Envisioning Medical Education

1
Envisioning Medical Education

• Emil R. Petrusa, Ph.D.
• Presentation to ADE
• University of Virginia School of Medicine
• February 8, 2006

2
Envisioning

• Context is competency-based education
• Focus is undergraduate medical education
• UGME as a system

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Goals

• To stimulate thinking out of the box about
  UGME
• To inspire action for UGME
• To clarify the notion of competency-based
  medical education

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Competency-based Education

• Why consider this?
• What is it?
• What would assessment look like?
• What would be possible?

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Why consider this?

• ACGMEs 6 Core Competencies
• LCME outcome data
• NIH study w/stent practice
• Malpractice cases
• Simulation-based training

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What is it?

• Examples
• Assessment Testing framework
• Clinical Standard of practice
• ACGME Domains of performance
• Performance judged against an expected or desired
  outcome
• Assessment any pass mark independent of
  performance of other test takers
• Clinical mutually agreed upon actions for
  adequate care of a patient

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Two Assessment Examples

• Physiology test
• Clinical Performance Examination

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(No Transcript)
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Physiology Test

• of organ systems 5
• of items 70
• Number of students 103
• Pass mark 62 correct (43 items)
• students passing 100 (97)

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Physiology Test

• If 62 correct is pass mark for each organ system
  . . .
• Number failing 0 organ systems 49
• Number failing 1 organ system 25
• Number failing 2 organ systems 17
  54
• Number failing 3 organ systems 10
• Number failing 4 organ systems 2
• GI organ system Number failing (62 correct)
• GI (21 items) 2
• GU (20 items) 26
• Endo (19 items) 3
• Exercise Phys (7 items) 27
• Cardio w/aging (3 items) 45

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Clinical performance

• Common problems or complaints that all students
  completing required clerkships should be able to
  handle
• Clinical performance examination (CPX)
• 15 cases
• Skill components (percent of points)
• Relationship Communication History-taking
• Physical exam Assessment Plan
• Unit of analysis cases (patients)
• Criterion referenced (competency?) - based pass
  mark
• A case critical actions for clinical
  competence
• The test 11 of 15 cases (Hofstee method)

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Critical Actions

• Actions must be done for minimal clinical
  competence (not educational)
• If all done, then case is passed.
• If any one not done, case is failed.

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Marvin Adams

• Mr. Marvin Adams is a 67 yo man in the hospital.
  Two days ago, he underwent elective transurethral
  resection of the prostate (TURP). The surgery
  was uncomplicated and he was scheduled to be
  discharged tomorrow.
• Thirty minutes ago, he developed chest pain and
  was moved to a treatment room on the same ward.
  The urologist ordered oxygen at 2 liters per
  minute and morphine 4 mg.IV. He also asked the
  nurse to summon you to do an evaluation. The
  following ancillary tests have been ordered
  EKG, CXR, Room Air, ABG, CBC, electrolytes.
• Blood pressure 122/70 mn Hg
• Pulse 76/min.
• Respirations 20/min.

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Clinical Skills

• Relationship
• Communication
• History-taking
• Physical examination
• Assessment Plan

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Critical Actions for Marvin Adams

• Rating 3 or more on all 3 items for
  Relationship 1
• Rating 3 or more on 4 of 5 items for
  Communication 1
• ID 4 of 9 cardiovascular risk factors
  History-taking 4
• Auscultates 4 areas of the precordium Physical
  Exam 1
• The ECG is most consistent with a diagnosis
• of Assessment Plan 1 0 a.
  pericarditis
  
• 29 b. anterior myocardial infarction
  
• 11 c. non-specific ST segment T wave
  changes
• 58 d. inferior myocardial infarction
  
• 1 e. normal ECG
• Total CAs 8
• Tolerance - 1
• net CAs 7

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Students Missing Critical Actions

• Relationship 2 students
• Communication 2 students
• History-taking 0 students
• Physical Exam 14 students
• Assess Plan 12 students

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CPX Cases

• Man with back pain
• Boy with a cough
• Woman asking to drive
• Man with sexual problem
• Older woman on many meds.
• Follow-up bicycle accident
• Woman with fatigue

• Man with a headache
• Man post-TURP in hosp
• Woman without NR/DNI orders
• Child brought to ER
• Man with cough
• Woman with headaches
• Woman with severe abdominal pain

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Initial Results

• Too many students failed each case
• Too many students failed the test
• Houston, we have a problem

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Class Outcome
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CPX Solution

• Create tolerances for each case
• Could miss any 1, 2 or 3 critical actions and
  still pass a case.
• Analysis of previous year to determine tolerances
  for each case
• We fudged competence to be acceptable

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What would you think if

• Using clinical competence as the perspective to
  set a pass mark for each case .
• 50 of your 3rd year students performed
  minimally competently on half of the 15 cases?

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CPX in the UGME System

• Common problems
• Assumption If you know complicated, easy will
  not be a problem
• Focused workups
• Full head-to-toe physical exams with complete ROS
• Diagnostic reasoning and next steps thinking
• For resident-level learning (just extend
  training)
• Learning activities in the educational system do
  NOT align with assessment strategy.
• Just live with inconsistency for competence
• Justify by practice for USMLE Step 2 CS

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Competence without change

• Confessions of an educational hit man
• Declare competency as the new framework
• Modify rating scales with behavioral anchors
• Admonish students to work harder
• Use ACGME core competencies to orient student
  evaluations
• Curriculum committee commissions task force for
  recommendations
• Declare victory for competency because
• students get good residencies,
• percent of top 3 is high,
• pass rate on boards is good,
• no residency program director calls to complain

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System Redesign

• Will take leadership vision and committed
  action
• Shift in educational values
• Current values (mostly implicit)
• Real patients are best
• Participating with team is motivating
• Maximum weeks on core specialties
• Competence possible, but not clinical

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What would be possible if .

• students performed as extenders in 4th year
• Similar to old rotating internship
• Seeing patients q 15 mins.
• One doctor supervises 4 students
• How many weeks to learn how UVA hospitals and
  clinics get their work done?
• Understanding physiology occurred at graduation
• Aware of cutting edge separated from core

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• What if medical school were 3 years?
• Debt reduction
• Younger and faster to practice
• What if last 6-8 months were contributing to
  practice plan
• What would prep look like?

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Leadership

• Scary
• Lonely
• Risky
• Uncertain
• Insufficient data
• Under funded
• Scrutiny by others for mistakes

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Changing clinical education

• Push back from
• Dept chairs
• Residency program directors
• Residents
• Students
• Colleagues
• Accreditation

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• Thank you for your attention.
• Lets talk.