Bridging the Continuum Between UME and GME

Bridging the Continuum Between Undergraduate and Graduate Medical Education: A Feedforward Mechanism for Graduating Medical Students

Helen Morgan MD, Nicholas Kman MD, Jennifer McCallister MD, Sally Santen MD, PhD

Introductions

AMA Accelerating Change in Medical Education

Disclosures

Objectives

1. Review background literature on:– Undergraduate Medical Education (UME) to Graduate Medical Education (GME)

continuum– Competency based medical education– Current state of the 4th year of medical school

2. Describe how a clinical track based on ACGME competencies could bridge the chasm between UME and GME.3. Identify strategies for creating specialty specific milestones reports at your institutions.

4. Identify barriers and derive solutions to these “feedforward” concepts.

UME to GME Continuum

Undergraduate Medical Education (UME)

Graduate Medical Education (GME)

MK ,PC, Prof, SBP, PBLI, ISC



Competency Based Medical Education









+ACGME Milestones Project

What are the current issues of the M4 year?

In an ideal world, what would be the core objectives of the M4 year?

Current State of the Senior Medical School Experience

Issues We All Face

▪Only 4th year constants across institutions:▪Expectation that students will take USMLE Step 2 CS

and CK▪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.

Course offerings in 4th Year

▪Subinternships were required by 122/136 (90%).▪Capstone courses used to fill curricular gaps. ▪Revisiting basic sciences. ▪Many schools require rotations in specific settings (EM,

ICU, Ambulatory). ▪A growing number of schools require participation in

research. ▪Students work with underserved populations or seek

experiences that will be henceforth unavailable▪Electives to "audition" at desired residency sites.

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Course Offerings in the Fourth Year of Medical School: How U.S. Medical Schools Are Preparing Students for Internship.Elnicki, et al for the CDIM/Association of Program Directors in Internal Medicine Committee on Transition to InternshipAcademic Medicine 2015

Course offerings in 4th Year

▪Subinternships were required by 122/136 (90%).▪Capstone courses used to fill curricular gaps (80/136 (59%)). ▪Revisiting basic sciences. ▪Many schools require rotations in specific settings (EM (45%),

ICU (34%), Ambulatory (35%)). ▪A growing number of schools require participation in research

(51/136 (38%)). ▪Students work with underserved populations or seek

experiences that will be henceforth unavailable▪Electives to "audition" at desired residency sites.

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Course Offerings in the Fourth Year of Medical School: How U.S. Medical Schools Are Preparing Students for Internship.Elnicki, et al for the CDIM/Association of Program Directors in Internal Medicine Committee on Transition to InternshipAcademic Medicine 2015

Lyss-Lerman P, et al. What training is needed in the fourth year of medical school? Views of residency program directors. Acad Med. 2009 Jul;84(7):823-9.

▪Common struggles of interns:▪Lack of self-reflection and improvement▪Poor organizational skills▪Underdeveloped professionalism▪Weak medical knowledge

▪Competencies MS IV students should gain before starting residency▪Advanced clinical reasoning▪Near intern level independence▪Ownership of patient care

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Lyss-Lerman P, et al. What training is needed in the fourth year of medical school? Views of residency program directors. Acad Med. 2009 Jul;84(7):823-9.

▪“Organizing the curriculum with specialty-specific tracks could be explored by looking at specialty-specific data and expanding the interviews to include more PDs.”

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Walling A, Merando A. The fourth year of medical education: a literature review. Acad Med. 2010 Nov;85(11):1698-704.

▪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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Walling A, Merando A. The fourth year of medical education: a literature review. Acad Med. 2010 Nov;85(11):1698-704.

▪ACGME policies and practices will increasingly influence medical student education▪4th 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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What is the 4th Year? What Can it Be?

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Reddy ST, et al. ACE perspective paper: recommendations for redesigning the "final year" of medical school. Teach Learn Med. 2014;26(4):420-7.

▪Demonstrate that they have mastered objectives (based on 6 ACGME Core Clinical Competencies)▪Complete a required capstone course prepares

students for residency. ▪Structure their 4th year schedules to accomplish

specialty-specific objectives that prepare them for their intended specialty. ▪Engage in thoughtful inventory of training. Identified

gaps should be addressed through deliberate participation in rotations that address identified areas.

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▪Demonstrate that they have mastered objectives (based on 6 ACGME Core Clinical Competencies)▪Complete a required capstone course prepares

students for residency. ▪Structure their 4th year schedules to accomplish

specialty-specific objectives that prepare them for their intended specialty. ▪Engage in thoughtful inventory of their medical

school training. Identified gaps should be addressed through the deliberate participation in rotations that address the identified areas.

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▪4th year is a bridge between medical school and Residency: ACGME Competencies and AAMC Core Entrustable Professional Activities (EPAs) should be used to guide curriculum development.▪These competencies and specialty-specific

milestones and EPAs provide guidance to medical schools for the minimum level of competency for starting intern and can be used to design 4th-year curricula.

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helen morgan

this would be a nice transition slide to segue into discussing the UME/GME continuum

What are some potential solutions to bridge the gap between UME and

GME?

Discussion

Potential Solution: Clinical Tracks

Advanced Management inHospital Based Care

Advanced Management in Relationship Centered Care

Advanced Competency Elective Clinical Tracks: A longitudinal experience in a specialty or subspecialty designed to prepare students to be an intern/incoming resident by meeting entry level milestones in that field.

Other Electives (4 total required including Advanced Competency)

Flex

Gateway Activities

Part ThreeAdvanced

Clinical Management

HSIQ Project

What is a Clinical Track?

Required rotations Recommended rotations

Supplemental activities

Clinical Tracks—requirements

How long should a Clinical Track be?

▪Not fulfilled by a required number of clinical rotations ▪Represent a combination of clinical rotations &

experiences ▪Allow student to develop necessary skills

Clinical Tracks—evaluation

ACGME Milestone-based

assessments

Competency based evaluations

Currently available Clinical Tracks

▪Anesthesiology▪Emergency Medicine▪Family Medicine▪Internal Medicine (Preliminary Medicine included)▪Internal Medicine-Pediatrics ▪Obstetrics/Gynecology▪Pediatrics▪Psychiatry▪Neurology▪Radiology▪Surgery/Surgical Subspecialties (Preliminary Surgery

included)

Description of the EM Clinical Track

Recommended Courses▪EM at OSUWMC

▪MICU, SICU, Cardiology, or Pulmonary.

▪Chronic Care▪Geriatrics, HIV Patient Care, CHF, Adult Kidney Disease, Child

Abuse/Child Advocacy, Alcohol & Drug Abuse.

▪Clinical Track Electives▪Advanced Topics in Emergency Medicine (ATEM), Away Elective in EM

(Tox, Ultrasound, EMS, Peds EM), Ultrasound Advanced Competency, Emergency Preparedness Advanced Competency, Radiology, Anesthesia, Sports Medicine, Dermatology, Plastics, ENT/Ophtho (two 2-week electives if possible), Hand Surgery, Orthopedics.

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Description of the IM Clinical Track

Recommended Courses▪Emergency Medicine adult, any site ▪Any IM mini-internship- at OSU▪Any two different ambulatory practice environments, at least

one must be IM▪Electives▪Consider two sub-internships in IM (one early, one late), consult

experience in a specialty of interest. Consider the 2- week Medicine Boot Camp (general intern survival skills) and the 4-week “Advanced Competency in Procedural Skills”.

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Assessments—IM Clinical TrackAssessment Items Data PC

1PC2

PC3

PC4

PC5

MK1

MK2

SBP1

SBP2

SBP3

Mini I—Patient Care (CEO 1.2.1)Obtained accurate and pertinent histories

x

Mini I—Patient Care (CEO 1.2.2)Demonstrated physical exam skills and identified exam findings

x

Mini I—Patient Care (CEO 1.2.4)Assessed and managed undiagnosed problems

x x x

Mini I—Patient Care (CEO 1.2.4)Interpreted clinical situations and diagnostic tests

x x

Min I—Procedures (CEO 2.4)Performed general procedures of a physician

x

Mini I—Medical knowledge (CEO 2.1.2)Applied knowledge to understand patient care

x x

Mini I—Systems-based Practice (CEO 5.1) Facilitated an interdisciplinary and team approach to coordinate care

x

Mini I—Systems-based Practice (CEO 5.2) Utilized healthcare resources effectively

x

Questions?

Feeding Forward

M3 Clerkship Experiences

ResidencyVariable fourth year experiences

M3 Clerkship Experiences

ResidencyVariable fourth year experiences

Specialty Specific Residency

Preparation Electives

(bootcamps)

Clerkship Experiences

Residency

Surgery (2008)Obstetrics and Gynecology (2013)

Pediatrics (2015)

Variable fourth year experiences

Specialty Specific Residency

Preparation Electives

(bootcamps)

Advanced Clinical Skills in Obstetrics and Gynecology Curriculum

15 hours: Embalmed cadaver and fresh frozen operative cadaver sessions

14 hours: Case based obstetric and gynecologic cases

17 hours: Laparoscopic and open skills testing and teaching

17 hours: Flipped classroom sessions with case-based discussions

10 hours: Pre-operative simulation based curriculum

Decision to Incision

Case dis-cussions

AnatomySimulation

Lecture

Surgical skills

APGO TestDecision to Incision

Pelvic Exam with GTA

Pelvic Anatomy

Literature Assessment

Paging Suture Skills

Antepartum Care and Complications of Pregnancy XCare of Patients in the Intrapartum Period XCare of Patients in the Postpartum Period XObstetrical Technical Skills X XImmediate Care of the Newborn

Gynecology Technical Skills: Laparotomy X XGynecology Technical Skills: Vaginal X XGynecology Technical Skills: Endoscopy X XPeri-Operative Care XFamily Planning XAmbulatory Gynecology XCare of the Patient with Non-Reproductive Medical Disorders XAbdominal/Pelvic Pain X XAbnormal Uterine Bleeding XPelvic Mass XPelvic Floor Disorders X XFirst Trimester Bleeding XPatient Safety and Systems Approach to Medical Errors XCost-effective Care and Patient Advocacy XSelf-Directed Learning/Critical Appraisal of the Medical Literature XQI Process: Systematically analyze practice using quality improvement methods and implement changes with the goal of practiceimprovement Compassion, Integrity and Respect for Others XAccountability and Responsiveness to the Needs of Patients, Society, and the Profession XRespect of Privacy, Autonomy and Pt/Physician Relationship X

Communication with Patients and Families XCommunication with Physicians and Other Health Professionals XInformed Consent and Shared Decision Making X

Interpersonal and Communication

Skills

Competency

Assessment Method

Topic

Patient Care

Medical Knowledge

Systems Based Practice

Problem Based Learning and Improvement

Professionalism

Not assessed

Not assessed

Domain Competency

APGO TestDecision to Incision

Pelvic Exam with GTA

Pelvic Anatomy

Literature Assessment

Paging Suture Skills

Antepartum Care and Complications of Pregnancy XCare of Patients in the Intrapartum Period XCare of Patients in the Postpartum Period XObstetrical Technical Skills X XImmediate Care of the Newborn

Gynecology Technical Skills: Laparotomy X XGynecology Technical Skills: Vaginal X XGynecology Technical Skills: Endoscopy X XPeri-Operative Care XFamily Planning XAmbulatory Gynecology XCare of the Patient with Non-Reproductive Medical Disorders XAbdominal/Pelvic Pain X XAbnormal Uterine Bleeding XPelvic Mass XPelvic Floor Disorders X XFirst Trimester Bleeding XPatient Safety and Systems Approach to Medical Errors XCost-effective Care and Patient Advocacy XSelf-Directed Learning/Critical Appraisal of the Medical Literature XQI Process: Systematically analyze practice using quality improvement methods and implement changes with the goal of practiceimprovement Compassion, Integrity and Respect for Others XAccountability and Responsiveness to the Needs of Patients, Society, and the Profession XRespect of Privacy, Autonomy and Pt/Physician Relationship X

Communication with Patients and Families XCommunication with Physicians and Other Health Professionals XInformed Consent and Shared Decision Making X

Interpersonal and Communication

Skills

Competency

Assessment Method

Topic

Patient Care

Medical Knowledge



Professionalism

Not assessed

Not assessed

Domain Competency

Post-Match Milestones-based Medical Student Performance Evaluation (mMSPE)

Department of Obstetrics and Gynecology L4001 University Hospital South 1500 E. Medical Center Drive, SPC 5276 Ann Arbor, MI 48109-5276

DATE

PD name PD address Dear Dr. PD,

(Student name) successfully completed an Advanced Clinical Skills in Obstetrics and Gynecology elective (ie

bootcamp) at the University of Michigan in March, 2016. The content of this four-week residency preparation

course was mapped to the ACGME OBGYN level one milestones (see appendix for a description of the course

curriculum). Assessments from this course, as well as high stakes assessments from the medical school

curriculum were utilized to determine whether (student name) met level one milestones for 25 of the 28

competencies. (Student name) met or exceeded level one milestones in ___ of the 25 competencies, and his/her

performance is detailed in the table on the following page. He/She stood out for_______________________.

We hope that this information is helpful to you, and can be utilized as you build your incoming PGY1 residents’

milestones portfolio.

Sincerely,

Helen Kang Morgan, MD & Anita Malone, MD Co-Directors, Advanced Clinical Skills in Obstetrics and Gynecology Course


Domain Competency Level One Milestone Assessments

Did not meet

Met Exceeded

Patient Care Antepartum Care and Complications of Pregnancy

APGO Assessment, APGO Antepartum Teaching Case

Care of Patients in the Intrapartum Period APGO Assessment, APGO Abnormal Labor Teaching Case, Shoulder Dystocia Simulation Case

Care of Patients in the Postpartum Period APGO Assessment, APGO Postpartum Teaching Case, Postpartum Hemorrhage Simulation Case

Obstetrical Technical Skills Suture Skills, Pelvic Exam with GTA, Decision to Incision

Immediate Care of the Newborn NA Gynecology Technical Skills: Laparotomy APGO Assessment, Decision to Incision, Pelvic

Anatomy

Gynecology Technical Skills: Vaginal Decision to Incision, Pelvic Anatomy Gynecology Technical Skills: Endoscopy APGO Assessment, Decision to Incision, Pelvic

Anatomy Peri-Operative Care APGO Assessment, Pelvic Anatomy

Family Planning APGO Assessment, APGO Family Planning Teaching Case

Ambulatory Gynecology APGO Assessment

Care of the Patient with Non-Reproductive Medical Disorders

APGO Assessment, M4CCA, APGO Gynecological Procedures Teaching Case

Medical Knowledge

Health Care Maintenance and Disease Prevention

APGO Assessment, APGO HME Teaching Case, M4CCA EBM

Abdominal/Pelvic Pain APGO Assessment, APGO Endometriosis Teaching Case

Abnormal Uterine Bleeding APGO Assessment, APGO Normal and Abnormal Uterine Bleeding Case,

Pelvic Mass APGO Assessment, APGO Ovarian Neoplasms Teaching Case, APGO Endometrial Hyperplasia Teaching Case

Pelvic Floor Disorders APGO Assessment, Pelvic Anatomy

First Trimester Bleeding APGO Assessment, APGO Spontaneous Abortion Teaching Case


Patient Safety and Systems Approach to Medical Errors

M4 CCA, Paging Curriculum

Cost-effective Care and Patient Advocacy NA


Self-Directed Learning/Critical Appraisal of the Medical Literature

Literature Assessment, M4CCA

QI Process: Systematically analyze practice using quality improvement methods and implement changes with the goal of practice improvement

NA

Professionalism Compassion, Integrity and Respect for Others

Paging Curriculum, M4CCA

Accountability and Responsiveness to the Needs of Patients, Society, and the Profession


Respect of Privacy, Autonomy and Pt/Physician Relationship

Paging Curriculum

Interpersonal and Communication Skills

Communication with Patients and Families M4 CCA, Paging Curriculum, Decision to Incision

Communication with Physicians and Other Health Professionals

Paging Curriculum, Decision to Incision

Informed Consent and Shared Decision Making

Paging Curriculum, M4CCA, Decision to Incision



Did not meet

Met Exceeded






Immediate Care of the Newborn NA Gynecology Technical Skills: Laparotomy APGO Assessment, Decision to Incision, Pelvic

Anatomy

Gynecology Technical Skills: Vaginal Decision to Incision, Pelvic Anatomy Gynecology Technical Skills: Endoscopy APGO Assessment, Decision to Incision, Pelvic

Anatomy Peri-Operative Care APGO Assessment, Pelvic Anatomy





Medical Knowledge

Health Care Maintenance and Disease Prevention

APGO Assessment, APGO HME Teaching Case, M4CCA EBM

Abdominal/Pelvic Pain APGO Assessment, APGO Endometriosis Teaching Case

Abnormal Uterine Bleeding APGO Assessment, APGO Normal and Abnormal Uterine Bleeding Case,

Pelvic Mass APGO Assessment, APGO Ovarian Neoplasms Teaching Case, APGO Endometrial Hyperplasia Teaching Case

Pelvic Floor Disorders APGO Assessment, Pelvic Anatomy

First Trimester Bleeding APGO Assessment, APGO Spontaneous Abortion Teaching Case


Patient Safety and Systems Approach to Medical Errors

M4 CCA, Paging Curriculum

Cost-effective Care and Patient Advocacy NA


Self-Directed Learning/Critical Appraisal of the Medical Literature

Literature Assessment, M4CCA

QI Process: Systematically analyze practice using quality improvement methods and implement changes with the goal of practice improvement

NA

Professionalism Compassion, Integrity and Respect for Others


Accountability and Responsiveness to the Needs of Patients, Society, and the Profession


Respect of Privacy, Autonomy and Pt/Physician Relationship

Paging Curriculum

Interpersonal and Communication Skills

Communication with Patients and Families M4 CCA, Paging Curriculum, Decision to Incision

Communication with Physicians and Other Health Professionals

Paging Curriculum, Decision to Incision

Informed Consent and Shared Decision Making

Paging Curriculum, M4CCA, Decision to Incision


Did not meet

Met Exceeded






Immediate Care of the Newborn NA Gynecology Technical Skills: Laparotomy APGO Assessment, Decision to Incision, Pelvic Anatomy

Gynecology Technical Skills: Vaginal Decision to Incision, Pelvic Anatomy

Gynecology Technical Skills: Endoscopy APGO Assessment, Decision to Incision, Pelvic Anatomy

Peri-Operative Care APGO Assessment, Pelvic Anatomy





Feedback

▪Student:

“it is always nice to have a snapshot

summary of your performance”

“I definitely think the letter is useful,

both for my PD and for me… I did

not realize that I was weak in

ambulatory gynecology”

▪Program Director:

“wow this is great”

“I found this very very helpful”

“it’s a great educational handoff”

“The majority thought the proposed assessment provided new information not available on the traditional MSPE, and one concluded that the proposed letter would allow for early intervention for areas of weakness”

At your institution, how would you bridge the gap between UME and GME (specifically what information would you use?)

Ideally how should we handover information about low performing learners?

Concluding thoughts




Questions?

Bridging the Continuum Between UME and GME

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