Welcome to the Third Year! Warren Newton, MD, MPH Vice Dean for Education UNC School of Medicine June 24, 2013

Review UNC SOM Outcomes for clinical years. Describe educational rationale for year III, with the core competencies expected by the end of the year. Describe what will be new this year, with points of emphasis Give rules for living for third year; start planning for the fourth year Objectives

Step 2—UNC vs National

Match Post-Mortem 94% UNC Match Rate (national average 93.7%) »5 completely unmatched students 2 Otolaryngology, 2 Pathology, 1 General Surgery »4 partially unmatched students who needed PGY1 year 2 Anesthesiology, 2 Ophthalmology, 1 Radiation Oncology “Differential diagnosis” of unmatched students »Academic/professionalism challenges »Competitive specialty »Geography »Interview problems/ambivalence about specialty

MSIII—Educational Rationale

UNC Curriculum

General Clinician Active Learning »Get involved in care »Read on individual patients Breadth of Experience »Varieties Patients/Specialties »AHEC—different systems, different patient mix Educational Rationale—Year III

See Clerkship Websites Clinical Evaluations Shelf Exams—20% of grade Honors – 35-40% OSCEs, either formative or summative End of Year (CPX, NBME II MK/CS) Grading

ACGME Core 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 Approach ACGME core competencies plus one other, improving the health of populations We have specifically defined the conditions all UNC students should see, inpatient and outpatient (the UNC 96) We have defined the procedures all students should learn—e.g., BLS, ACLS, venipuncture and placing IVs

Medical Knowledge Tests of knowledge are foundation of our current system You will take tests for the rest of your life. Assessment: shelf exams, clinical evaluations

Clinical Skills History/Physical Differential Diagnosis, Management Plan, Procedures Assessment: Clinical Evaluation, OSCE, CPX

Communication Skills Your reputation, patient satisfaction, pay and liability risk depend on communication skills Not just with patients and residents/ attendings, but also staff Oral and Written; including cultural sensitivity Specialty and situation dependent Assessment: Clerkship evaluations, OSCE’s, CPX

Systems Based Practice— How you take care of patients WebCIS CPOE Care Management Speech Therapy, etc Referrals Discharge Planning Time-outs before procedures Assessments: Ward Evaluations, OSCE/CPX

Systems Based Practice Being Aware of Systems

Problem Based Learning “Life Long Learners” Case by case learning Critical appraisal of literature and application to cases Assessment: Clinical evaluations, special assignments

Improving the Health of Populations Focus on populations (and not just the whole population) Managing costs, quality and access Both primary and subspecialty care »Diabetes, Asthma, CHF in primary care »Center of Excellence for Bariatric Surgery »ACOs and Bundled Payments for common major procedures Assessment: Projects, Family Medicine Clerkship and others being piloted

Professionalism Why all the fuss? Social Contract: trade off of autonomy, privilege and financial security for self regulation Increasing public concern that doctors and hospital systems have their own financial interests foremost…

Professionalism in Third Year Honesty/Integrity Confidentiality Being on Time, Dress Respect for patients, peers and staff Seeking out and Learning from feedback… Assessment: Clinical Evaluations Remember, some professionalism issues are one strike you’re out…

What’s new this year…

Changes for Evolving curriculum: critical incidents in inpatient medicine and ob/gyn + end of life in outpatient medicine, population health project in family medicine, procedures CAR/CBSP implementation – Dr. McNeil Spread of teaching practices—FM, OPM and Pediatrics Consistent processes: direct observation of clinical skills in all clerkships; similar experiences across clerkships. Timely grades; Honors set at about 40%. Regular review of duty hours, timeliness and distribution of grades across clerkships/sites

Common Assessment Form

UNC 96 Conditions all UNC students need to learn about in both inpatient and outpatient settings Each attributed to a clerkship and in One45; ongoing improvements in user friendliness You need to see/learn about them all, and we need to make sure that experiences are comparable across the state At mid clerkship, you and your clerkship site leader will see/review what you’ve seen, and develop a plan if necessary Be assertive; take responsibility for your education.

Clinical Log

Procedures Essential to learn hands on skills and also about procedures... Both psychomotor and interpersonal You have to go to internship with competence in some of these (venipuncture, IVs, injections, throat swabs, paps) and exposure to others (lumbar punctures, etc) Be assertive…

Mid-rotation Review With clerkship or site director Review »How is it going? »Performance so far… »Exposure to conditions and procedures—any adjustments necessary?

Patricia White, MD Charlotte Bert Fields, MD Greensboro Orientation Student Health Counseling Services Needlestick Protocols Housing John Perry, MD Wake Joseph Pino, MD Wilmington Campus Directors Robyn Latessa, MD Asheville AHEC Infrastructure

Improving the Learning Environment

What is mistreatment? Not being asked questions or to do things for patients Rarely nurse vs. student Rare physical violence, inappropriate sexual advances, or ethnic/racial slurs.

Disrespect for Patients or Students “There are patients that residents and attendings make fun of… there is 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!!!!”

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.”

David Carl Charlotte Michelle Kane, PsychD Greensboro Gary Gala, MD UNC Chapel Hill Dale Fell, MD Asheville Joe Kertesz, MA Wilmington Ombudsmen David Gittleman, DO Wake John Perry, MD Wake Rev. Barbara Bullock Charlotte Ongoing work… Promoting 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, let us know: contact your Site or Clerkship Director, the Campus Director, the Chair, the local or Chapel Hill Ombudsmen, Dr. Dent or me. Grades handed in before we review; 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-in, or Jake Achey Student Health – remember the waiver; take off for care Any 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! CBSP – Dr. Cheryl McNeil Advisors, Dr. Dent Academic Difficulty

50% in July of third year (1/2 will later change their minds…) 75% by April Next Year 5-10% will apply in 2 or more specialties 5% will change after internship Natural History of Specialty Choice

College Advisors once a semester (phone/ fine) December 13, 2013 Specialty Information Sessions Meet with Career Goal Advisors before turning in 4 th year schedule (3/14) 2014 Summer/Fall MS IV »CPX, NBME Part II MK/CS »Audition Electives Dean’s Letter Deadline—10/1/14 ***Identify writers of recommendations this year Specialty Choice Timeline

Year IV

Specialty Choice/Applications Advanced Skills (AI, Critical Care, Specialty specific areas) Schedule Flexibility/Choice »For Boards and Interviewing »Student Choice: Electives and Advanced Practice, Science and Medicine Selectives »You will never be as free again! Year IV Educational Rationale Getting Ready for Residency

Students are extending medical school 2012 # Students 2013 # Students MD/MPH MD/PhD 9 8 MD/MBA 0 1 MD/JD 1 0 MD/MTS 1 0 Research Year Other 2 0 Total 75 62

Timelines Remember the longitudinal course Introduction to Acute Care; includes ACLS and other procedures in specific clerkships Take CPX at end of junior or beginning of senior year; must pass to graduate. Take NBME II CK that summer, and take II CS as early as possible MSPE (Dean’s letters) due earlier—October 1, which means interviews for letters will need to be earlier

Midpoint Survey This Week New this year Your feedback on first two years, curriculum, preparation for part I and help with career goals Thanks!

GOOD LUCK!