2.  Accreditation requires direct observation  Pace of clinical environment threatens traditional opportunities for bedside teaching  Compliance issues limit activities of clinical clerks compared to historical training  Trend identified in GME that arriving interns are not ready; increasing numbers of boot camps  Patient safety initiative relies upon individuals who seek feedback and are committed to continual improvement processes

3.  Prime directive: direct observation of the student with the patient and provision of meaningful performance feedback.  MCTs provide coaching by competency domain to support longitudinal improvement in student performance across the FCC phase.  MCT observations are critical to the “educational handover.”  Competency-based approach shifts role of MCT from judging student performance based upon level of training to documenting behaviors observed.  MCTs provide multiple data points into the student’s portfolio for an aggregate view of performance. This informs the student’s Personalized Learning Plan.  MCTs also serve as observers in centralized assessment events (first year “capstone” and end-clerkship VC3).

4.  Discipline-specific  Snapshot assessments of clinical skills related to VC3 and clerkship-specific diagnoses  Each student undergoes direct observation by an MCT at least once during each clerkship ◦ Psych: 2 obs; neuro: 1; peds/OB 3; med/surg:4 ◦ Scheduled per clerkship coordinators  Immediate feedback  Information is entered into Portfolio and performance is tracked over time

5. Abdominal Pain Abnormal Vaginal Bleeding Abnormal Vaginal Discharge Abnormalities of Mood Altered Mental Status Back Pain Breast Complaints Chest Pain Cough Dysuria Fever GI Bleed Headache Jaundice Loss of Consciousness Obesity Pelvic Pain Rash Seizures Shock Shortness of Breath Sore Throat Substance Abuse Trauma Unexplained Weight Loss

6. DEBRIEF WITH SNAPPS (20 minutes) STUDENT ORGANIZES THOUGHTS MCT COMPLETES part 1 of OBSERVER FORM (5 minutes) Patient orientated by student or MCT Focused H+P Student presents preliminary thoughts to patient MCT provides real-time feedback and any correction / elaboration of H+P at bedside Forces student to generate and analyze DDx Allows MCT better insight into student’s clinical reasoning Requires student to generate questions and learning plan MCT documents assessment of student attitude toward process= Practice-Based Learning and Improvement OBSERVE STUDENT-PATIENT ENCOUNTER (20 minutes) *Direct observation and feedback is the primary charge to the MCTs The SNAPPS model will serve as a shared format for case discussion

7.  S ummarize Briefly the History and Physical Findings (bedside)  N arrow the Differential to Two or Three Relevant Possibilities (away from bedside)  A nalyze the Differential by Comparing and Contrasting the Possibilities  P robe the Preceptor by Asking Questions  P lan Management for the Patient  S elect a Case-Related Issue for Self-Directed Learning

8. DEBRIEF WITH SNAPPS (20 minutes) ASSESSING: Medical Knowledge Patient Care Interpersonal and Communication Skills (with patient and family) Professionalism ASSESSING: Additional insights to MK, PC (clinical reasoning), Professionalism Interpersonal and Communication Skills (with colleague) presentation skills; providing feedback Practice-Based Learning and Improvement: Self-assessment, receptivity to feedback, learning plan OBSERVE STUDENT-PATIENT ENCOUNTER (20 minutes) ASSESSMENT and FEEDBACK

9.  PC1a1: thoroughness of history (can be focused)  PC1a2: organization of history  PC1b1: thoroughness of PE (can be focused)  PC1b2: organization of PE  IPCS7a1: rapport with patient/family  PC2b: differential diagnosis  PC7b: assessment and plan  IPCS7b1: presentation content  PC2c: diagnostic work-up  PC7a: self-knowledge  PC7e: OGRIME  PR: professional demeanor  PBLI3b: ability to interpret feedback

11. Models for patient selection MCT-directed MCT selects patient (outpatient or inpatient) Patient is unknown to student Good for snapshot of student skills in initial evaluation Student-directed Student selects patient (likely inpatient) Can demonstrate specific skill or finding that student needs Opportunity to probe student understanding of “known” case Peer-directed Student-pair selects patients for each other (likely inpatient) Patient is unknown to examining student Can demonstrate specific skill or finding Opportunity to probe student understanding of “known” case Providing feedback may be more challenging