Welcome to the Third Year!

1. Welcome to the Third Year! Warren Newton, MD, MPH Vice Dean for Education UNC School of Medicine June 24, 2013

2. Objectives • Review UNC SOM Outcomes for clinical years. • Describe educational rationale for year III, with the core competencies expected by the end of the year. • Describe what will be new this year, with points of emphasis • Give rules for living for third year; start planning for the fourth year

3. Step 2—UNC vs National

4. Match Post-Mortem • 94% UNC Match Rate (national average 93.7%) • 5 completely unmatched students • 2 Otolaryngology, 2 Pathology, 1 General Surgery • 4 partially unmatched students who needed PGY1 year • 2 Anesthesiology, 2 Ophthalmology, 1 Radiation Oncology • “Differential diagnosis” of unmatched students • Academic/professionalism challenges • Competitive specialty • Geography • Interview problems/ambivalence about specialty

5. MSIII—Educational Rationale

6. UNC Curriculum 2013-14

7. Educational Rationale—Year III • General Clinician • Active Learning • Get involved in care • Read on individual patients • Breadth of Experience • Varieties Patients/Specialties • AHEC—different systems, different patient mix

8. Grading • See Clerkship Websites • Clinical Evaluations • Shelf Exams—20% of grade • Honors – 35-40% • OSCEs, either formative or summative • End of Year (CPX, NBME II MK/CS)

9. ACGME Core Competencies • Practicing medicine requires more than medical knowledge • In late 90’s, organized medicine committed to explicit training in six domains of competence in residencies • All US residencies (and CME) focus training in medical knowledge, communication, clinical skills, professionalism, problem based learning, systems based practice

10. UNC Approach • ACGME core competencies plus one other, improving the health of populations • We have specifically defined the conditions all UNC students should see, inpatient and outpatient (the UNC 96) • We have defined the procedures all students should learn—e.g., BLS, ACLS, venipuncture and placing IVs

11. Medical Knowledge • Tests of knowledge are foundation of our current system • You will take tests for the rest of your life. • Assessment: shelf exams, clinical evaluations

12. Clinical Skills • History/Physical • Differential Diagnosis, Management Plan, Procedures • Assessment: Clinical Evaluation, OSCE, CPX

13. Communication Skills • Your reputation, patient satisfaction, pay and liability risk depend on communication skills • Not just with patients and residents/ attendings, but also staff • Oral and Written; including cultural sensitivity • Specialty and situation dependent • Assessment: Clerkship evaluations, OSCE’s, CPX

14. Systems Based Practice—How you take care of patients • WebCIS • CPOE • Care Management • Speech Therapy, etc • Referrals • Discharge Planning • Time-outs before procedures • Assessments: Ward Evaluations, OSCE/CPX

15. Systems Based PracticeBeing Aware of Systems

16. Problem Based Learning“Life Long Learners” • Case by case learning • Critical appraisal of literature and application to cases • Assessment: Clinical evaluations, special assignments

17. Improving the Health of Populations • Focus on populations (and not just the whole population) • Managing costs, quality and access • Both primary and subspecialty care • Diabetes, Asthma, CHF in primary care • Center of Excellence for Bariatric Surgery • ACOs and Bundled Payments for common major procedures • Assessment: Projects, Family Medicine Clerkship and others being piloted

18. ProfessionalismWhy all the fuss? • Social Contract: trade off of autonomy, privilege and financial security for self regulation • Increasing public concern that doctors and hospital systems have their own financial interests foremost…

19. Professionalism in Third Year • Honesty/Integrity • Confidentiality • Being on Time, Dress • Respect for patients, peers and staff • Seeking out and Learning from feedback… • Assessment: Clinical Evaluations • Remember, some professionalism issues are one strike you’re out…

20. What’s new this year…

21. Changes for 2013-14 • Evolving curriculum: critical incidents in inpatient medicine and ob/gyn + end of life in outpatient medicine, population health project in family medicine, procedures • CAR/CBSP implementation – Dr. McNeil • Spread of teaching practices—FM, OPM and Pediatrics • Consistent processes: direct observation of clinical skills in all clerkships; similar experiences across clerkships. Timely grades; Honors set at about 40%. Regular review of duty hours, timeliness and distribution of grades across clerkships/sites

22. Common Assessment Form

23. UNC 96 • Conditions all UNC students need to learn about in both inpatient and outpatient settings • Each attributed to a clerkship and in One45; ongoing improvements in user friendliness • You need to see/learn about them all, and we need to make sure that experiences are comparable across the state • At mid clerkship, you and your clerkship site leader will see/review what you’ve seen, and develop a plan if necessary • Be assertive; take responsibility for your education.

24. Clinical Log

25. Procedures • Essential to learn hands on skills and also about procedures... • Both psychomotor and interpersonal • You have to go to internship with competence in some of these (venipuncture, IVs, injections, throat swabs, paps) and exposure to others (lumbar punctures, etc) • Be assertive…

26. Mid-rotation Review • With clerkship or site director • Review • How is it going? • Performance so far… • Exposure to conditions and procedures—any adjustments necessary?

27. AHEC Infrastructure • Orientation • Student Health • Counseling Services • Needlestick Protocols • Housing Campus Directors Patricia White, MD Charlotte Bert Fields, MD Greensboro Robyn Latessa, MD Asheville Joseph Pino, MD Wilmington John Perry, MD Wake

28. Improving the Learning Environment

29. What is mistreatment? • Not being asked questions or to do things for patients • Rarely nurse vs. student • Rare physical violence, inappropriate sexual advances, or ethnic/racial slurs.

30. Disrespect forPatients or Students • “There are patients that residents and attendings make fun of… there is judgment about whether they have had too many kids, shouldn't have kids, about their social situation, about whether they can afford kids, and most often that they are large.” • Another student, seeing that the patient was being placed on the wrong side in the OR, made the resident aware of this and the resident said, “YOU’RE A MEDICAL STUDENT, YOU DON’T SPEAK! I DON’T EVEN WANT YOU TO THINK!!!!”

31. What is mistreatment? Specialty Bashing/Bigotry • “I was interested in ------- until my third year rotations. EVERY single specialty talked trash about --- physicians stating how frustrating and incompetent most of them were.” • “Because the residents knew that I did not plan to go into ---, they did not give me the opportunity to do many things in the OR despite my attempts to show enthusiasm and motivation.”

32. Ongoing work… Ombudsmen • Promoting positive learning environment, with emphasis on respect, engagement in patient care, and student participation in care (pagers, WebCIS, POE) • Zero-tolerance approach, with close to real time monitoring through clerkship evaluations, clerkship directors, chairs, and ombudsmen • Ensure safety of process for students, continue separation of grading from evaluation David Carl Charlotte Michelle Kane, PsychD Greensboro Dale Fell, MD Asheville John Perry, MD Wake David Gittleman, DO Wake Joe Kertesz, MA Wilmington Gary Gala, MD UNC Chapel Hill Rev. Barbara Bullock Charlotte

33. Next Steps—What you can do? • Get involved in patient care and your teams • If you have questions or concerns, let us know: contact your Site or Clerkship Director, the Campus Director, the Chair, the local or Chapel Hill Ombudsmen, Dr. Dent or me. • Grades handed in before we review; we will respond to every case, and report your name only with your permission.

34. Surviving and Thriving as an MSIII

35. Rules for Living • Keep in touch: Advisors, Dean Dent, Student Affairs Staff; day backs • Laptops—OIS walk-in, or email Jake Achey • Student Health – remember the waiver; take off for care • Any Difficulties--Communicate With Course Directors • Excuses through local staff, tracked by student affairs office

36. Academic Difficulty • 5-10% of Students • Differential Diagnosis • Test Taking • Clinical Skills • Professionalism Issues • Get In Touch With Us! • CBSP – Dr. Cheryl McNeil (mcneilc@neurology.unc.edu) • Advisors, Dr. Dent

37. Natural History of Specialty Choice • 50% in July of third year (1/2 will later change their minds…) • 75% by April Next Year • 5-10% will apply in 2 or more specialties • 5% will change after internship

38. Specialty Choice Timeline • College Advisors once a semester (phone/email fine) • December 13, 2013 Specialty Information Sessions • Meet with Career Goal Advisors before turning in 4th year schedule (3/14) • 2014 Summer/Fall MS IV • CPX, NBME Part II MK/CS • Audition Electives • Dean’s Letter Deadline—10/1/14 • ***Identify writers of recommendations this year

39. Year IV

40. Year IV Educational RationaleGetting Ready for Residency • Specialty Choice/Applications • Advanced Skills (AI, Critical Care, Specialty specific areas) • Schedule Flexibility/Choice • For Boards and Interviewing • Student Choice: Electives and Advanced Practice, Science and Medicine Selectives • You will never be as free again!

41. Students are extending medical school

42. Timelines • Remember the longitudinal course Introduction to Acute Care; includes ACLS and other procedures in specific clerkships • Take CPX at end of junior or beginning of senior year; must pass to graduate. • Take NBME II CK that summer, and take II CS as early as possible • MSPE (Dean’s letters) due earlier—October 1, which means interviews for letters will need to be earlier

43. Midpoint SurveyThis Week • New this year • Your feedback on first two years, curriculum, preparation for part I and help with career goals • Thanks!

44. GOOD LUCK!