Beyond the Clerkship: Advanced
Competencies and the Senior Year of
Medical School Training
Dr. David Wald, DO
Dr. Nicholas...
Objectives
 Review the literature on current and future structure
of the fourth year of medicine as it relates to EM.
 D...
The Past
The Past
The Past
The Present
 Only 4th year constants across institutions:
 Expectation that students will take USMLE Step 2
 Select a s...
The 4th Year: Purpose
 Preparing for residency through increased responsibility
for patient care
 Making wise and judici...
8
Flexner, Abraham (1910), Medical Education in the United States and Canada: A Report to the
Carnegie Foundation for the ...
The 4th Year of Medical
School
9
What do the Program Director’s think?
 Semi structured interviews
 30 PD’s, broad range of specialties
 3 EM PD’s
10
Common struggles of interns
Identify problems that could be better addressed in
the MS IV year
 Lack of self-reflection a...
Competencies
Competencies MS IV students should gain before
staring residency
 Advanced clinical reasoning
 Near intern ...
Recommended rotations
 Subinternship in field in which applying
 IM subinternship
 IM subspecialty
 Critical care
 Am...
Comments from the Author – M Harper
Additional insight or comments
 Curricular change is hard
 Currently involved in a c...
Expert recommendations for MS IV
curriculum
 English language literature review (1974-2009)
 66 publications
 40 – Aspe...
Three recurring themes
 Lack of clarity about the educational purpose
 Problems in curricular content and organization
...
Lack of clarity about the educational
purpose
 Preparation for residency
 “Preresidency syndrome”
 Culmination of medic...
Problems in curricular content and
organization
 Recommendations from specialty organizations
 College and pathway progr...
Concerns about educational quality
 No publications specifically addressing
educational quality
 Unclear course objectiv...
Comments from the Author – A Walling
Additional insight or comments
 ACGME policies and practices will increasingly
influ...
 Description of the impact of an innovative
MS IV curriculum
 “College Program” UCLA – implemented
2001
 Improved caree...
College structure
 Organized around a set of related specialties that
share similar traits
 College Chair and faculty
 ...
23
College structure – 6 UCLA colleges
Acute Care: time-based decision-making specialties
(Anesthesia, critical care EM)
A...
24
25
Comments from the Author – W Coates
 Variable college sizes year to year
 Yearly reallocation of resources
 Interdiscip...
Comments from the Author – L Wilkerson
 Senior scholarship day
 Facilitated poster and oral presentations
 Colleges spo...
28
 “Undergraduate Rotations” Listing from
www.saem.org
 Ultrasound, International, Disaster Medicine,
Geriatric EM, Toxico...
What does VSAS say?
 353 Electives under “Emergency Medicine”
30
What does VSAS say?
 353 Electives under “Emergency Medicine”
31
Peds 21
Research 12
Toxicology 16
Ultrasound 24
Trauma C...
 Didactics
 Small group case-based discussions
 Small group labs
 Self-directed learning
 Critical care workbook
 Cl...
 Students identify a critical care patient in the
ED during their eve shift (2 pm – 11 pm)
 Students present the case on...
 Integrating critical care via a longitudinal
experience emphasizes the importance of
patient’s ED care on their hospital...
The Ohio State Experience
 Currently, we have 2 “Honors” longitudinal rotations
for students bound for EM
 Advanced Topi...
The Ohio State Experience
 Currently, we have 2 “Honors” longitudinal rotations
for students bound for EM
 Advanced Topi...
Bahner, DP.; Royall, NA. “Advanced ultrasound training for fourth-year medical students: a novel training
program at The O...
Honor’s Ultrasound Requirements
Honors Ultrasound
 @EDUltrasoundQA
 @EDUltrasound
 Facebook at OSU Ultrasound
 There's an App for that!
Kman, NE., et al. “Advanced topics in emergency medicine: curriculum development and initial
evaluation.” Western Journal ...
ATEM Purpose
 9 month longitudinal honors elective with goal of
producing most capable and experienced residents
possible.
Course Components
 Teaching shifts
 Journal Club
 Small Group Didactic Sessions
 PALS and ATLS Training
 High Acuity ...
Course Components
 Teaching shifts
 Journal Club
 Small Group Didactic Sessions
 PALS and ATLS Training
 High Acuity ...
Course Components
 Teaching shifts
 Journal Club
 Small Group Didactic Sessions
 PALS and ATLS Training
 High Acuity ...
Course Components
 Chest Tubes
 Adult and Pediatric Airway
 Procedural Teaching in
Clinical Skills Lab
 Ultrasound
 E...
Course Components
 Chest Tubes
 Adult and Pediatric Airway
 Procedural Teaching in
Clinical Skills Lab
 Ultrasound
 E...
Course Components
 Chest Tubes
 Adult and Pediatric Airway
 Procedural Teaching in
Clinical Skills Lab
 Ultrasound
 E...
The Future
The Future: Competency Based Education
Advanced Competencies and Electives
 16 weeks for advanced competencies and advanced
electives (4 total elective blocks)....
Advanced Competencies
 Medical Administration
 Inter-professional Collaboration
 Social Media in Medicine
 Ultrasound
...
Advanced Competencies
 Professionalism
 Bioinformatics
 Health Coaching
 Health Literacy & Healthcare Disparities
 Ge...
Advanced Competencies
 Professionalism
 Bioinformatics
 Health Coaching
 Health Literacy & Healthcare Disparities
 Ge...
Advanced Clinical Electives
 The Ohio State University has 30 clinical
departments. 21 specialties are presented to
stude...
The Future
 Fit Advanced Topics in Emergency Medicine
Objectives to Level 1 Emergency Medicine
Milestones
 Develop this ...
Advanced Competencies Pearls
 The link is of EM to EPA’s is undeniable! Emergency
Medicine will have an integral part in ...
References
 Wolf, S J (02/19/2014). "Students' Perspectives on the Fourth Year of Medical School: A Mixed-
Methods Analys...
Questions and Discussion?
59
Questions and Discussion?
60
Advanced Competencies in EM: Moving Beyond the Clerkship
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Advanced Competencies in EM: Moving Beyond the Clerkship

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Presenters: David Wald, DO (david.wald@tuhs.temple.edu) and Nicholas Kman, MD (Nicholas.kman@osumc.edu)
In the traditional fourth year of medical school, students choose electives and sub-internships based on perceived knowledge gaps, specialty choice, personal interest or ease of schedule. Some students approach the fourth year with the “pre-residency syndrome”, where they select courses relating to their future field. In this typical medical school curriculum, there is very little opportunity to pursue fully integrated, in-depth learning. This session will explore opportunities for advanced learning in Emergency Medicine after the EM Clerkship.

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  • The structure of medical school (especially the 4th year) has been stable since the Flexner Report. Do we do anything in Medicine the same as we did it in 1910?
  • The structure of the 3rd and 4th years has remained unchanged and unexamined at many institutions.
  • Flexner goes on to say, “Full mastery of a specialty belongs to the postgraduate years.” We are beginning to question this!
  • This quote describes the direction we should be headed in the fourth year!
  • Dave Wald to give a literature based talk on the fourth year and direction its headed.
  • Nick Kman
  • NickKman
  • Introduce Kathy Hiller, give the slides in the interest of time.
  • Longitudinal advanced ultrasound curriculum for 4th year students pursuing specialties that require focused ultrasound. Didactic lectures, journal club sessions, hands-on training, teaching and patient-modeling activities, and complete a final project.Experienced faculty are recruited from EM, internal medicine, OB/GYN, surgery.
  • Students working the Arnold Fitness Expo
  • Discuss Disaster Curriculum
  • Discuss Disaster Curriculum
  • Discuss Disaster Curriculum
  • Discuss my role as Part 3 Director
  • I will be fortunate to run Part 3 of our new curriculum.
  • Achieving certificate or recognition encouraged
  • Advanced Competencies in EM: Moving Beyond the Clerkship

    1. 1. Beyond the Clerkship: Advanced Competencies and the Senior Year of Medical School Training Dr. David Wald, DO Dr. Nicholas Kman, MD @drnickkman
    2. 2. Objectives  Review the literature on current and future structure of the fourth year of medicine as it relates to EM.  Describe the specialization of medical students during 4th year.  Describe curricula that can be implemented to provide advanced opportunities for students in EM.  Explain the concept of Advanced Competencies in EM as they relate to Entrustable Professional Activities (EPAs).
    3. 3. The Past
    4. 4. The Past
    5. 5. The Past
    6. 6. The Present  Only 4th year constants across institutions:  Expectation that students will take USMLE Step 2  Select a specialty  Interview for residency positions. Cosgrove, E M (02/19/2014). "Empowering Fourth-Year Medical Students: The Value of the Senior Year". Academic medicine (1040-2446), p. 1.
    7. 7. The 4th Year: Purpose  Preparing for residency through increased responsibility for patient care  Making wise and judicious career choices  Creating defined time for guidance and preparation for USMLE examinations and residency interviews  Having the time to study/explore specialty in depth  Developing an understanding of different practice settings to prepare for later decisions  Having time to foster and nurture socially responsible activities and interests such as service learning Cosgrove, E M (02/19/2014). "Empowering Fourth-Year Medical Students: The Value of the Senior Year". Academic medicine (1040-2446), p. 1.
    8. 8. 8 Flexner, Abraham (1910), Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching, Bulletin No. 4., New York City: The Carnegie Foundation for the Advancement of Teaching, p. 346, OCLC 9795002.
    9. 9. The 4th Year of Medical School 9
    10. 10. What do the Program Director’s think?  Semi structured interviews  30 PD’s, broad range of specialties  3 EM PD’s 10
    11. 11. Common struggles of interns Identify problems that could be better addressed in the MS IV year  Lack of self-reflection and improvement  Poor organizational skills  Underdeveloped professionalism  Weak medical knowledge 11
    12. 12. Competencies Competencies MS IV students should gain before staring residency  Advanced clinical reasoning  Near intern level independence  Responsibility and reliability  Ownership of patient care 12
    13. 13. Recommended rotations  Subinternship in field in which applying  IM subinternship  IM subspecialty  Critical care  Ambulatory care  EM 13
    14. 14. Comments from the Author – M Harper Additional insight or comments  Curricular change is hard  Currently involved in a curricular renewal process  Most of the focus is on the 3rd year  Under consideration  All 4th year students should develop an individualized learning plan approved by a career advisor 14
    15. 15. Expert recommendations for MS IV curriculum  English language literature review (1974-2009)  66 publications  40 – Aspects of MS IV education  26 – Overview / general reviews 15
    16. 16. Three recurring themes  Lack of clarity about the educational purpose  Problems in curricular content and organization  Concerns about the educational quality of courses 16
    17. 17. Lack of clarity about the educational purpose  Preparation for residency  “Preresidency syndrome”  Culmination of medical school education  Clear understanding of the objectives and competencies to be mastered by graduation  No publications on the role of the MS IV year in the preparation of the medical graduate 17
    18. 18. Problems in curricular content and organization  Recommendations from specialty organizations  College and pathway programs  Accelerated programs  Specific MS IV courses 18
    19. 19. Concerns about educational quality  No publications specifically addressing educational quality  Unclear course objectives  Lack of structured learning  Grade inflation 19
    20. 20. Comments from the Author – A Walling Additional insight or comments  ACGME policies and practices will increasingly influence medical student education  Fourth year as capstone for medical school versus preparation year for residency  Turned in favor of the pre-residency viewpoint  Other factors that increase the pressure towards using the fourth year to prepare for residency are student debt and the growing specter of unmatched US graduates  20
    21. 21.  Description of the impact of an innovative MS IV curriculum  “College Program” UCLA – implemented 2001  Improved career advising and mentoring 21
    22. 22. College structure  Organized around a set of related specialties that share similar traits  College Chair and faculty  Delivering specific curricular activities  Advising students / mentoring  Overseeing scholarly projects 22
    23. 23. 23 College structure – 6 UCLA colleges Acute Care: time-based decision-making specialties (Anesthesia, critical care EM) Applied Anatomy: structure-oriented fields (Surgery, radiology, pathology) Medical Leadership: dual-degree programs in public health or business administration Medical Subspecialties: subspecialties focused on clinical reasoning and advance fellowship training Primary Care: longitudinal care specialties (FM, IM, pediatrics) Urban Underserved: focuses on care of underserved communities
    24. 24. 24
    25. 25. 25
    26. 26. Comments from the Author – W Coates  Variable college sizes year to year  Yearly reallocation of resources  Interdisciplinary faculty  Mentoring junior faculty  Residents as teachers  Two tiered level of student advising / mentoring  Group / peer  Structural individual 26
    27. 27. Comments from the Author – L Wilkerson  Senior scholarship day  Facilitated poster and oral presentations  Colleges sponsor the Special Interest Groups and electives in the preclinical years  Earlier college involvement  Colleges shifting to an earlier start date  Considering new senior year requirements  More elective time  Reviewing the role of the College Chairs in preparing the MSPE 27
    28. 28. 28
    29. 29.  “Undergraduate Rotations” Listing from www.saem.org  Ultrasound, International, Disaster Medicine, Geriatric EM, Toxicology, and Pediatric EM 29
    30. 30. What does VSAS say?  353 Electives under “Emergency Medicine” 30
    31. 31. What does VSAS say?  353 Electives under “Emergency Medicine” 31 Peds 21 Research 12 Toxicology 16 Ultrasound 24 Trauma Critical Care 5 EMS/Disaster 14 Wilderness Medicine 6 Global/International Health 4 Hyperbaric/Undersea 1 103
    32. 32.  Didactics  Small group case-based discussions  Small group labs  Self-directed learning  Critical care workbook  Clinical shifts (12 x 9-hour shifts) at 2 clinical sites  Critical care experience/workbook (5 days)  Exam
    33. 33.  Students identify a critical care patient in the ED during their eve shift (2 pm – 11 pm)  Students present the case on morning teaching rounds in the ICU the next day  Repeat the eve shift, then 4 days in the ICU  Students follow their patients in ICU and complete workbook
    34. 34.  Integrating critical care via a longitudinal experience emphasizes the importance of patient’s ED care on their hospital course and highlights importance of multidisciplinary approach
    35. 35. The Ohio State Experience  Currently, we have 2 “Honors” longitudinal rotations for students bound for EM  Advanced Topics in Emergency Medicine (ATEM)  Honors U/S
    36. 36. The Ohio State Experience  Currently, we have 2 “Honors” longitudinal rotations for students bound for EM  Advanced Topics in Emergency Medicine (ATEM)  Honors U/S  Wilderness Medicine  Global Health
    37. 37. Bahner, DP.; Royall, NA. “Advanced ultrasound training for fourth-year medical students: a novel training program at The Ohio State University College of Medicine.” Academic Medicine, v. 88 issue 2, 2013, p. 206-13.
    38. 38. Honor’s Ultrasound Requirements
    39. 39. Honors Ultrasound  @EDUltrasoundQA  @EDUltrasound  Facebook at OSU Ultrasound  There's an App for that!
    40. 40. Kman, NE., et al. “Advanced topics in emergency medicine: curriculum development and initial evaluation.” Western Journal of Emergency Medicine, v. 12 issue 4, 2011, p. 543-50.
    41. 41. ATEM Purpose  9 month longitudinal honors elective with goal of producing most capable and experienced residents possible.
    42. 42. Course Components  Teaching shifts  Journal Club  Small Group Didactic Sessions  PALS and ATLS Training  High Acuity Code Training  EMS and Emergency Preparedness Training (MedFlight)  Toxicology
    43. 43. Course Components  Teaching shifts  Journal Club  Small Group Didactic Sessions  PALS and ATLS Training  High Acuity Code Training  EMS and Emergency Preparedness Training (MedFlight)  Toxicology
    44. 44. Course Components  Teaching shifts  Journal Club  Small Group Didactic Sessions  PALS and ATLS Training  High Acuity Code Training  EMS and Emergency Preparedness Training (MedFlight)  Toxicology
    45. 45. Course Components  Chest Tubes  Adult and Pediatric Airway  Procedural Teaching in Clinical Skills Lab  Ultrasound  EMS Lecture/Experience  Mentorship  Research or Q/A Project
    46. 46. Course Components  Chest Tubes  Adult and Pediatric Airway  Procedural Teaching in Clinical Skills Lab  Ultrasound  EMS Lecture/Experience  Mentorship  Research or Q/A Project
    47. 47. Course Components  Chest Tubes  Adult and Pediatric Airway  Procedural Teaching in Clinical Skills Lab  Ultrasound  EMS Lecture/Experience  Mentorship  Research or Q/A Project
    48. 48. The Future
    49. 49. The Future: Competency Based Education
    50. 50. Advanced Competencies and Electives  16 weeks for advanced competencies and advanced electives (4 total elective blocks).  Students can choose a variety of advanced competencies and advanced clinical electives.  Advanced electives are a place for students to become proficient at level 1 milestones for their chosen residency specialty.  This 16 week period will include time for assessments. 50
    51. 51. Advanced Competencies  Medical Administration  Inter-professional Collaboration  Social Media in Medicine  Ultrasound  Procedures  Patient Experience  Research (will require preapproval with preceptor)  Teaching in Medicine  Clinical Practice Guidelines & Evidence-based Medicine 51
    52. 52. Advanced Competencies  Professionalism  Bioinformatics  Health Coaching  Health Literacy & Healthcare Disparities  Genetics  Quality Improvement/Patient Safety  Emergency Preparedness and Disaster Response  Global Health  Latino Health 52
    53. 53. Advanced Competencies  Professionalism  Bioinformatics  Health Coaching  Health Literacy & Healthcare Disparities  Genetics  Quality Improvement/Patient Safety  Emergency Preparedness and Disaster Response  Global Health  Latino Health 53
    54. 54. Advanced Clinical Electives  The Ohio State University has 30 clinical departments. 21 specialties are presented to students for Career Exploration week.  The Advanced Clinical Tracks will offer a variety of experiences and electives to prepare students for Milestone 1 (intern level for that specialty).  Example EM Advanced Clinical Track: Selectives in EM, ICU, Diabetes, Pain & Palliative, or CHF; Advanced Competency in Ultrasound, Advanced Topics in EM, elective in Wilderness Medicine. 55
    55. 55. The Future  Fit Advanced Topics in Emergency Medicine Objectives to Level 1 Emergency Medicine Milestones  Develop this into an Advanced Clinical Track from students going into Emergency Medicine  Graduate the finest EM interns our colleagues could hope to match! 56
    56. 56. Advanced Competencies Pearls  The link is of EM to EPA’s is undeniable! Emergency Medicine will have an integral part in the clinical years of medical school.  Fourth year of medical school is a necessary component of medical student clinical development.  Opportunities such as Ultrasound, International, Disaster Medicine, Geriatric EM, Toxicology, Wilderness, EMS, and Pediatric EM exist for our graduates. 57
    57. 57. References  Wolf, S J (02/19/2014). "Students' Perspectives on the Fourth Year of Medical School: A Mixed- Methods Analysis". Academic medicine (1040-2446), p. 1.  Cosgrove, E M (02/19/2014). "Empowering Fourth-Year Medical Students: The Value of the Senior Year". Academic medicine (1040-2446), p. 1.  Bahner, DP.; Royall, NA. “Advanced ultrasound training for fourth-year medical students: a novel training program at The Ohio State University College of Medicine.” Academic Medicine, v. 88 issue 2, 2013, p. 206-13.  Kman, NE., et al. “Advanced topics in emergency medicine: curriculum development and initial evaluation.” Western Journal of Emergency Medicine, v. 12 issue 4, 2011, p. 543-50.  Alliance for Clinical Education Perspective Paper: Recommendations for Redesigning the “Final Year" of Medial School. Accepted for publication in Teach Learn Med.  Pacella CB. Advanced opportunities for student education in emergency medicine. Acad Emerg Med 2004; 11(10): 1028e9-1028e11.  Flexner, Abraham (1910), Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching, Bulletin No. 4., New York City: The Carnegie Foundation for the Advancement of Teaching, p. 346, OCLC 9795002.
    58. 58. Questions and Discussion? 59
    59. 59. Questions and Discussion? 60

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