1. Making the Most of Virtual Patient Cases: Integration of fmCASES in Four Family Medicine Departments

2. Educational Goals and Objectives: Participants will be able to: Describe four schools' approaches to using fmCASES. Discuss positive and negative aspects to different implementation strategies. Imagine new ways to incorporate fmCASES into one's own institution.

3. Schedule Introduction(5 minutes) Demonstrations of applications of the fmCASES – 20 minutes: 5 min each Please hold questions Group Discussion/Q and A (20 min)

4. Presenters Alpert Medical School of Brown University – David Anthony, MD, MSc University of Oklahoma – Rachel Franklin, MD University of Alabama – John Waits, MD University of Vermont – Martha Seagrave, PA-C, BSN

5. fmCASES Overview Development: 2008-2010 33 virtual patient cases – fmCASES subscription includes 5 CLIPP cases and 2 SIMPLE cases Comprehensive coverage of STFM FM Curriculum (4C) Peer-reviewed/updated annually Validated 100-item exam and 300-item question bank

6. Current Subscribing Schools: 84 Number of Case Sessions: – 2010-2011 (First Subscription Year): 148,209 completed case sessions – 2011-2012 235,791 completed case sessions Subscriptions and Case Use

7. Alpert Medical School of Brown University David Anthony, MD

8. Clerkship in Family Medicine Six weeks Didactics at Brown every Wednesday – Lectures, Skills workshops, Case Discussions, PCMH project, Journal Club, Reflective Writing Discussions – Silva Family Cases Simulated Family taught in small groups Readings and facilitation questions Focus on communication and vulnerable populations

9. Issues seen as of 2010-2011 Lack of a validated exam – We were using the modified Sloane exam Students didn’t “know how to study for the final” Variable clinical experiences – OB or not, rich in Peds or not, etc. Didactics content sometimes redundant with IM and Peds Clerkships

10. Integrating the Cases Rewrite of the Silva Paper Cases – Remove the dry medical content from discussion – Link 1-2 fmCASES as prior reading to each paper case – Add one extra reading on “Grey area” Shared decision making, health literacy, options counseling, etc.

11. Integrating the Cases All other lectures have fmCASES linked as assigned reading In all, 24 cases “Required” as prior reading But examined on all 40!!! – Using the validated exam

12. Tracking their use Students know we can track them Open discussion about it at mid-clerkship meeting – I have reviewed the Log Data beforehand – Opportunity for coaching on learning skills No direct penalty for not completing the “Required” cases – Natural consequences

13. Outcome to date – Use data 89 students have completed the new Clerkship – Completed Cases Average30.8 Median34 Minimum6 – 16 students completed fewer than the “required” 24 And did ‘significantly’ worse on the exam

14. Final Exam Data Prior exam (80 item Sloane exam) in 2010- 2011 – Average Score - 73.12% – Standard Deviation - 7.06% (N=106) – Max/Min92%/44.6% fmCASES exam – Average Score-76.1% – Standard Deviation - 6.67% (N=87) – Max/Min - 87.3%/58.7%

15. University of Oklahoma College of Medicine Rachel Franklin, MD

16. Background Public University 2 campuses: Oklahoma City and Tulsa, OK Campuses linked but separately administered (Ed-8 challenge) 160 medical students/year (total) Family Medicine: 4 week required rotation (MS-3)

17. fmCASES Fills a Need Curricular feedback: – Too many classroom sessions (students) – Lacking skills in clinical decision making (USMLE) Tulsa challenge: faculty shortage LCME site visit 2011 – Ed-2: needed standardized remedial component – Ed-8: needed to help Tulsa if possible iInTIME: beta testers needed

18. Changes to Curricular Structure Weekly: Longitudinal Patient-Based Learning session (PBL) Twice-Weekly: PBL sessions on acute/chronic care Online quiz bank Dermatology lecture Musculoskeletal lectures (3) and skills session Mid-clerkship feedback Objective Clinical Skills Examination (OSCE) Criterion-referenced in-house written examination Weekly: Longitudinal Patient-Based Learning session (PBL) fmCASES Quiz and Faculty-led feedback session Progress Note presentation and feedback session Dermatology lecture Musculoskeletal lectures (3) and skills session Mid-clerkship feedback Objective Clinical Skills Examination (OSCE) fmCASES exam

19. Integrating fmCASES 22 cases required – Week 1: Preventive Care and Musculoskeletal Pain (cases 1,2,4,10,11) – Week 2: Chronic Disease and Complications (cases 6,7,8,9,13,18) – Week 3: Assessing Undifferentiated Complaints (cases 3,19,20,21,23,24,26) – Week 4: Reproductive Health and Dermatologic Lesions (cases 14,16,17,27) Written exam: – based on 22 cases – 100 questions

20. Benefits Standardized curricular component – Guaranteed remediation of Ed-2 – How we track in MedHub – OB/STD most often not seen in “real” patients Fewer classroom sessions – OKC students happy not to have 2X/week – Tulsa faculty able to cover feedback Improved efficiency of classroom sessions – Added EKG analysis PBL to longitudinal patient – Added Progress Note assignment and feedback sessions

21. University of Alabama – Tuscaloosa John B. Waits, MD

22. fmCASES Integration University of Alabama - Tuscaloosa Julia Boothe, MD – Clerkship Director John B. Waits, MD – Rural Residency Training Track, fmCASES

23. FM Clerkship Two month integrated Rural FM Rotation – 65% Family Medicine Preceptor – 35% Community Diagnosis Friday AM Didactics (in Tuscaloosa) fmCASES use… – 15 required cases 10 chosen by FM Clerkship Director 5 chosen by student – 3 optional cases for extra credit – Replaced some Friday am didactic time

24. TERM – Tuscaloosa Experience in Rural Medicine 3 rd Year Curriculum – IM, Peds, Surgery, ObGyn compressed to 6 weeks Family Medicine – Expanded to 16 weeks – Choice of 1 of 3 approved rural sites Med-U is the “glue” to this curriculum

25. Residency Opportunities PGY-1 Pre-Orientation – Off-shore (e.g., Caribbean schools) graduates – International graduates – Out of medicine for several years – U.S. graduates with gaps in knowledge base and/or test-taking struggles, preparing for November In-Training Exam

26. Residency Opportunities PGY-1 Remediation / Gaps in Knowledgebase – in-training remediation – rotation-specific issues

27. The University Of Vermont College of Medicine Martha Seagrave PA-C,BSN

28. University of Vermont College of Medicine Martha Seagrave PA-C, BSN

29. UVM FM Clerkship Curriculum Prior to March 2011After March 2011 3.5 week clerkship6 week clerkship 2 clinical campuses1 clinical campus (3 affiliated sites) Sites in Vermont and southern MaineSites in Vermont, Maine and Connecticut 60+ different preceptor sites, over 100 individual preceptors “Collaborative Primary Care Bridge” week with shared curricular elements Family Medicine Skills Week—Sim Center, SP experiences, didactics Patient Interaction Tracker TextbookfmCASES—20 cases Modified Text-based examCase driven fmCASES exam Case Report or Community ProjectCommunity Project Mid clerkship “visit”

30. Expanded Clerkship Benefits Increased diversity More choice increasing quality of options Less burnout Challenges Maintaining comparable educational experience Delivery of comprehensive FM curriculum Insuring information is up to date

31. 20 preselected cases required, all encouraged 7 cases directly related to topics covered in skills week Other MedU cases used at UVM include: CLIPP students choose 5 out of 8 recommended cases (32 total) WiseMD cases are optional SIMPLE and CORE not utilized at this time Students have access to all cases--purchased by COM fmCASES at UVM

32. fmCASES exam 75 questions, 2 hours Questions associated with identified cases, selected from FEQ database All questions grouped by case—~ 10 questions available per case, 3-4 each chosen for UVM exam Outcomes More challenging for students than previous exam It is now the determining factor—honors/pass

33. Family Medicine Clerkship - Class of 2013 fmCASES Exam Scores

34. Considerations Which cases to include Inconsistent internet access at rural sites Benchmarking exam results Time to complete cases Students using PDF’s vs cases Consistent curriculum-- large geographic area Active learning experience Encourages clinical reasoning Models the effective preceptor Student satisfaction

35. Innovations Used for FM resident remediation Encouraged for FM residents with borderline performance and others for enhancement Working with academic and community faculty – CME – Evidence-based resource – Familiarity with student curriculum

36. Discussion

37. Thank You For Coming!