New challenge for students and staff! Marijke van Santen-Hoeufft ass. prof. internal medicine/rheumatology, consultant in clinical education, curriculum development and assessment Maastricht, the Netherlands My name is… I was asked to tell you about… Clinical phase

The ambulatory and clinical environment in a modern medical curriculum My name is… I was asked to tell you about… Clinical phase

The Maastricht Curriculum Educational buildings and laboratories Hospital Educational buildings and laboratories Good afternoon everyody You are sitting here…in the cellar. My workingplace is there on the 5th level of the hospital, internal medicine. About 3 minutes walking to give you an impression Clinical phase

How do we prepare our future doctors best for the challenges of the 21st century? ‘The Maastricht experience’ My name is… I was asked to tell you about… Clinical phase

Outline of presentation Motivation for curriculum change Year 3 Strenghts and weaknesses of clinical rotations Conclusion Motivation… the old curr. Wasn’t that bad…why change? Cost a lot of money Clinical phase

A tremendous ‘shock of practice’! Many motivations for curriculum change in Maastricht 2001… The most important overall: The transition of preclinical to clinical phase is experienced as quite a shock of practice and… The transition of graduate to post-graduate training is experienced as… As an academic clinician I work with starting postgraduates, hardly celebrated their graduation to physician orhaving to deal With the burden of stressy routine care A tremendous ‘shock of practice’! Clinical phase

Why shock of practice? Post-graduate training requires: Working under time pressure Facing larger responsibility Dealing with more complex problems Having insufficient competencies There is so much more timepressure compared to being a clerk, so much more… Clinical phase

How to prevent shock of practices? Critical appraisal of current content year 4 - 6 Better preparation for the ‘real work’ in year 3 HOW TO DO THIS? Start with real patient encounters in year 3 Broadening of competencies other than medical expert I don’t know whether you recognize these shortcomings in the clerkships and if you have ever wondered wether the preparation for the clerkships in the preclinical years was adequate in your faculty. Anyway we thought to… Clinical phase

Structure of the 2001 curriculum Year C o n t e n t 1 Emergency care and regulatory systems 2 Stages of life and diagnostics 3 Chronic disorders, ambulatory patient contacts 4 Internships, focus basic sciences 5 Internships 6 Participation in research and patient care All this made us to develop a curriculum with early practice contacts and with structured time for theory till the last days Practice Theory Clinical phase

Why early patient contacts? There is so much more timepressure compared to being a clerk, so much more… Clinical phase

How do we learn best ? Teach 80% Practice by doing 75% Average Retention Rate1 Teach others 80% Practice by doing 75% Discussion group 50% Demonstration 30% An intermezzo…you undoubtedly recognize this slide where different educational tools have been compared according to the amount of knowledge students remembered later on… you can see that practicing by doing and teaching/telling others score best Audiovisual 20% Reading 10% Lecture 5% 1 National Training Laboratories, Bethel, Maine, USA Clinical phase

Educational objectives Integration theory & practice Patients are starting point for learning Instructional methods Variability in instructional methods in which students are required to be active Learner control Active learning Collaborative learning Self-directed learning Teachers Teachers as coach Clinical phase

Activities around patient encounter Formulation learning objectives The learning cycle Patient vignette/case Preparation in tutorial group Self study Report to Tutorial group Activities around patient encounter Preparation with clinical supervisor Self study Patient encounter Evaluation & Formulation learning objectives Clinical phase

Tutorial group 10 weak cycle n = 10 1x per week 4 hours presentation and discussion of patient problems (3 hours). Preparing next patient encounter (1 hour) staff member is coach Clinical phase

‘SOEPEL’: Structured Consultation Report Subjective Objective Evaluation Planning Elaboration: discussing learning goals with clinical supervisor, after patient encounter. Student formulates new learning goals Learning goals: the new learning goals are the guide for further self study and for report in the base group The basis is a the format of a medical record extended with E and L explicitly. The E from… Clinical phase

Activities around patient encounter Formulation learning objectives The learning cycle Patient vignette/case Preparation in tutorial group Self study Report to Tutorial group Activities around patient encounter Preparation with clinical supervisor Self study Patient encounter Evaluation & Formulation learning objectives Clinical phase

Formulating learning goals……. Eindtermen basisarts Formulating learning goals……. Clinical phase

Year 3 A students’ week Participating disciplines Gastro-enterology Gynecology / Obstetrics Surgery heart / lungs / vessels abdomen locomotion brain and behaviour Family medicine Urology Eindtermen basisarts Pediatrics Participating disciplines Clinical phase

Back to Brazil, back to the transition of students from the safe escola Pernambucana to the challenging IMIP environments… How to use PBL in a ambulatory and clinical context? Clinical phase

All medical faculties want to prepare their students the best they can for the 6th year and post graduate education But what is the best way? Evidence for ‘best practice’? A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation Clinical phase

“It may not be a perfect wheel, but it’s a state-of-the-art wheel.”

Effectiveness of clinical rotations?? A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation Clinical phase

Strenghts of internships Learning in real, relevant context Integration of theory and workplace learning Active participation in practice Coping with increasing complex and diverse patient problems Increasing self-reliance success depends on length of internship! A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation Clinical phase

Why are internships generally less effective than ideally possible? Unfortunately all internships have their weaknesses too… Why are internships generally less effective than ideally possible? A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation Clinical phase

The effectiveness of internships is hampered by problems regarding: the teacher the workplace the students the elements of good clinical teaching A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation Clinical phase

Common problems in clinical phase regarding the teacher(1): Time pressures Competing demands (clinical with parttime availability; administrative; research) Teaching often opportunistic, making planning more difficult Often under-resourced Rewards and recognition for teachers poor Good teaching needs intrinsic motivation of teacher A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation Clinical phase

Common problems in clinical phase regarding the teacher(2): Lack of knowledge about: the effects of being a role model motivating students assessing competence giving constructive feedback the curriculum content, end-objectives… etc. Lack of training in: educational skills evaluating his own teaching and asking feedback (self reflection) A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation Clinical phase

Common problems in clinical phase regarding the workplace: Increasing numbers and types of students Fewer patients (shorter hospital stays; patients too ill or complex) Competing demands (patient-care related actions come first) Clinical environment not ‘teaching friendly’ (busy hospital ward; no suitable meetingplace with students; no learning climat) Ambulatory care insufficiently involved in education A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation Clinical phase

Common problems in clinical phase regarding the teacher(1): Time pressures Competing demands (clinical with parttime availability; administrative; research) Teaching often opportunistic, making planning more difficult Often under-resourced Rewards and recognition for teachers poor Good teaching needs intrinsic motivation of teacher A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation Clinical phase

Common problems in clinical phase regarding the teacher(2): Lack of knowledge about: the effects of being a role model motivating students assessing competence giving constructive feedback the curriculum content, end-objectives… etc. Lack of training in: educational skills evaluating his own teaching and asking feedback (self reflection) A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation Clinical phase

Common problems in clinical phase regarding the workplace: Increasing numbers and types of students Fewer patients (shorter hospital stays; patients too ill or complex) Competing demands (patient-care related actions come first) Clinical environment not ‘teaching friendly’ (busy hospital ward; no suitable meetingplace with students; no learning climat) Ambulatory care insufficiently involved in education A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation Clinical phase

Common problems in clinical phase regarding the students: Insufficiently prepared (knowledge, skills) Don’t take the opportunities for examining patients independently Stay passive observers in stead of active participants due to too short clerkships (no time for professional socialisation) A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation Clinical phase

Common problems with clinical teaching(1): Lack of clear objectives and expectations Focus on factual recall rather than on development of problem solving skills and attitutes Teaching pitched at the wrong level (too high or too specialistic) Inadequate supervision and provision of feedback (due to lack of time, lack of skills or motivation, no continuity) A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation Clinical phase

Isn’t it a wonder there are competent physicians anyway Isn’t it a wonder there are competent physicians anyway?! At least we think we are…. A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation Clinical phase

Important determinants of the effectiveness of student learning in a clinical environment: Patient mix Opportunities for examining patients independently Received supervision and feedback Organisational quality Student being part of a team Number of students at one time Educational sessions Positive attitude of staff towards students A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation Clinical phase

Most important determinants of the effectiveness of student learning in a clinical environment: 1- received supervision and feedback 2- opportunities for examining patients independently 3- patient mix A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation Clinical phase

Measures to improve effectiveness of clerkships: Clerkship study guides Teach the teachers trainings Create a positive learning environment More direct observation and feedback Include protected time for selfstudy Integration of learning and assessing on the workplace by using miniCEX, logbooks etc. A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation Clinical phase

Integration of learning and assessing by: Observing multiple events during clerkship involving multiple people Using mini CEX (Clinical Evaluation eXercise) or other ‘on the job assessment tools’ Using the logbook in which structured clinical records are gathered of all patients seen by the student Coaching Critical incident analysis Portfolio etc. A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation Clinical phase

Integration in medical curricula Faculty of Medicine Universiteit Maastricht Clinical phase

Clinical phase

In summary, improvement of the effectiveness of the ambulatory and clinical phase can be achieved, but not without effort and lots of motivation of organisation, staff and students! A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation Clinical phase

Thank you for your attention!

Traineeship year 6 Participation in health care: 20 weeks junior doctor in general practice or hospital setting Focus on doctor’s role of medical expert, scientist, health care worker, person Further development of competencies in: medical acting communication cooperation knowledge/science social acting organisation professionalism And meet the more extended competencies our postgraduates have to meet Clinical phase