New Basic Core I Design

1. New Basic Core I Design CLEVELAND CLINIC

2. Overall Design Structure Basic Core I at The Cleveland Clinic is a 16 week Core Designed to integrate learning by medical students of Internal Medicine, Surgery, Perioperative Care and Acute Pain. The 16-week Core is comprised of: 2 weeks of an integrated rotation preceding team-based Surgery: Anatomy refresher, Perioperative Care & Acute Pain, Surgery Clinics 6 weeks Surgery team experience (inpatient, OR, and clinic) 2 weeks Outpatient Internal Medicine 6 weeks Inpatient Internal Medicine Didactics (Student-driven Morning Reports and Point-Counterpoint sessions; Case-based seminars) Morning Reports facilitated by Surgeon and Internist who also form your Core Assessment Team Assessment � Core Assessment Team members meet with you every 4 weeks to review your logs and assessment Strongly held principlesStrongly held principles

4. Schedule on 8 week Surgery, Perioperative Care/Acute Pain Rotation (8-12 students) We had not modified our curriculum but students had modified their learning. Case � long and proud tradition of curriculum innovation Winter coat story Kept thinking it�s not brokenWe had not modified our curriculum but students had modified their learning. Case � long and proud tradition of curriculum innovation Winter coat story Kept thinking it�s not broken

5. Sample Schedule on Weeks 1-2 of 8-wk Surgery, Perioperative Care/Acute Pain Rotation in BCI at Cleveland Clinic We had not modified our curriculum but students had modified their learning. Case � long and proud tradition of curriculum innovation Winter coat story Kept thinking it�s not brokenWe had not modified our curriculum but students had modified their learning. Case � long and proud tradition of curriculum innovation Winter coat story Kept thinking it�s not broken

6. Schedule on 8 week Internal Medicine Rotation(2-3 students in each of 4 �tracks�)

7. Typical Week on Inpatient IM

8. Conferences/Didactics Friday AMs - all students on BCI � conferences Morning Report: Fridays, 7:00 am - 9:00 am (except the 4 wks of Point/Counterpoint) 7-8AM: Surgery 8-9AM: Internal Medicine Student presentations, w/ clinical reasoning in a group of 5-8 students, w/ faculty facilitator IM Morning Report: Presentation and clinical reasoning Development of question by group, to be answered using evidence-based medicine techniques, by presenters of the week Cram for the boards; forget for the wardsCram for the boards; forget for the wards

9. Conferences/Didactics POINT/COUNTERPOINT: Fridays, 7:30 am - 9:00 am (4 sessions over 16 wks, in lieu of Morning Report) Topics/Debates: GERD (Nissen fundoplication vs. Long-term medical therapy for severe GERD) Ulcerative colitis (Proctocolectomy vs. Medical management and colonoscopic surveillance) Atrial fibrillation/Bridging anticoagulation (�Bridging� with low molecular weight heparin vs. Simply holding warfarin peri-operatively) Hereditary Breast Cancer Risk (BRCA2) (Close clinical and radiologic surveillance, vs. Prophylactic bilateral mastectomy and oophorectomy)

10. Conferences/Didactics POINT/COUNTERPOINT (Cont.) Presentation: Four student �debaters� (2 on each side of the debate, one reviewing basic science, and the other clinical evidence) will present arguments supporting either surgical or medical management (10 min. each) Group Discussion: All students on the core are to have read the articles in order to fully participate in the debate Fellow students and faculty mentors will critique the arguments and data Students on the Core will discuss how they would counsel a patient who presents with a similar problem

11. Conferences/Didactics CASE CONFERENCE SEMINARS/CLINICAL ROUNDS: Fridays, 9:15 am � 11:30 am IM, Surgery, Anesthesia, Periop/Hospital Medicine, or multi-disciplinary approach to clinical topics In addition to readings, students will draw on experiences from their clinical rotations Brief clinical scenarios will be given Students will work through the history, physical exam, diagnostic work-up, assessment, and treatment for cases

12. Conferences/Didactics CASE CONFERENCE SEMINARS/CLINICAL ROUNDS � Topics Prevention & Treatment of post-operative complications Acute Pain Abdominal Pain Acute and Chronic Renal Failure, Acid-Base/Electrolytes Chest Pain Dyspnea/Cough/Hemoptysis Hematemesis/Dysphagia

13. Conferences/Didactics CASE CONFERENCE SEMINARS/CLINICAL ROUNDS � Topics Rectal Bleeding Venous Thromboembolism and Peripheral Vascular Disease Wound Care and Soft Tissue Infection Diabetes and Hypertension Obesity, Thyroid and Parathyroid Disease Jaundice Breast Pain and Nipple Discharge

14. Design Features Orientation Held the first Monday morning of the Core Orientation to overall schedule, and each discipline component: IM, Surgery, Acute Pain, Perioperative Care (Anesthesia and Hospital Medicine) Introduction to our EMR (may be given online) Expectations specified: # of patient encounters, patient logs, requesting assessments, role in clinical experiences and in conferences

15. Design Features Learning Relationships and Faculty Supervision Supervision by attending physicians This includes direct one-on-one supervision on all the outpatient experiences, and in the Operating Room Students part of team on inpatient services (Surgery and IM), including residents and attending physicians Inpatient Internal Medicine You are to present all new patients to your attending Submit a copy of your write-up (daily online in EMR) Students receive feedback about presentations and write-ups from your attending (ASK if not receiving) Teaching Attending/Bedside Rounds: one time per week when on General IM Inpatient service to augment teaching given by your team attending

16. Design Features Direct observation Occurs in many settings Especially on outpatient IM Ask attendings and residents to observe you Timely, specific feedback part of Lerner College culture

17. Design Features Feedback and Assessment Student reports of clinical encounters (patient logs), written and oral presentations, assessments from faculty and residents, and an oral examination in surgery will be used to assess student performance Discipline Leaders will review student assessments frequently, ensure you are having adequate experience and assessment by faculty Core Assessment Team (Internist and Surgeon who are your morning report leaders) will meet w/you every 4 wks to monitor progress Students are to submit learning plans every 4 weeks (prior to the CAT meeting) Mid-rotation feedback will occur for IM and Surgery Disciplines (weeks 4 & 12) You are required to complete a patient log for each meaningful patient encounter You are required to request assessments Every meaningful pt encounter on Surgery Every new admission on Inpatient IM Every half-day on Outpatient IM (group pt logs) Oversee students� patient logs and assessment data Assure that students have assessment data from faculty that will provide information to make accurate assessment decisions Ensure that students are getting adequate patient interactions in each discipline (and to advise supplemental clinical or online experiences to fill in gaps) You are required to complete a patient log for each meaningful patient encounter You are required to request assessments Every meaningful pt encounter on Surgery Every new admission on Inpatient IM Every half-day on Outpatient IM (group pt logs) Oversee students� patient logs and assessment data Assure that students have assessment data from faculty that will provide information to make accurate assessment decisions Ensure that students are getting adequate patient interactions in each discipline (and to advise supplemental clinical or online experiences to fill in gaps)

18. Design Features Inpatient-outpatient balance Internal Medicine 6 Weeks Inpatient IM 2 Weeks Outpatient IM Surgery 5 Weeks Inpatient Surgery (6 Weeks of Team-Based Surgery, Clinic should occur during total of about 10-12 half-days of this) 2 Weeks Outpatient Surgery (Initial �week� (5-6 half-days) then 10-12 Clinics during Surgery Team rotations) Perioperative Care and Pain 75-80% Inpatient (Airway and Hemodynamics, Acute Pain, PACU) 20-25% Outpatient (IMPACT Clinic)

19. Design Features On-Call Schedules Internal Medicine � Call during Inpatient IM Call is overnight every 4th night, no call over weekend between your two inpatient rotations Exception: �Long� Call on Thursday nights is until 9 p.m. to accommodate Friday conferences 8-10 calls over the six weeks of Inpatient Medicine You should do a thorough work-up of one to two patients admitted on each of your team�s call days (�Day call� until 4pm on weekdays 2 days before & 2d after �long call� � should usually work up one new pt)

20. Design Features On-Call Schedules Surgery Students will take in-house call on weekends during their surgery team rotations A schedule of calls (4-5 calls) will be arranged. Students are expected to contact the Senior resident in house on the weekend The goal is to assess new patients for emergency consultations and to assist the residents in evaluating ward patients On call patient encounters should be submitted to the resident involved for assessment

21. Design Features - Integration of Advanced Core Learning Objectives Perioperative Care & Acute Pain Clinical Conditions and Diagnoses in BCI Acute Pain Airway Management Peri-operative Care Objectives from current Advanced Core map onto these Objectives Delivered by: Clinical rotations in the OR, PACU (Post-Anesthesia Care Unit), Acute Pain, and IMPACT (pre-operative Medical Assessment) Case conference seminars on Acute Pain, and on Perioperative Care (Prevention and Treatment of Post-operative complications) Point-Counterpoint: Anticoagulation bridging peri-operatively

22. Design Features Exposure to career options Anesthesia: Several components of Anesthesia, including Pain Management Internal Medicine: Outpatient, Comprehensive, Hospital-based General IM; Consultative IM; Several IM Subspecialties Surgery: Several subsets of General Surgery, many Surgical Subspecialties

23. What are the unique features of this rotation? Integration of outpatient and inpatient surgery Anatomy refresher before surgery Strong peri-operative evaluation and care component, with hands-on experiences Most robust Outpatient IM in system: Experience Outpatient and Comprehensive IM Bedside Teaching Attending Rounds on Inpatient Internal Medicine Evidence-based Physical Exam & Clinical Reasoning Student-Directed conferences: Morning Report (Presentation and Clinical Reasoning) Debates on controversial issues in Medicine and Surgery (Point/Counterpoint) Robust Assessment System, helping adjust learning plan and experiences

24. Cleveland Clinic New Basic Core I Design Team BC I Director: Dr. Mark Mayer Internal Medicine: Drs. Seema Baranwal (Discipline Leader), Adele Fowler, David Gugliotti Surgery: Drs. Matt Walsh (Discipline Leader), Matt Kroh, Tracy Hull Anesthesia/Acute Pain: Dr. Sam Irefin Perioperative Care/Hospital Medicine: Dr. Frank Michota Anatomy: Richard Drake, PhD Coordinators: Core: Gwen Dove IM: Linda Krencik Surgery: Sharon Preztak