Teaching Students from Jan to June:Reaching the Unreachable

Sundip Patel, M.D.Drew Nyce, M.D.

Council of Residency Directors MeetingApril 3rd 2012

Atlanta, Georgia

Outline

• Qualifications • LCME Rules & Unreachable• Why it’s Important to Reach the Unreachable• Key Motivational Factors for the Unreachable• Methods to Reach the Unreachable• Do’s and Don’ts

Qualifications• Cooper AAMC Graduation Survey Data

Year Poor Fair Good Excellent

2007Our Clerkship 0.0 25.0 50.0 25.0

National Avg 6.0 13.9 36.7 43.4

2008Our Clerkship 3.8 11.5 26.9 57.7

National Avg 6.1 13.7 35.0 45.2

2009Our Clerkship 3.6 3.6 32.1 60.7

National Avg 4.5 11.5 33.1 51.0

2010Our Clerkship 0.0 2.3 34.9 62.8

National Avg 4.3 11.3 32.4 51.9

2011Our Clerkship 0.0 12.0 12.0 76.0

National Avg 4.3 11.1 32.1 52.6

LCME & Unreachable

LCME ED – 17

“Educational opportunities must be available in a medical education program in multidisciplinary content areas (e.g., emergency medicine, geriatrics)”

• Where in the curriculum?• How is it covered?

LCME & Unreachable

• ED – 17– Requirement not met in Surgery / Medicine

clerkships• Limited EM exposure• H&P on patient in ED not enough

– Easiest way for med school to fulfill• Required EM clerkship• All students must rotate • Hence the “Unreachable Students”

LCME & Unreachable

• EM rotations– 36% mandatory, 14% selective in 20071

– 65% clerkships have EM rotation only in 4th yr 1

– In 2012• These numbers likely higher• If not a required EM clerkship, just wait……• More Unreachable students

1 Wald DA, Manthey DE, Kruus L, et al. The state of the clerkship: a survey of Emergency Medicine clerkship directors. Acad Emerg Med. 2007; 14: 629-634.

LCME & Unreachable

ED – 10 “must include behavioral and socioeconomic subjects…”

– Exposure to suicidal, psychotic, drug abuse pts– Exposure to homeless, inability to pay for meds– How do students meet this requirement?

Just have them see the first pt on overnight ED shift

LCME & Unreachable

• Summary– EM clerkship meets many LCME requirements– If not required EM clerkship, just wait…..

• All students• Jan to June• Unreachable students

– Engage?– Personalize?– Motivate?

Why Reach out to the Unreachable

• Need to answer to your dean, chairman– Clerkship stats

• Organization• Educational experience• Patient care• Faculty / resident educators• Dreaded “Additional Comments”

– All stats affected by “Unreachable” students

Why Reach out to the Unreachable• You are ALWAYS showcasing your EM program

– Mistreatment of “Unreachable” student• Creates bad reputation for your dept• Turns off home students interested in EM• Has this really happened??

Why Reach out to the Unreachable

• We’re educators, Darn it!!– We enjoy educating everyone

• Even those not going into EM– We’ve never shown preferential treatment to

students going into EM– We want to create a reputation that we enjoy

educating everyone

Key Motivational Factors for Unreachable Students

• Fulfill a required rotation• Fulfill a required rotation• Fulfill a required rotation and…………………..• Where to go on vacation?

Key Motivational Factors for Unreachable Students

• Things you need to remind students to motivate them– Procedures

• Fulfill medical school requirements• Practice procedures will be doing as interns

– Opportunity to see things may never see again• Peds student seeing elderly patients• IM student seeing surgical abdomens• Pathology student seeing living patients

Key Motivational Factors for Unreachable Students

• Things you need to remind them to engage them– 6 months argument i.e. “You will soon be an intern”

• Committing to plans• Working on interpersonal skills

– Handling sick patients• 2am on-call page - “Mrs. Smith is really short of breath and

doesn’t look good….”• ACLS algorithms

Key Motivational Factors for Unreachable Students

• How do we motivate & engage the Unreachable?– EM Clerkship Orientation Day – Our orientation is different depending on the time of

year• July – Nov orientation (For EM bound students)

– Focus on LORs– Additional EM experiences– If deciding late, how to go about the process / visiting rotations

Key Motivational Factors for Unreachable Students

• Jan – May orientation (geared for non-EM bound students)

– Focus on procedures– Completing med school requirements– Obtaining skills to help when they are an intern

Methods to Reach the Unreachable

• Simulation…..with a twist…..• Teaching shifts• EBM• Enrichment Experience• Ultrasound• Mid-Clerkship Feedback

Simulation• Other clerkships focus on small area

– Anesthesia – Airways– OB/Gyn – Deliveries

• EM sim gives students opportunity to do more– ACLS protocols

• Real life, students never run codes• Ability to manage sick pts on own

– Medications – Procedures– Learn how to run a team

Simulation

• Do students love running ACLS protocols?– Yeung CJEM 2010; 12: 212-219– 2 x 2hr ACLS lectures with 8 hr skills session– Students ranked ACLS training above

• Clinical shifts• Supervised shifts (teaching shifts)• Procedural skills lab

– ACLS is a hands-on activity that they can apply clinically

Simulation

• What’s our twist?• Tailor sim experience to student’s interest

– Example – Student going into Dermatology• Take septic shock case • Have pt with toxic epidermal necrolysis become septic• Show images of TEN • Benefits

– YOU cover septic shock– THEY love it

Simulation• Other examples

– Optho – globe rupture with trauma sim– Ortho – long bone fxs with trauma sim– Radiology – pregnant trauma

• Discuss radiation exposures• Other imaging options

– Family Medicine • Sim about end of life• Breaking bad news

– Pathology • Nothing you can do for them• Send them to the anatomy lab

Simulation

• Tailoring sim to student interest– More work / prep on your part– Students have total buy-in– Still covering main topics– Great evaluations

Teaching Shifts

• We have used for over 7 yrs • Teach 2-3 students on a 6 hr shift• Dedicated faculty member

– Does not hear resident cases– Generally does not see pts primarily

• More time for education• Directly observe students

– Real time feedback– LCME requirement

Teaching Shifts

• Problems– Need buy-in from faculty worried about RVUs– Need lots of

• It works (Cassidy-Smith CJEM 2011; 13: 259-266)– Students – better bedside teaching, rotation– Faculty – more available, quicker dispositions– Residents – increased faculty availability

Other Shifts

• Besides Teaching shifts– Only 1 student each shift

• Constant engagement• No competition for procedures• Can’t hide

– One on One faculty interactions• Fast Track• “Broadway” Shift

Evidence Based Medicine

• LCME ED-6 provide EBM to students• ED provides real scenarios• So many different aspects of EBM

– Gold standards– Sensitivity, specificity, NPV– Intention to treat– Applicable to your patient population

Evidence Based Medicine

• Tailor the EBM to their future interests– Ortho – do open distal tuft fxs need OR washout?– Pediatrics – fever workup in children 8 weeks old?– Surgery – Does morphine prevent an accurate

abdominal exam?– Pathology – Will you ever raise your hand in a

plane if they ask for a doctor?

Evidence Based Medicine

• On-line Journal Club– Article posted online– Questions about article also posted online

• Design of study, sensitivity, specificity• Strengths, weaknesses• Apply to your patients

– Go over the article and questions on test day– Student feedback very positive

Enrichment Experience

• Optional experience• Student meets with EM faculty member twice in 4 weeks• Must cover the following

1. ECG Module• Clinical Vignettes with ECGs• Questions

2. Enrichment Case• Slow dissection of a case

» Pertinent positives and negatives in H&P» Work-up and treatment plans» Interpretation of labs and xrays

Enrichment Experience3. Interesting case selected by the student

• Student gives oral presentation• Discussion of differentials• Gives faculty member something new each block

4. EBM presentation• 10 min powerpoint presentation• Summary of ED case with a question• Journal article that answers question

Enrichment Experience

• Overall good student feedback– Love one-on-one interaction with faculty– Really like ECG module

• Problems– Large time commitment by faculty– Initial startup requires time / effort

• Creating ECG module• Creating Enrichment Case

Ultrasound

• No experience on other rotations• Radiology rotation

– Read ultrasounds– Don’t do them

• Perfect marriage – Disease process– Imaging– Procedure– Patient contact

Ultrasound

• Could provide ultrasound experience– Integrated into EM clerkship

• Pros – Every student gets exposure– Enhances rotation

• Cons– Time taken from other aspects of the clerkship– Not enough time to gain ultrasound competence

Ultrasound

• Solutions– Separate ultrasound rotation

• More time to focus on ultrasound techniques• However students not going into EM won’t do it• Another course you need to run

– Concentrate on one aspect during clerkship• Pelvic ultrasound for first trimester pregnancies• FAST exams in trauma• Peripheral IV insertion

Mid-Clerkship Feedback• Students appreciate feedback• Not given well in other rotations• Hard to do in 4 weeks• LCME requirement

Mid-Clerkship Feedback

• Wake-up call to students not motivated• More detailed the better• Solutions to correct deficiencies• Example of the feedback at Cooper

– Focus on 3 areas• Clinical work• Required patient encounters• Written patient notes

Mid-Clerkship Feedback

• Feedback on the Feedback

Do’s and Don’ts

• Do’s• Let them see cases in desired field in a limited basis (Ex – student going into ortho picking up ankle fracture)

– If prevent them from seeing cases they’re interested in» Unhappy student» Poor evaluations

– If you allow them to focus primarily on those cases » Miss out on true EM experience» Not really an EM rotation» Faculty will be resentful

• Need a nice mix

Do’s and Don’ts

• Do’s– Flexibility in scheduling

• Allow students to go to ortho conference, meet with advisor, etc.

• However students still need to make up shift• Must meet all requirements

Do’s and Don’ts

• Do’s– SAME expectations in seeing patients

• Don’t lower the bar for what is expected in clinical work • If you lower the bar, students going into EM unhappy• Short-changing these students

– Think what they are doing is ok – Will transfer this practice to actual patient care as interns

Do’s and Don’ts

• Don’t– Cut down shift number Jan-July

• Your faculty will pressure you into doing this• You may really want to do this• Unfair to non-EM student who rotated in July • Sends wrong message

Do’s and Don’ts

• Don’t– Allow faculty to ignore or let non-EM students

slide• Don’t allow faculty to send students home early• Don’t allow students

– To stop seeing patients early – Shadow residents

• Your chairman should support you in preventing this

Summary

• EM fulfills many LCME requirements• If not required EM clerkship, just wait• Motivations of the Unreachable

– Fulfill a requirement– Gain skills to become good house officers

• Techniques to Reach the Unreachable– Motivate– Personalize– Challenge

Summary

Methods to motivate / challenge the “Unreachable”1. Tailoring Sim to their interests2. Teaching Shifts3. EBM

• Shifts• On-line journal club

4. Enrichment Experience5. Ultrasound6. Mid-clerkship Feedback7. Can’t reach pathology students……lost cause