Teaching Students from Jan to June: Reaching the Unreachable

1. Teaching Students from Jan to June:Reaching the Unreachable Sundip Patel, M.D. Drew Nyce, M.D. Council of Residency Directors Meeting April 3rd 2012 Atlanta, Georgia

2. 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

3. Qualifications • Cooper AAMC Graduation Survey Data

4. 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?

5. 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”

6. LCME & Unreachable • EM rotations • 36% mandatory, 14% selective in 20071 • 65% clerkships have EM rotation only in 4thyr1 • 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. AcadEmerg Med. 2007; 14: 629-634.

7. 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?

8. Just have them see the first pt on overnight ED shift

9. 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?

10. 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

11. 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??

12. 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

13. Key Motivational Factors for Unreachable Students • Fulfill a required rotation • Fulfill a required rotation • Fulfill a required rotation and………………….. • Where to go on vacation?

14. Key Motivational Factors for Unreachable Students • Things youneed 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

15. Key Motivational Factors for Unreachable Students • Things youneed 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

16. 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

17. 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

18. Methods to Reach the Unreachable • Simulation…..with a twist….. • Teaching shifts • EBM • Enrichment Experience • Ultrasound • Mid-Clerkship Feedback

19. 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

20. Simulation • Do students love running ACLS protocols? • YeungCJEM 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

21. 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 necrolysisbecome septic • Show images of TEN • Benefits • YOU cover septic shock • THEY love it

22. Simulation • Other examples • Optho – globe rupture with trauma sim • Ortho – long bone fxswith trauma sim • Radiology – pregnant trauma • Discuss radiation exposures • Other imaging options • Family Medicine • Simabout end of life • Breaking bad news • Pathology • Nothing you can do for them • Send them to the anatomy lab

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

24. Teaching Shifts • We have used for over 7 yrs • Teach 2-3 students on a 6 hrshift • 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

25. 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

26. 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

27. 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

28. 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?

29. 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

30. Enrichment Experience • Optional experience • Student meets with EM faculty member twice in 4 weeks • Must cover the following • ECG Module • Clinical Vignettes with ECGs • Questions • Enrichment Case • Slow dissection of a case • Pertinent positives and negatives in H&P • Work-up and treatment plans • Interpretation of labs and xrays

31. Enrichment Experience • Interesting case selected by the student • Student gives oral presentation • Discussion of differentials • Gives faculty member something new each block • EBM presentation • 10 min powerpoint presentation • Summary of ED case with a question • Journal article that answers question

32. 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

33. Ultrasound • No experience on other rotations • Radiology rotation • Read ultrasounds • Don’t do them • Perfect marriage • Disease process • Imaging • Procedure • Patient contact

34. 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

35. 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

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

37. 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

38. Mid-Clerkship Feedback • Feedback on the Feedback

39. 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

40. 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

41. Do’s and Don’ts • Do’s • SAMEexpectations 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

42. 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

43. 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

44. 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

45. Summary Methods to motivate / challenge the “Unreachable” • Tailoring Sim to their interests • Teaching Shifts • EBM • Shifts • On-line journal club • Enrichment Experience • Ultrasound • Mid-clerkship Feedback • Can’t reach pathology students……lost cause