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 Medicine Curriculum 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 Learning Learning 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 JERossouw 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.Anderson GLPrentice RL LaCroix AZKooperberg CStefanick ML Jackson RDBeresford SAHoward BV Johnson KCKotchen JMOckene J Writing Group for the Women's Health Initiative Investigators Abstract CONTEXT: Despite decades of accumulated observational evidence, the balance of risks and benefits for hormone use in healthy postmenopausal women remains uncertain.

Practice Based Learning Quality 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 A Social Contract

Professionalism Key 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, MD Charlotte Bert Fields, MD Greensboro Student Health Services Counseling Services Needlestick Protocols Housing Orientation John Perry, MD Wake Mark Darrow, MD Wilmington Campus Directors Jeff Heck, MD Asheville 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% - 3 rd year »19% - 4 th year »31% report Experience or observe

UNC vs. National All schoolsUNC

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 for Patients 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, PsychD Greensboro Gary Gala, MD UNC Chapel Hill Alan Cross, 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 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 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 Rationale Specialization