Beyond the Clerkship: Advanced Competencies and the Senior Year of Medical School Training

Dr. David Wald, DO

Dr. Nicholas Kman, MD

@drnickkman

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).

The Past

The Past

The Past

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.

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.

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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.

The 4th Year of Medical School

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What do the Program Director’s think?

Semi structured interviews

30 PD’s, broad range of specialties

3 EM PD’s

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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

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Competencies

Competencies MS IV students should gain before staring residency

Advanced clinical reasoning

Near intern level independence

Responsibility and reliability

Ownership of patient care

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Recommended rotations

Subinternship in field in which applying

IM subinternship

IM subspecialty

Critical care

Ambulatory care

EM

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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

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Expert recommendations for MS IV curriculum

English language literature review (1974-2009)

66 publications

40 – Aspects of MS IV education

26 – Overview / general reviews

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Three recurring themes

Lack of clarity about the educational purpose

Problems in curricular content and organization

Concerns about the educational quality of courses

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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

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Problems in curricular content and organization

Recommendations from specialty organizations

College and pathway programs

Accelerated programs

Specific MS IV courses

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Concerns about educational quality

No publications specifically addressing educational quality

Unclear course objectives

Lack of structured learning

Grade inflation

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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

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Description of the impact of an innovative MS IV curriculum

“College Program” UCLA – implemented 2001

Improved career advising and mentoring

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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

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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

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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

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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

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“Undergraduate Rotations” Listing from www.saem.org

Ultrasound, International, Disaster Medicine, Geriatric EM, Toxicology, and Pediatric EM

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What does VSAS say?

353 Electives under “Emergency Medicine”

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What does VSAS say?

353 Electives under “Emergency Medicine”

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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

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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

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

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

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

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

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.

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 of Emergency Medicine, v. 12 issue 4, 2011, p. 543-50.

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 Code Training

EMS and Emergency Preparedness Training (MedFlight)

Toxicology

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

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

Course Components

Chest Tubes

Adult and Pediatric Airway

Procedural Teaching in Clinical Skills Lab

Ultrasound

EMS Lecture/Experience

Mentorship

Research or Q/A Project

Course Components

Chest Tubes

Adult and Pediatric Airway

Procedural Teaching in Clinical Skills Lab

Ultrasound

EMS Lecture/Experience

Mentorship

Research or Q/A Project

Course Components

Chest Tubes

Adult and Pediatric Airway

Procedural Teaching in Clinical Skills Lab

Ultrasound

EMS Lecture/Experience

Mentorship

Research or Q/A Project

The Future

The Future: Competency Based Education

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.

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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

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Advanced Competencies

Professionalism

Bioinformatics

Health Coaching

Health Literacy & Healthcare Disparities

Genetics

Quality Improvement/Patient Safety

Emergency Preparedness and Disaster Response

Global Health

Latino Health

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Advanced Competencies

Professionalism

Bioinformatics

Health Coaching

Health Literacy & Healthcare Disparities

Genetics

Quality Improvement/Patient Safety

Emergency Preparedness and Disaster Response

Global Health

Latino Health

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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.

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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!

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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.

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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 EmergMed 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.

Questions and Discussion?

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Questions and Discussion?

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