ThefollowingslidescontainatemplatethatillustratesthegeneralformatusedforaY3orY4clerkshipreview.Inthe“notes”sectionofsomeslidestherearefurtherinstructionstoclarifywhatisneededforaparticularsectionofthereview.

Thecomponentsoftherevieware:1. revisitprioractionplanandinvestigateprogress2. assesscourseobjectivesincludingessentialskills/diagnoses3. evaluateplanned/unplannedredundancy4. assesspedagogy5. evaluateassessmentofcourseobjectives6. reviewmeasuresofquality(e.g.courseevaluations)

TheDeansoftheappropriateyear,ortheiragents,willserveastheteamleaderforeachcoursereview.Theresponsibilitiesoftheteamleaderare:

1. Assigntaskstothefacultyandstudentteammembersandconveydeadlinesforwhentheworkneedstobedone.

2. Recruitmembersforthereviewteamifnecessary(typicallyteammemberswillbeassignedbytheMEC).

3. Contacttheclerkshipdirectortoarrangeameetingwiththeteamtodiscusstheclerkship;informtheclerkshipdirectorofthedatethereviewwillbepresentedattheMECmeetingsotheycanputitontheircalendar/indicateavailability.

4. CollectalltheworkcompletedbytheteammembersandcollateintoonePowerPointpresentation;collecttheactionplanfromtheclerkshipdirectorandinsertitattheendoftheslides;sendtheslidestoRachel2weeksbeforetheMECmeeting.

5. PresentthefinalrecommendationsofthesubcommitteeattheMECmeeting(lastfewslides)

ReviewofNeurologyClerkship

• ClerkshipoccursinYear4(somestudentsonYear3)• ClerkshipDirector

– JustinMowchun,MD• ClerkshipCoordinator

– MaghanPorter• ClerkshipLength– 4weeks,12cycles• Sitesused

– DH,DHpeds,VA,DH-Manchester,CPMC,MayoJacksonville

• ClerkshipwaslastreviewedinJune2014• ReviewDate/Team:6/28/16:JohnDick(MEC,GAME),NormSnow(MEC),Glenda

Shoop(OME),LynnSymonds(4th yearstudent– MEC),AlisonRicker(OCE)

ActionPlanfromPriorReview

• NeurologicExam:ThesubcommitteeexpressedinterestinbetterunderstandinghowthistopicwascoveredacrosstheGeiselcurriculum.– Response:willmakeaconcertedefforttomeetandiscusspreparationduringOnDoctoringwiththeOnDoctoring

Directorstoprovideoversightandfeedback.Inparticular,wewillshareourneuroexam checklist.- DONE• CourseObjectives – thesubcommitteerecommendedchangingasfollows:

• Delete#15“meetprofessionalresponsibilitiesfully”asthisseemsmuchtoobroadandiscoveredinmoredetailinsubsequentobjectives

• Delete#18“Describebarrierstoaccesstobasichealthservicesanditseffectonvulnerablepopulations”asthisisnotafocusoftheclerkshipyouarenotuniformlyorformallyassessingorteachingthisobjective.

• Delete#19“Contributeconstructivefeedbackduringpeerreview”asyouarenotdoingthisatthistime.• Delete#24“Identifytheroleofthephysicianinaddressingthemedicalconsequencesofcommonsocialand

publichealthfactors,andtoadvocateforoptimalcareinneurologicallyillpatients”asyouarenotuniformlyassessingorteachingthis.

– Response – willmakeallchanges- DONE

• Werecommendthatyouintegratecosteffectiveapproachofbrainimagingintoyourexistingmoduleonbrainimaging.– Response – willincludeaclearmoduleconcerningcostandbenefitduringtheHeadachelectureofthemedstudent

series.ThiswillbeavailableinPPTformforCPMC,VAandManchesterstudentswhodonotattendlecturesatDHMC.- DONE

ActionPlanfromPriorReview• Decreasenumberofgradedwriteupsfrom4to2andaddcomponentofreportingonthe

evidencebasefordiagnosticortreatmentorprognosis.Committeefeltthat4gradedwriteupswasexcessiveforthis4weekclerkshipandthatevidencebasecouldreceivegreaterweight.– Response – willmakeallchanges- DONE

• Adjustscheduletobetterallowstudentstomorefullyparticipatewhileonoutpatientclinics.

• Discussissueoftardyorabsentlecturerswithyourstaffandchair– Response – willinstituteregularscheduledpatientsforstudentstobediscussedwith

clinicattending.Chairtomakecleartheimportanceoftimelinessoflecturerstoallfacultyinvolved. - DONE

• Pleasemakesuretoemphasizetheinterprofessional natureofroundssothatstudentsnotonlywitnessandparticipatein,butalsoappreciatetherolesofthevariousteammembers.AssigningPT/OTcoordinationofcareasanessentialskillmayhelpwiththis.– Response – willmakeconcertedefforttoincludeweeklyOT/PTroundswithstudents

residentsattendings nursingandOT/PTstaff.Willalsomakestrongeffortstoincludenursingstaffinmultidisciplinarycasediscussions. - DONE

CourseObjectivesLearningObjective Assessment LearningActivity

1 Apply current clinical and translational sciences to diagnosis and treatment questions in patient care.

PerformanceEvaluationsWriteUpsCaseDiscussionsNBMEexam

Wards/ClinicsWriteUpsCaseDiscussions

2 Apply current knowledge of disease prevention, risk factor modification, end-of-life and palliative care, substance abuse, pain management, medical ethics, and medical-legal issues to clinical problems in neurology.

PerformanceEvaluationsWriteUpsCaseDiscussionsNBMEexam

Wards/ClinicsWriteUpsCaseDiscussions

3 Apply knowledge about the impact of social, economic, cultural, and personal factors on health to clinical problems in neurology.

PerformanceEvaluationsWriteUpsCaseDiscussionsNBMEexam

Wards/ClinicsWriteUpsCaseDiscussions

4 Establish comfortable and mutually respectful student-patient and student-family relationships with diverse patients and families and establishing a respectful basis for the doctor-patient relationship. (redundant, would strike words in red)

PerformanceEvaluationsSkillsForm

Wards/clinic

CourseObjectivesLearningObjective Assessment Learning

Activity5 Interview patients skillfully, utilizing a neurologically focused history. Performance

EvaluationsSkillsForm

Wards/clinic

6 Examine neurologic patients skillfully and respectfully, with appropriate attention to student cleanliness, infection control, and patient comfort and privacy.

PerformanceEvalSkillsFormFormalNeuroExamAssessement

Wards/clinic

7 Define and prioritize the patient’s problems accurately and generate an appropriate differential diagnosis for patients with disorders of the nervous system.

PerformanceEvaluationsCaseDiscussionsNBMEexam

Wards/ClinicsCasePresentationsDiscussions

8 Explain the indications, complications, limitations, and performance of a CT scan, MRI, electrodiagnostic studies (EMG, NCV, evoked potentials and EEG) and lumbar puncture.

PerformanceEvalsNBMEExam

Wards/ClinicsCaseDiscussions

9 Correctly identify, and prioritize, common abnormalities on CT, MRI and spinal fluid analysis.

PerformanceEvalsNBMEexam

Wards/ClinicsCaseDiscussions

CourseObjectivesCourse Objectives Assessments Learning

Activities

10

Communicate effectively with patients and families especiallywhen special barriers to communication exist, including cultural, linguistic or those based on a neurologic disorder (e.g. aphasia).

PerformanceEvalsSkillsForm

Wards/ClinicsCaseDiscussions

11

Assist patients appropriately in understanding their treatment options. To assist patients appropriately in understanding their prognosis. (would change to make a single sentence…”Assist patients appropriately in understanding their treatment options and prognosis.”)

PerformanceEvals Wards/Clinics

12

Communicateeffectivelyandcollegiallywithphysiciancolleaguesandothermembersofthehealth-careteamverbally,inwritingandintheelectronicmedicalrecord.

PerformanceEvalsWriteUpsSkillsForm

Wards/ClinicsWriteUpsCaseDiscussions

13

Behaverespectfullyandresponsiblytowardspatients,families,colleagues,andallmembersofthehealth-careteamandempathizeandberespectfulofeachpatient

PerformanceEvalsCasediscussions

Wards/Clinics

CourseObjectivesCourse objectives Assessments Learning Activities

14

Adheretohighethicalandmoralstandards,acceptresponsibilityforpersonalactions,acceptconstructivecriticismandrespectpatientconfidentiality.

PerformanceEvals,WriteUps

Wards/Clinics

15

Take responsibility for his or her own medical education, and develop the habits of mindfulness and reflection.

PerformanceEvals,WriteUps

Wards/Clinics

16

Identifyandcriticallyevaluaterelevantinformationaboutevidence-based,cost-consciousstrategiesinthecareofpatientsandpopulationsandtoapplythistopatientcareandtocontinuousupdatingofskills.

PerformanceEvalsCaseDiscussionsWriteUps

Wards/ClinicCaseDiscussionsWriteUps

17

Assess the effect of social environment on clinical care and outcomes and apply the concepts of improving quality of care, patient safety, and value of care in neurologically ill patients.

PerformanceEvalStudentCaseDiscussions

Wards/Clinics

CourseObjectivesCourse objectives Assessments Learning Activities

18

Identify appropriate resources to support patient care and to collaborate effectively with all members of the inter-professional team.

PerformanceEvals Wards/Clinics

19

Describe how healthcare is currently organized, financed, and delivered, and the larger environment in which healthcare occurs and the impact on neurologically ill patients.

CourseObjectives– Comments• Appropriatenumber,understandable• Coversover-archingGeiselcompetencies

FormatofCourse&SessionObjectives• Courseobjectivesareprovidedinthesyllabus• Courseobjectivesarewritteninthecorrectformat• Sessionobjectivesareprovidedinthecoursematerialsand

areprovidedinIlios• Sessionobjectivesarewritteninthecorrectformat

HowdoY1/2coursesprepareforY3• Questionsaskedatendofclerkship– 1=poorand5=excellent

Results:Overall

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

FM MED OB PEDS PSYCH SURG GAM NEURO

13-14

14-15

15-16

Results:Communication

00.51

1.52

2.53

3.54

4.55

FM MED OB PSYCH SURG PEDS GAM NEURO

13-14

14-15

15-16

Results:PE

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

FM MED OB PED PSYCH SURG GAM NEURO

13-14

14-15

15-16

Results:MedicalKnowledge

00.51

1.52

2.53

3.54

4.55

FM MED OB PED PSYCH SURG GAM NEURO

13-14

14-15

15-16

IssuesofRedundancy• Aretheremajorissuesofredundancywithothercourses?– Ilios searchforneurologicaltopics(neurologicexam,stroke,dementia,HeadCT)showoverlapwithYear1Neuroscience,Year2SBM(NeuroandPsychandPBL)aswellasYear1andYear2On-Doctoring.Alloftheseseemedlikeappropriateprimingand/orrepetition.

– DementiaisasharedEssentialConditionwithGeriatricsbutthisseemsappropriate.

EssentialSkills

• Aretheseappropriateforthisclerkship?Yes• Wouldyouaddorsubtractany?No• Aretheremajorissuesofredundancywithotherclerkships?Appropriate.

Skill Duplication LevelofPerformanceCoordinatecarewithPT/OT Withsupervision

Counseling:Medications Medicine;GAM

CThead

HPI

MentalStatusExam Psych

MRIhead

NeurologicExam

Oralpresentation,ambulatoryencounter

Oralpresentation,initialinpt encounter

Writtennote,initialinpt encounter

EssentialConditions

• Aretheseappropriateforthisclerkship?Yes

• Wouldyouaddorsubtractany?No

• Aretheremajorissuesofredundancywithotherclerkships?Appropriate

Condition Duplicationwithotherclerkship Level ofEngagement

BrainTumor ManagewithAssistance

CerebralorSAhemorrhage ManagewithAssistance

Coma,stupororalteredMS ManagewithAssistance

Dementia yes(GAM) ManagewithAssistance

Headache Yes(PEDI) ManagewithAssistance

MultipleSclerosis ManagewithAssistance

Paralysis(ALS,GBS,etc) ManagewithAssistance

PeripheralNeuropathy ManagewithAssistance

Seizure,epilepsy ManagewithAssistance

TIAorstroke ManagewithAssistance

Vertigo ManagewithAssistance

ExplorationofEthicsandCulturalCompetencies

• SessiononBrainDeathethicsbeingplannedwithDr.Bernat– Dr.MowchuntonotifyBillNelson

CourseLearningOpportunities• Clinicalexperiences

– 4weeksinpt andoutpt mix;2callnights(until10pmatDH)

• SmallGroupSessions– Orientation:LecturesonExamandLocalization;IntrotoNeuro-Imaging;handsonLPsession

– Topicseries– casebased• DeliriumAndComa,Epilepsy,Headache,InfectiousAndInflammatoryDisorders,MovementDisordersandAtaxia,NeuromuscularDisorders,Stroke

• Mini-CEXs• 2WriteUps

Assessment

• Midclerkshipfeedback– selfassess,reviewskills/conditions• Studentperformanceevaluationform(Filledoutbypreceptors)• Skillsform• OASISlog• WriteUps(2)• NBMEShelfExam• Mini-CEX

• Grading(2015-16)– PreceptorEval – 60%ofGrade– Shelfexam– 30%ofGrade– WriteUps– 10%ofGrade

MeasuresofQuality– StepIICK

*valuesdepictedareSDabovetheUS/CanmeanforGeiselmeanscores

Measuresof

Quality–AAMCGQ

Geiselmean2011

Geiselmean2012

Geiselmean2013

Geiselmean2014

Geiselmean2015

Allschoolsmeans2015

CFM 3.2 3.1 2.9 3.2 3.5 3.3

MED 3.5 3.6 3.5 3.6 3.6 3.5

NEURO 3.1 3.4 2.7 3.1 3.1 3.1

OBGYN 3.1 3.0 3.0 3.1 3.2 3.2

PEDS 3.3 3.1 3.2 3.5 3.6 3.4

PSYCH 3.5 3.6 3.4 3.7 3.6 3.3

SURG 3.0 2.8 2.9 3.1 3.3 3.3

MeasuresofQuality– AAMCGQ“Ratethequalityofyoureducationalexperiencesinthefollowingclinicalclerkships.”[1=poor;2=fair;3=good;4=excellent]

NBME“Shelf”ScorePercentiles

0

10

20

30

40

50

60

70

80

90

2010 2011 2012 2013 2014 2015 2016

MED

SURG

OBGYN

NEURO

PSYCH

FM

Measuresof

Quality–AAMCGQ

ClerkshipsOverall SatisfactionAY

2013-14OverallSatisfactionAY

2014-2015PEDS 4.3 4.5

MED 4.1 4.5

CFM 4.2 4.5

PSYCH 4.3 4.3

SURG 4.2 4.2

GAM 4.3 4.2

OBGYN 4.2 4.2

NEURO 4.1 4.0

MeasuresofQuality– CourseEvaluation

scale[1=poor;2=fair;3=good;4=verygood;5=excellent]

scale[1=poor;2=fair;3=good;4=verygood;5=excellent]

MeasuresofQuality– CourseEvaluationNEUROLOGY

2014-15 2015-16

OverallExperience 4.0 4.13

Objectiveswelldefinedandclearly presented 4.2 4.53Ability forY1and2topreparemeforthisclerkship 3.71 3.56

Expectationswelldefinedand clear 4.1 4.46Volumeadequate forlearning 4.21 4.26Varietyofdxadequateforlearning 4.2 4.29Quality ofteachingbyattendings 4.36 4.49

Quality ofteachingbyresidents 3.85 4.11SiteDirectors responsivetoconcerns 4.57 4.68Methodsusedto eval studentperformancemadeclear 4.1 4.36

Qualityof mid-clerkshipfeedback 3.74 4.04

scale[1=poor;2=fair;3=good;4=verygood;5=excellent]

MeasuresofQuality– CourseEvaluationNEUROLOGY

2014-15 2015-16

Quality ofcasebasedlearning n/a 4.2

Exam/Localization 3.9 3.96

Imaging 3.83 3.92

CNSinfx 4.41 4.21Stroke 3.88 3.82

NMDx 4.06 4.31

MovementDx 3.98 4.37

Delirium/Coma 4.08 4.12

HA 4.19 4.34

LP 3.97 4.06

MeasuresofQuality– StudentCommentsStrengths:• Atalmosteverysite,studentscommentedthattheyappreciatedthediversityofpatientsand

diagnosesthattheysaw:– Diversityofexposureinpatient(stroke,criticalcare)andespeciallyoutpatient(neuromuscular,

epilepsy,headache,generalneuro,hospitalistneuro,IR,neurosurgery)– Hadanopportunitytoseepatientswithalotofclassicneurologicaldiseasessuchasstroke,seizure,

headache,peripheralneuropathy,NMJdisease,multiplesclerosis,etc.-- oninpatientandoutpatientbasis.

– Goodvarietyoflearningenvironments(greatbalancebetweenclinicandwardsw/pedi,EEGlabdailyintheAM,smallgroups,overnightcallonadultservice,etc)

• Moststudentsfounddidacticstobewell-runandvaluable– Thedidacticswerewelleditedtoincludecontentthatwaspertinentandappropriateformylevelof

training.– Teachingsessionsweresimple,onpoint,anddidnotrequiretoomuchprepworkwhichallowedfor

moreactiveparticipation

• Manystudentscommentedontheexcellentteachingfromattendings andresidentsonthewards– Thefacultyandresidentsareveryeagertoteachandhelpstudentimprovetheirskills

MeasuresofQuality– StudentComments

SuggestionsforImprovement:• DidacticsessionswerechallengingatCPMCduetotechnologyandtiming:

– Thedidacticsessionswerealmostalwaysuselessforpeoplethatwerecallingin.Moreover,therewere2sessionswhenIwasonInpatientandduetothetimedifferenceIhadtomissrounds.

– Alsopleaseprovidebettervideoconferencingtoolssoawaysitescouldhearandparticipate.

• ManystudentsatDHMCenjoyedthestrokeservice,butfelttwoweekswastoomuchtimeandthattimemightbebetterspentonageneralserviceorinclinic– IfeltlikeIhadmorestrokeservicetime(2weeks)attheexpenseofseeingotherbasicneurology

diagnoses.– MightbenicetoshortenDHMCstroketo1week,andeithergiveanadditionalweekofinpatientor

adedicatedweekofclinic.

• Studentswhodidpediatricneurology,feltlesspreparedfortheshelf– Theshelfhasverylittlepediatricssotherewasastruggleontheclerkshipformetolearn/studyfor

theshelfandalsoforthepatientsIwasseeinginclinicorwhowouldhelpmeformycareer

MeasuresofQuality– StudentCommentsSuggestionsforImprovement:• Studentsfeltthatthereweretoomanymini-CEXs:

– Decreasethenumberofmini-CEX's!Eightwasfartoomanyforsuchacompactrotation.– Iknowwewerethelaunchgroupformini-CEX,butIthinktheprogramwouldbemoresuccessfulif

theattendings weremoreclearonthepointoftheexercisesandiftherewerehalfasmanyrequired.

– Lesspaperwork-- the8miniCEX'swereabitmuch.It'sharderthanyou'dthinktoapproachanattending8timesandaskforthatmuchtimefromthem.

• Themajorityofstudentshadpositiveexperienceswithresidents,butsomeraisedconcernsaboutunprofessionalbehaviorfromindividualresidents– Ithinkhertreatmentoftheinternduringatleasttwoseparateinstanceswasunprofessionaland

putusinanawkwardpositionasstudents– Thereisaclearproblemofunprofessionalismfromresidentsaffectingpatient-care.Irepetitively

sawresidentsplacetheirpersonalinterestaheadofpatientcareandneeds…itreallyseemedliketheresidentsdidnotcareabouttheirpatientsandoftentalkedpoorlyofthem

– Someresidentshadaveryrespectableattentiontoprofessionalismwhileothersseemedtocarelessaboutpatientcareandmoreabouttheirpersonallifeissues,oftenseemingtobrushworkoffontomedstudentswhichtheythendidn'tappropriatelycheckon.

SummaryregardingMeasuresofQuality• Summary:

– Overall,studentsenjoyedtheclerkship:theyespeciallyappreciatedtheinterestingvarietyofcasesandthequalityofteachingfromresidents/attendings

– Studentsatremotesitesexpresseddifficultywiththevideoconferenceformatofdidactics

– AtDHMC,manystudentsfelttherotationonthestrokeservicecouldbeshortenedto1weektomakemoretimeeitherforclinicorgeneralinpatientneurology

– Thereweresomestudentswhoexpressedconcernsaboutprofessionalismamongindividualresidents

– StudentsseemedtoliketheMini-CEXs,butfeltthereweretoomanyfora4weekrotation

Recommendations• Objectives

– #4:“Establish comfortable and mutually respectful student-patient and student-family relationships with diverse patients and families and establishing a respectful basis for the doctor-patient relationship.” • redundant, would strike words in red

– #10: “Communicate effectively with patients and families especially when special barriers to communication exist, including cultural, linguistic or those based on a neurologic disorder (e.g. aphasia).”• Focus of this clerkship should be on communication with pts with neuro disorders.

Would add “especially” and strike “cultural, linguistic”– #11: Assist patients appropriately in understanding their treatment options. To assist

patients appropriately in understanding their prognosis. • Would change to make a single sentence…”Assist patients appropriately in

understanding their treatment options and prognosis.”– #19: Describe how healthcare is currently organized, financed, and delivered, and the larger

environment in which healthcare occurs and the impact on neurologically ill patients.• Would delete. Did not seem like this was a clerkship appropriate objective and is

covered in both Years 1 course and Year 4 HSP.

Recommendations– HealthandValuesCurriculumCoordination

• EnsurethatBillNelsonisawareofnewemphasisonEthicsofBrainDeathsession

– ContinuetoworkonimprovingvideoconferencingformatforstudentsatCPMC

– BalancetimeonDHstrokeservicecomparedwithGeneralService

– Continuetoinnovatewithmini-CEXandcontinuefacultydevelopmenteffortssothesebecomemoreeffective,expectedandstandardized

– ContinuetoworkwithChairandResidencyDirectortoaddressconcernswithresidentprofessionalism

ActionPlan

– CommunicatetoBillNelsonofnewcomponentonEthicsofBrainDeathintheComacasebasedsession

– VideoconferencingforstudentsatCPMCstarted1yearago(monitorsystem,feedbackfromfacultyandstudents)

– ReducedvascularserviceatDHMCto1weekandincreasegeneralinpatientby1week(startedJune27th,2016)

– Continuetoinnovatewithnewmini-CEXsystemandcontinuefacultydevelopmentandcommunication

– ContinuetoworkwithChairandResidencyDirectortoaddressconcernswithresidentprofessionalism