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Bridging the Continuum Between UME and GME

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1. Review background literature on:
Undergraduate Medical Education (UME) to Graduate Medical Education (GME) continuum
Competency based medical education
Current state of the 4th year of medical school
2. Describe how a clinical track based on ACGME competencies could bridge the chasm between UME and GME.
3. Identify strategies for creating specialty specific milestones reports at your institutions.
4. Identify barriers and derive solutions to these “feedforward” concepts.

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Bridging the Continuum Between UME and GME

  1. 1. Bridging the Continuum Between Undergraduate and Graduate Medical Education: A Feedforward Mechanism for Graduating Medical Students Helen Morgan MD, Nicholas Kman MD, Jennifer McCallister MD, Sally Santen MD, PhD
  2. 2. Introductions
  3. 3. AMA Accelerating Change in Medical Education Disclosures
  4. 4. Objectives 1. Review background literature on: – Undergraduate Medical Education (UME) to Graduate Medical Education (GME) continuum – Competency based medical education – Current state of the 4th year of medical school 2. Describe how a clinical track based on ACGME competencies could bridge the chasm between UME and GME. 3. Identify strategies for creating specialty specific milestones reports at your institutions. 4. Identify barriers and derive solutions to these “feedforward” concepts.
  5. 5. UME to GME Continuum
  6. 6. Undergraduate Medical Education (UME) Graduate Medical Education (GME)
  7. 7. MK ,PC, Prof, SBP, PBLI, ISC Undergraduate Medical Education (UME) Graduate Medical Education (GME) Competency Based Medical Education
  8. 8. MK ,PC, Prof, SBP, PBLI, ISC Undergraduate Medical Education (UME) Graduate Medical Education (GME) Competency Based Medical Education
  9. 9. MK ,PC, Prof, SBP, PBLI, ISC Undergraduate Medical Education (UME) Graduate Medical Education (GME) Competency Based Medical Education +ACGME Milestones Project
  10. 10. What are the current issues of the M4 year? In an ideal world, what would be the core objectives of the M4 year?
  11. 11. Current State of the Senior Medical School Experience
  12. 12. Issues We All Face ▪ Only 4th year constants across institutions: ▪ Expectation that students will take USMLE Step 2 CS and CK ▪ 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.
  13. 13. Course offerings in 4th Year ▪ Subinternships were required by 122/136 (90%). ▪ Capstone courses used to fill curricular gaps. ▪ Revisiting basic sciences. ▪ Many schools require rotations in specific settings (EM, ICU, Ambulatory). ▪ A growing number of schools require participation in research. ▪ Students work with underserved populations or seek experiences that will be henceforth unavailable ▪ Electives to "audition" at desired residency sites. 13 Course Offerings in the Fourth Year of Medical School: How U.S. Medical Schools Are Preparing Students for Internship. Elnicki, et al for the CDIM/Association of Program Directors in Internal Medicine Committee on Transition to Internship Academic Medicine 2015
  14. 14. Course offerings in 4th Year ▪ Subinternships were required by 122/136 (90%). ▪ Capstone courses used to fill curricular gaps (80/136 (59%)). ▪ Revisiting basic sciences. ▪ Many schools require rotations in specific settings (EM (45%), ICU (34%), Ambulatory (35%)). ▪ A growing number of schools require participation in research (51/136 (38%)). ▪ Students work with underserved populations or seek experiences that will be henceforth unavailable ▪ Electives to "audition" at desired residency sites. 14 Course Offerings in the Fourth Year of Medical School: How U.S. Medical Schools Are Preparing Students for Internship. Elnicki, et al for the CDIM/Association of Program Directors in Internal Medicine Committee on Transition to Internship Academic Medicine 2015
  15. 15. Lyss-Lerman P, et al. What training is needed in the fourth year of medical school? Views of residency program directors. Acad Med. 2009 Jul;84(7):823-9. ▪ Common struggles of interns: ▪ Lack of self-reflection and improvement ▪ Poor organizational skills ▪ Underdeveloped professionalism ▪ Weak medical knowledge ▪ Competencies MS IV students should gain before starting residency ▪ Advanced clinical reasoning ▪ Near intern level independence ▪ Ownership of patient care 15
  16. 16. Lyss-Lerman P, et al. What training is needed in the fourth year of medical school? Views of residency program directors. Acad Med. 2009 Jul;84(7):823-9. ▪ “Organizing the curriculum with specialty-specific tracks could be explored by looking at specialty- specific data and expanding the interviews to include more PDs.” 16
  17. 17. Walling A, Merando A. The fourth year of medical education: a literature review. Acad Med. 2010 Nov;85(11):1698-704. ▪ Three recurring themes: ▪ Lack of clarity about the educational purpose ▪ Problems in curricular content and organization ▪ Concerns about the educational quality of courses 17
  18. 18. Walling A, Merando A. The fourth year of medical education: a literature review. Acad Med. 2010 Nov;85(11):1698-704. ▪ ACGME policies and practices will increasingly influence medical student education ▪ 4th 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 18
  19. 19. What is the 4th Year? What Can it Be? 19
  20. 20. Reddy ST, et al. ACE perspective paper: recommendations for redesigning the "final year" of medical school. Teach Learn Med. 2014;26(4):420-7. ▪ Demonstrate that they have mastered objectives (based on 6 ACGME Core Clinical Competencies) ▪ Complete a required capstone course prepares students for residency. ▪ Structure their 4th year schedules to accomplish specialty-specific objectives that prepare them for their intended specialty. ▪ Engage in thoughtful inventory of training. Identified gaps should be addressed through deliberate participation in rotations that address identified areas. 20
  21. 21. Reddy ST, et al. ACE perspective paper: recommendations for redesigning the "final year" of medical school. Teach Learn Med. 2014;26(4):420-7. ▪ Demonstrate that they have mastered objectives (based on 6 ACGME Core Clinical Competencies) ▪ Complete a required capstone course prepares students for residency. ▪ Structure their 4th year schedules to accomplish specialty-specific objectives that prepare them for their intended specialty. ▪ Engage in thoughtful inventory of their medical school training. Identified gaps should be addressed through the deliberate participation in rotations that address the identified areas. 21
  22. 22. Reddy ST, et al. ACE perspective paper: recommendations for redesigning the "final year" of medical school. Teach Learn Med. 2014;26(4):420-7. ▪ 4th year is a bridge between medical school and Residency: ACGME Competencies and AAMC Core Entrustable Professional Activities (EPAs) should be used to guide curriculum development. ▪ These competencies and specialty-specific milestones and EPAs provide guidance to medical schools for the minimum level of competency for starting intern and can be used to design 4th-year curricula. 22
  23. 23. What are some potential solutions to bridge the gap between UME and GME? Discussion
  24. 24. Potential Solution: Clinical Tracks
  25. 25. Advanced Management in Hospital Based Care Advanced Management in Relationship Centered Care Advanced Competency Elective Clinical Tracks: A longitudinal experience in a specialty or subspecialty designed to prepare students to be an intern/incoming resident by meeting entry level milestones in that field. Other Electives (4 total required including Advanced Competency) Flex Gateway Activities Part Three Advanced Clinical Management HSIQ Project What is a Clinical Track?
  26. 26. Required rotations Recommended rotations Supplemental activities Clinical Tracks—requirements
  27. 27. How long should a Clinical Track be? ▪ Not fulfilled by a required number of clinical rotations ▪ Represent a combination of clinical rotations & experiences ▪ Allow student to develop necessary skills
  28. 28. Clinical Tracks—evaluation ACGME Milestone-based assessments Competency based evaluations
  29. 29. Currently available Clinical Tracks ▪ Anesthesiology ▪ Emergency Medicine ▪ Family Medicine ▪ Internal Medicine (Preliminary Medicine included) ▪ Internal Medicine-Pediatrics ▪ Obstetrics/Gynecology ▪ Pediatrics ▪ Psychiatry ▪ Neurology ▪ Radiology ▪ Surgery/Surgical Subspecialties (Preliminary Surgery included)
  30. 30. Description of the EM Clinical Track Recommended Courses ▪ EM at OSUWMC ▪ MICU, SICU, Cardiology, or Pulmonary. ▪ Chronic Care ▪ Geriatrics, HIV Patient Care, CHF, Adult Kidney Disease, Child Abuse/Child Advocacy, Alcohol & Drug Abuse. ▪ Clinical Track Electives ▪ Advanced Topics in Emergency Medicine (ATEM), Away Elective in EM (Tox, Ultrasound, EMS, Peds EM), Ultrasound Advanced Competency, Emergency Preparedness Advanced Competency, Radiology, Anesthesia, Sports Medicine, Dermatology, Plastics, ENT/Ophtho (two 2-week electives if possible), Hand Surgery, Orthopedics. 30
  31. 31. Description of the IM Clinical Track Recommended Courses ▪ Emergency Medicine adult, any site ▪ Any IM mini-internship- at OSU ▪ Any two different ambulatory practice environments, at least one must be IM ▪ Electives ▪ Consider two sub-internships in IM (one early, one late), consult experience in a specialty of interest. Consider the 2- week Medicine Boot Camp (general intern survival skills) and the 4- week “Advanced Competency in Procedural Skills”. 32
  32. 32. Assessments—IM Clinical Track Assessment Items Data PC 1 PC 2 PC 3 PC 4 PC 5 MK 1 MK 2 SB P1 SB P2 SB P3 Mini I—Patient Care (CEO 1.2.1) Obtained accurate and pertinent histories x Mini I—Patient Care (CEO 1.2.2) Demonstrated physical exam skills and identified exam findings x Mini I—Patient Care (CEO 1.2.4) Assessed and managed undiagnosed problems x x x Mini I—Patient Care (CEO 1.2.4) Interpreted clinical situations and diagnostic tests x x Min I—Procedures (CEO 2.4) Performed general procedures of a physician x Mini I—Medical knowledge (CEO 2.1.2) Applied knowledge to understand patient care x x Mini I—Systems-based Practice (CEO 5.1) Facilitated an interdisciplinary and team approach to coordinate care x Mini I—Systems-based Practice (CEO 5.2) Utilized healthcare resources effectively x
  33. 33. Questions?
  34. 34. Feeding Forward
  35. 35. M3 Clerkship Experiences ResidencyVariable fourth year experiences
  36. 36. M3 Clerkship Experiences ResidencyVariable fourth year experiences Specialty Specific Residency Preparation Electives (bootcamps)
  37. 37. Clerkship Experiences Residency Surgery (2008) Obstetrics and Gynecology (2013) Pediatrics (2015) Variable fourth year experiences Specialty Specific Residency Preparation Electives (bootcamps)
  38. 38. Advanced Clinical Skills in Obstetrics and Gynecology Curriculum 15 hours: Embalmed cadaver and fresh frozen operative cadaver sessions 14 hours: Case based obstetric and gynecologic cases 17 hours: Laparoscopic and open skills testing and teaching 17 hours: Flipped classroom sessions with case-based discussions 10 hours: Pre-operative simulation based curriculum Decision to Incision Case discussions Anatomy Simulation Lecture Surgical skills
  39. 39. APGO Test Decision to Incision Pelvic Exam with GTA Pelvic Anatomy Literature Assessment Paging Suture Skills Antepartum Care and Complications of Pregnancy X Care of Patients in the Intrapartum Period X Care of Patients in the Postpartum Period X Obstetrical Technical Skills X X Immediate Care of the Newborn Gynecology Technical Skills: Laparotomy X X Gynecology Technical Skills: Vaginal X X Gynecology Technical Skills: Endoscopy X X Peri-Operative Care X Family Planning X Ambulatory Gynecology X Care of the Patient with Non-Reproductive Medical Disorders X Abdominal/Pelvic Pain X X Abnormal Uterine Bleeding X Pelvic Mass X Pelvic Floor Disorders X X First Trimester Bleeding X Patient Safety and Systems Approach to Medical Errors X Cost-effective Care and Patient Advocacy X Self-Directed Learning/Critical Appraisal of the Medical Literature X QI Process: Systematically analyze practice using quality improvement methods and implement changes with the goal of practice improvement Compassion, Integrity and Respect for Others X Accountability and Responsiveness to the Needs of Patients, Society, and the Profession X Respect of Privacy, Autonomy and Pt/Physician Relationship X Communication with Patients and Families X Communication with Physicians and Other Health Professionals X Informed Consent and Shared Decision Making X Interpersonal and Communication Skills Competency Assessment Method Topic Patient Care Medical Knowledge Systems Based Practice Problem Based Learning and Improvement Professionalism Not assessed Not assessed Domain Competency
  40. 40. APGO Test Decision to Incision Pelvic Exam with GTA Pelvic Anatomy Literature Assessment Paging Suture Skills Antepartum Care and Complications of Pregnancy X Care of Patients in the Intrapartum Period X Care of Patients in the Postpartum Period X Obstetrical Technical Skills X X Immediate Care of the Newborn Gynecology Technical Skills: Laparotomy X X Gynecology Technical Skills: Vaginal X X Gynecology Technical Skills: Endoscopy X X Peri-Operative Care X Family Planning X Ambulatory Gynecology X Care of the Patient with Non-Reproductive Medical Disorders X Abdominal/Pelvic Pain X X Abnormal Uterine Bleeding X Pelvic Mass X Pelvic Floor Disorders X X First Trimester Bleeding X Patient Safety and Systems Approach to Medical Errors X Cost-effective Care and Patient Advocacy X Self-Directed Learning/Critical Appraisal of the Medical Literature X QI Process: Systematically analyze practice using quality improvement methods and implement changes with the goal of practice improvement Compassion, Integrity and Respect for Others X Accountability and Responsiveness to the Needs of Patients, Society, and the Profession X Respect of Privacy, Autonomy and Pt/Physician Relationship X Communication with Patients and Families X Communication with Physicians and Other Health Professionals X Informed Consent and Shared Decision Making X Interpersonal and Communication Skills Competency Assessment Method Topic Patient Care Medical Knowledge Systems Based Practice Problem Based Learning and Improvement Professionalism Not assessed Not assessed Domain Competency
  41. 41. Post-Match Milestones-based Medical Student Performance Evaluation (mMSPE) Department of Obstetrics and Gynecology L4001 University Hospital South 1500 E. Medical Center Drive, SPC 5276 Ann Arbor, MI 48109-5276 DATE PD name PD address Dear Dr. PD, (Student name) successfully completed an Advanced Clinical Skills in Obstetrics and Gynecology elective (ie bootcamp) at the University of Michigan in March, 2016. The content of this four-week residency preparation course was mapped to the ACGME OBGYN level one milestones (see appendix for a description of the course curriculum). Assessments from this course, as well as high stakes assessments from the medical school curriculum were utilized to determine whether (student name) met level one milestones for 25 of the 28 competencies. (Student name) met or exceeded level one milestones in ___ of the 25 competencies, and his/her performance is detailed in the table on the following page. He/She stood out for_______________________. We hope that this information is helpful to you, and can be utilized as you build your incoming PGY1 residents’ milestones portfolio. Sincerely, Helen Kang Morgan, MD & Anita Malone, MD Co-Directors, Advanced Clinical Skills in Obstetrics and Gynecology Course
  42. 42. Post-Match Milestones-based Medical Student Performance Evaluation (mMSPE) Domain Competency Level One Milestone Assessments Did not meet Met Exceeded Patient Care Antepartum Care and Complications of Pregnancy APGO Assessment, APGO Antepartum Teaching Case Care of Patients in the Intrapartum Period APGO Assessment, APGO Abnormal Labor Teaching Case, Shoulder Dystocia Simulation Case Care of Patients in the Postpartum Period APGO Assessment, APGO Postpartum Teaching Case, Postpartum Hemorrhage Simulation Case Obstetrical Technical Skills Suture Skills, Pelvic Exam with GTA, Decision to Incision Immediate Care of the Newborn NA Gynecology Technical Skills: Laparotomy APGO Assessment, Decision to Incision, Pelvic Anatomy Gynecology Technical Skills: Vaginal Decision to Incision, Pelvic Anatomy Gynecology Technical Skills: Endoscopy APGO Assessment, Decision to Incision, Pelvic Anatomy Peri-Operative Care APGO Assessment, Pelvic Anatomy Family Planning APGO Assessment, APGO Family Planning Teaching Case Ambulatory Gynecology APGO Assessment Care of the Patient with Non-Reproductive Medical Disorders APGO Assessment, M4CCA, APGO Gynecological Procedures Teaching Case Medical Knowledge Health Care Maintenance and Disease Prevention APGO Assessment, APGO HME Teaching Case, M4CCA EBM Abdominal/Pelvic Pain APGO Assessment, APGO Endometriosis Teaching Case Abnormal Uterine Bleeding APGO Assessment, APGO Normal and Abnormal Uterine Bleeding Case, Pelvic Mass APGO Assessment, APGO Ovarian Neoplasms Teaching Case, APGO Endometrial Hyperplasia Teaching Case Pelvic Floor Disorders APGO Assessment, Pelvic Anatomy First Trimester Bleeding APGO Assessment, APGO Spontaneous Abortion Teaching Case Systems Based Practice Patient Safety and Systems Approach to Medical Errors M4 CCA, Paging Curriculum Cost-effective Care and Patient Advocacy NA Problem Based Learning and Improvement Self-Directed Learning/Critical Appraisal of the Medical Literature Literature Assessment, M4CCA QI Process: Systematically analyze practice using quality improvement methods and implement changes with the goal of practice improvement NA Professionalism Compassion, Integrity and Respect for Others Paging Curriculum, M4CCA Accountability and Responsiveness to the Needs of Patients, Society, and the Profession Paging Curriculum, M4CCA Respect of Privacy, Autonomy and Pt/Physician Relationship Paging Curriculum Interpersonal and Communication Skills Communication with Patients and Families M4 CCA, Paging Curriculum, Decision to Incision Communication with Physicians and Other Health Professionals Paging Curriculum, Decision to Incision Informed Consent and Shared Decision Making Paging Curriculum, M4CCA, Decision to Incision
  43. 43. Post-Match Milestones-based Medical Student Performance Evaluation (mMSPE) Domain Competency Level One Milestone Assessments Did not meet Met Exceeded Patient Care Antepartum Care and Complications of Pregnancy APGO Assessment, APGO Antepartum Teaching Case Care of Patients in the Intrapartum Period APGO Assessment, APGO Abnormal Labor Teaching Case, Shoulder Dystocia Simulation Case Care of Patients in the Postpartum Period APGO Assessment, APGO Postpartum Teaching Case, Postpartum Hemorrhage Simulation Case Obstetrical Technical Skills Suture Skills, Pelvic Exam with GTA, Decision to Incision Immediate Care of the Newborn NA Gynecology Technical Skills: Laparotomy APGO Assessment, Decision to Incision, Pelvic Anatomy Gynecology Technical Skills: Vaginal Decision to Incision, Pelvic Anatomy Gynecology Technical Skills: Endoscopy APGO Assessment, Decision to Incision, Pelvic Anatomy Peri-Operative Care APGO Assessment, Pelvic Anatomy Family Planning APGO Assessment, APGO Family Planning Teaching Case Ambulatory Gynecology APGO Assessment Care of the Patient with Non-Reproductive Medical Disorders APGO Assessment, M4CCA, APGO Gynecological Procedures Teaching Case Medical Knowledge Health Care Maintenance and Disease Prevention APGO Assessment, APGO HME Teaching Case, M4CCA EBM Abdominal/Pelvic Pain APGO Assessment, APGO Endometriosis Teaching Case Abnormal Uterine Bleeding APGO Assessment, APGO Normal and Abnormal Uterine Bleeding Case, Pelvic Mass APGO Assessment, APGO Ovarian Neoplasms Teaching Case, APGO Endometrial Hyperplasia Teaching Case Pelvic Floor Disorders APGO Assessment, Pelvic Anatomy First Trimester Bleeding APGO Assessment, APGO Spontaneous Abortion Teaching Case Systems Based Practice Patient Safety and Systems Approach to Medical Errors M4 CCA, Paging Curriculum Cost-effective Care and Patient Advocacy NA Problem Based Learning and Improvement Self-Directed Learning/Critical Appraisal of the Medical Literature Literature Assessment, M4CCA QI Process: Systematically analyze practice using quality improvement methods and implement changes with the goal of practice improvement NA Professionalism Compassion, Integrity and Respect for Others Paging Curriculum, M4CCA Accountability and Responsiveness to the Needs of Patients, Society, and the Profession Paging Curriculum, M4CCA Respect of Privacy, Autonomy and Pt/Physician Relationship Paging Curriculum Interpersonal and Communication Skills Communication with Patients and Families M4 CCA, Paging Curriculum, Decision to Incision Communication with Physicians and Other Health Professionals Paging Curriculum, Decision to Incision Informed Consent and Shared Decision Making Paging Curriculum, M4CCA, Decision to Incision Domain Competency Level One Milestone Assessments Did not meet Met Exceeded Patient Care Antepartum Care and Complications of Pregnancy APGO Assessment, APGO Antepartum Teaching Case Care of Patients in the Intrapartum Period APGO Assessment, APGO Abnormal Labor Teaching Case, Shoulder Dystocia Simulation Case Care of Patients in the Postpartum Period APGO Assessment, APGO Postpartum Teaching Case, Postpartum Hemorrhage Simulation Case Obstetrical Technical Skills Suture Skills, Pelvic Exam with GTA, Decision to Incision Immediate Care of the Newborn NA Gynecology Technical Skills: Laparotomy APGO Assessment, Decision to Incision, Pelvic Anatomy Gynecology Technical Skills: Vaginal Decision to Incision, Pelvic Anatomy Gynecology Technical Skills: Endoscopy APGO Assessment, Decision to Incision, Pelvic Anatomy Peri-Operative Care APGO Assessment, Pelvic Anatomy Family Planning APGO Assessment, APGO Family Planning Teaching Case Ambulatory Gynecology APGO Assessment Care of the Patient with Non-Reproductive Medical Disorders APGO Assessment, M4CCA, APGO Gynecological Procedures Teaching Case
  44. 44. Feedback ▪Student: “it is always nice to have a snapshot summary of your performance” “I definitely think the letter is useful, both for my PD and for me… I did not realize that I was weak in ambulatory gynecology” ▪Program Director: “wow this is great” “I found this very very helpful” “it’s a great educational handoff”
  45. 45. “The majority thought the proposed assessment provided new information not available on the traditional MSPE, and one concluded that the proposed letter would allow for early intervention for areas of weakness”
  46. 46. At your institution, how would you bridge the gap between UME and GME (specifically what information would you use?) Ideally how should we handover information about low performing learners?
  47. 47. Concluding thoughts
  48. 48. MK ,PC, Prof, SBP, PBLI, ISC Undergraduate Medical Education (UME) Graduate Medical Education (GME)
  49. 49. Questions?

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