ofGrade
MeasuresofQuality– StepIICK
*valuesdepictedareSDabovetheUS/CanmeanforGeiselmeanscores
Measuresof
Quality–AAMCGQ
Geiselmean2011
Geiselmean2012
Geiselmean2013
Geiselmean2014
Geiselmean2015
Allschoolsmeans2015
CFM 3.2 3.1 2.9 3.2 3.5 3.3
MED 3.5 3.6 3.5 3.6 3.6 3.5
NEURO 3.1 3.4 2.7 3.1 3.1 3.1
OBGYN 3.1 3.0 3.0 3.1 3.2 3.2
PEDS 3.3 3.1 3.2 3.5 3.6 3.4
PSYCH 3.5 3.6 3.4 3.7 3.6 3.3
SURG 3.0 2.8 2.9 3.1 3.3 3.3
MeasuresofQuality– AAMCGQ“Ratethequalityofyoureducationalexperiencesinthefollowingclinicalclerkships.”[1=poor;2=fair;3=good;4=excellent]
NBME“Shelf”ScorePercentiles
0
10
20
30
40
50
60
70
80
90
2010 2011 2012 2013 2014 2015 2016
MED
SURG
OBGYN
NEURO
PSYCH
FM
Measuresof
Quality–AAMCGQ
ClerkshipsOverall SatisfactionAY
2013-14OverallSatisfactionAY
2014-2015PEDS 4.3 4.5
MED 4.1 4.5
CFM 4.2 4.5
PSYCH 4.3 4.3
SURG 4.2 4.2
GAM 4.3 4.2
OBGYN 4.2 4.2
NEURO 4.1 4.0
MeasuresofQuality– CourseEvaluation
scale[1=poor;2=fair;3=good;4=verygood;5=excellent]
scale[1=poor;2=fair;3=good;4=verygood;5=excellent]
MeasuresofQuality– CourseEvaluationNEUROLOGY
2014-15 2015-16
OverallExperience 4.0 4.13
Objectiveswelldefinedandclearly presented 4.2 4.53Ability forY1and2topreparemeforthisclerkship 3.71 3.56
Expectationswelldefinedand clear 4.1 4.46Volumeadequate forlearning 4.21 4.26Varietyofdxadequateforlearning 4.2 4.29Quality ofteachingbyattendings 4.36 4.49
Quality ofteachingbyresidents 3.85 4.11SiteDirectors responsivetoconcerns 4.57 4.68Methodsusedto eval studentperformancemadeclear 4.1 4.36
Qualityof mid-clerkshipfeedback 3.74 4.04
scale[1=poor;2=fair;3=good;4=verygood;5=excellent]
MeasuresofQuality– CourseEvaluationNEUROLOGY
2014-15 2015-16
Quality ofcasebasedlearning n/a 4.2
Exam/Localization 3.9 3.96
Imaging 3.83 3.92
CNSinfx 4.41 4.21Stroke 3.88 3.82
NMDx 4.06 4.31
MovementDx 3.98 4.37
Delirium/Coma 4.08 4.12
HA 4.19 4.34
LP 3.97 4.06
MeasuresofQuality– StudentCommentsStrengths:• Atalmosteverysite,studentscommentedthattheyappreciatedthediversityofpatientsand
diagnosesthattheysaw:– Diversityofexposureinpatient(stroke,criticalcare)andespeciallyoutpatient(neuromuscular,
epilepsy,headache,generalneuro,hospitalistneuro,IR,neurosurgery)– Hadanopportunitytoseepatientswithalotofclassicneurologicaldiseasessuchasstroke,seizure,
headache,peripheralneuropathy,NMJdisease,multiplesclerosis,etc.-- oninpatientandoutpatientbasis.
– Goodvarietyoflearningenvironments(greatbalancebetweenclinicandwardsw/pedi,EEGlabdailyintheAM,smallgroups,overnightcallonadultservice,etc)
• Moststudentsfounddidacticstobewell-runandvaluable– Thedidacticswerewelleditedtoincludecontentthatwaspertinentandappropriateformylevelof
training.– Teachingsessionsweresimple,onpoint,anddidnotrequiretoomuchprepworkwhichallowedfor
moreactiveparticipation
• Manystudentscommentedontheexcellentteachingfromattendings andresidentsonthewards– Thefacultyandresidentsareveryeagertoteachandhelpstudentimprovetheirskills
MeasuresofQuality– StudentComments
SuggestionsforImprovement:• DidacticsessionswerechallengingatCPMCduetotechnologyandtiming:
– Thedidacticsessionswerealmostalwaysuselessforpeoplethatwerecallingin.Moreover,therewere2sessionswhenIwasonInpatientandduetothetimedifferenceIhadtomissrounds.
– Alsopleaseprovidebettervideoconferencingtoolssoawaysitescouldhearandparticipate.
• ManystudentsatDHMCenjoyedthestrokeservice,butfelttwoweekswastoomuchtimeandthattimemightbebetterspentonageneralserviceorinclinic– IfeltlikeIhadmorestrokeservicetime(2weeks)attheexpenseofseeingotherbasicneurology
diagnoses.– MightbenicetoshortenDHMCstroketo1week,andeithergiveanadditionalweekofinpatientor
adedicatedweekofclinic.
• Studentswhodidpediatricneurology,feltlesspreparedfortheshelf– Theshelfhasverylittlepediatricssotherewasastruggleontheclerkshipformetolearn/studyfor
theshelfandalsoforthepatientsIwasseeinginclinicorwhowouldhelpmeformycareer
MeasuresofQuality– StudentCommentsSuggestionsforImprovement:• Studentsfeltthatthereweretoomanymini-CEXs:
– Decreasethenumberofmini-CEX's!Eightwasfartoomanyforsuchacompactrotation.– Iknowwewerethelaunchgroupformini-CEX,butIthinktheprogramwouldbemoresuccessfulif
theattendings weremoreclearonthepointoftheexercisesandiftherewerehalfasmanyrequired.
– Lesspaperwork-- the8miniCEX'swereabitmuch.It'sharderthanyou'dthinktoapproachanattending8timesandaskforthatmuchtimefromthem.
• Themajorityofstudentshadpositiveexperienceswithresidents,butsomeraisedconcernsaboutunprofessionalbehaviorfromindividualresidents– Ithinkhertreatmentoftheinternduringatleasttwoseparateinstanceswasunprofessionaland
putusinanawkwardpositionasstudents– Thereisaclearproblemofunprofessionalismfromresidentsaffectingpatient-care.Irepetitively
sawresidentsplacetheirpersonalinterestaheadofpatientcareandneeds…itreallyseemedliketheresidentsdidnotcareabouttheirpatientsandoftentalkedpoorlyofthem
– Someresidentshadaveryrespectableattentiontoprofessionalismwhileothersseemedtocarelessaboutpatientcareandmoreabouttheirpersonallifeissues,oftenseemingtobrushworkoffontomedstudentswhichtheythendidn'tappropriatelycheckon.
SummaryregardingMeasuresofQuality• Summary:
– Overall,studentsenjoyedtheclerkship:theyespeciallyappreciatedtheinterestingvarietyofcasesandthequalityofteachingfromresidents/attendings
– Studentsatremotesitesexpresseddifficultywiththevideoconferenceformatofdidactics
– AtDHMC,manystudentsfelttherotationonthestrokeservicecouldbeshortenedto1weektomakemoretimeeitherforclinicorgeneralinpatientneurology
– Thereweresomestudentswhoexpressedconcernsaboutprofessionalismamongindividualresidents
– StudentsseemedtoliketheMini-CEXs,butfeltthereweretoomanyfora4weekrotation
Recommendations• Objectives
– #4:“Establish comfortable and mutually respectful student-patient and student-family relationships with diverse patients and families and establishing a respectful basis for the doctor-patient relationship.” • redundant, would strike words in red
– #10: “Communicate effectively with patients and families especially when special barriers to communication exist, including cultural, linguistic or those based on a neurologic disorder (e.g. aphasia).”• Focus of this clerkship should be on communication with pts with neuro disorders.
Would add “especially” and strike “cultural, linguistic”– #11: Assist patients appropriately in understanding their treatment options. To assist
patients appropriately in understanding their prognosis. • Would change to make a single sentence…”Assist patients appropriately in
understanding their treatment options and prognosis.”– #19: Describe how healthcare is currently organized, financed, and delivered, and the larger
environment in which healthcare occurs and the impact on neurologically ill patients.• Would delete. Did not seem like this was a clerkship appropriate objective and is
covered in both Years 1 course and Year 4 HSP.
Recommendations– HealthandValuesCurriculumCoordination
• EnsurethatBillNelsonisawareofnewemphasisonEthicsofBrainDeathsession
– ContinuetoworkonimprovingvideoconferencingformatforstudentsatCPMC
– BalancetimeonDHstrokeservicecomparedwithGeneralService
– Continuetoinnovatewithmini-CEXandcontinuefacultydevelopmenteffortssothesebecomemoreeffective,expectedandstandardized
– ContinuetoworkwithChairandResidencyDirectortoaddressconcernswithresidentprofessionalism
ActionPlan
– CommunicatetoBillNelsonofnewcomponentonEthicsofBrainDeathintheComacasebasedsession
– VideoconferencingforstudentsatCPMCstarted1yearago(monitorsystem,feedbackfromfacultyandstudents)
– ReducedvascularserviceatDHMCto1weekandincreasegeneralinpatientby1week(startedJune27th,2016)
– Continuetoinnovatewithnewmini-CEXsystemandcontinuefacultydevelopmentandcommunication
– ContinuetoworkwithChairandResidencyDirectortoaddressconcernswithresidentprofessionalism