Browsing by Subject "Clinical Clerkship"
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Item The 18-Month Curriculum: The Impact of Mixed Learning Clerkships(2022-05) Kwon, Adelaide Jiwon; Sendelbach, Dorothy; Faulkner, Christopher; Tessnow, AlexBACKGROUND: UT Southwestern implemented a new, 18-month, shortened pre-clerkship curriculum in the Fall of 2015 in order to increase the clerkship phase from 1 year to 18 months, beginning mid-second year. In keeping with this new curriculum schedule, it was necessary to combine MS2 and MS3 students on clerkships from January to June; during that time, both MS2 and MS3 students are on the same clerkship simultaneously, creating opportunities for informal near-peer learning. Each clerkship handles this mixing differently: some create mixed-year teams, others group students together with their peers, while still others do not create teams at all. OBJECTIVE: We are interested in determining the impact of mixing students on team dynamics, narrative assessments, and grades. HYPOTHESIS: Upperclassmen and underclassmen participating on the same clerkships in a mixed learning environment will report predominantly positive experiences but will have significant differences in their grades and narrative assessments compared to each other. METHODS: A tri-pronged approach was taken, looking at qualitative student perspectives, qualitative attending perspectives, and quantitative scores on de-identified student evaluations. In the first arm of the study, students in the classes of 2020 and 2021 were sent a voluntary survey seeking comments regarding their experiences on mixed clerkships and to indicate their interest in participating in a follow-up 30-minute focus group interview. Four purposeful focus groups of 4-5 students, two groups from each class, were interviewed to learn more about perceived advantages and disadvantages of mixed clerkships. Interviews were audio-recorded, transcribed, and coded for themes. Transcripts were validated by the interviewees and de-identified prior to analysis. In the second and third arms of the study, student evaluations from 2019 in the Internal Medicine, Pediatrics, and Psychiatry clerkships were gathered and de-identified. From these, 120 narrative assessments were randomly selected for qualitative analysis. Final grades and four scored skills were selected for quantitative analysis. Finally, de-identified quantitative data from 2015-2016, prior to the implementation of the 18-month curriculum, were analyzed for additional insights. RESULTS: In the first arm of the study, interviewees reported overall positive experiences with mixed clerkships. Common perceived advantages as an MS2 paired with MS3s included being able to ask "dumb" questions without being judged; being taught "practical" skills such as how to use the electronic medical record (EMR) and how to write a note; having fears allayed through candid discussions; and having a sense of camaraderie. Common advantages as an MS3 paired with MS2s included satisfaction in teaching MS2s and being motivated by MS2 enthusiasm. Perceived disadvantages were less commonly mentioned but still present, and mostly centered around fears of being compared by evaluators. In the second and third arms of the study, the mixed clerkships of Pediatrics and Psychiatry tended to show more significant differences in MS2 and MS3 evaluations than the non-mixed clerkship of Internal Medicine. However, this was highly nuanced, and there was some, but not consistent, division between differences observed in "learned" skills such as history-taking or note-writing and "inherent" skills such as professionalism or confidence. Comparison with students on the old curriculum also revealed significant differences with different MS2 and MS3 cohorts suggesting both positive and negative effects of the mixed learning environment on student evaluations. CONCLUSION: Overall, students reported more positive experiences and perceived advantages on mixed clerkships than negative experiences and disadvantages. However, attendings reported a higher proportion of significant differences between less and more experienced students on mixed clerkships. Despite this, the impact of cross-class comparison versus other factors, such as natural student improvement, contributing to these differences is unclear, and therefore mixed clerkships resulting from the 18-month curriculum have had a generally positive impact despite some negative effects. Further research, including research into other assessments of educational outcomes such as shelf exam scores as well as research into cross-clerkship comparisons, is needed to provide a fuller picture of the impact of these mixed clerkships.Item Assessing the Need for and Developing a Standardized Patient Handover Curriculum for Undergraduate Medical Education(2017-04-03) Gajera, Prakash; Reed, W. Gary; Greilich, Philip; Ambardekar, AditeeBACKGROUND: Improving patient handoff communication is a national patient safety goal; however, few medical schools have standardized handoff training curricula for their medical students. Studies show that a large number of medical students perform handoffs and observe handoff errors during their clerkships [1,2]. This lack of formalized training has a negative impact on medical student perceptions of handoffs [3]. This project assessed the need for handoff education at our institution and developed a curriculum aimed at medical students. IMPLEMENTATION: Clerkship directors were interviewed & preclinical medical students were surveyed for a stakeholder analysis. Prior to starting core clerkships, 200 total students participated in four 1-hour workshops consisting of a 20-minute lecture and three 10-minute handoff scenarios. Trained residents performed the scenarios and led group discussions. Pre- and post-course engagement surveys were used to evaluate the workshop. EVALUATION & OUTCOMES: Clerkship directors desired handoff training before clerkships; however, there was concern that the curriculum would be too advanced. Survey of pre-clinical students showed 71% had heard of standardized patient handoffs, but 94% had no training. 75% believed training should be done prior to core clerkships, and 64% believed handoff simulations were the best method for learning. Students scored 10.7% higher on the post-engagement quiz and 98% of students believed they better understood the elements of a good handoff after the workshop. IMPACT & LESSONS LEARNED: Standardized patient handoff curriculum designed for preclinical medical students improved confidence and knowledge about the handoff process. Concerns about creating handoff curriculum for medical students were addressed by focusing on general concepts rather than specific handoff tools and by creating simple handoff evaluation scenarios. Further work will focus on evaluating the impact of this workshop on the handoff experience during clerkships.Item Doctor in Training: A Year of Medical Studies Abroad(2012-03-27) Quintana, Andrea; Mihalic, AngelaMs. Quintana spent a year visiting medical education clerkships in three different nations (Cambodia, Burkina Faso, and France), examining the systems and the roles of the students in each nation. She provides additional information to those considering an international clerkship in each of the nations, including basic information about the nation’s health care system, the culture, and where to live and what to bring.Item Formative Feedback Passport: A Tool to Engage Students in Reflecting on and Incorporating Mid-Point Feedback(2022-05) Postma, Heather Elizabeth; Abraham, Reeni; Collins, Sarah; Brinker, StephanieBACKGROUND: The importance of formative feedback in undergraduate medical education is widely appreciated; however, it is historically inadequate. The formative feedback passport (FF tool) was developed and implemented in the Internal Medicine (IM) clerkship at UT Southwestern to address these concerns. OBJECTIVE: This dissertation examines the FF tool's role in facilitating an optimal formative feedback process. METHODS: Initially, a pre-intervention study was conducted, in which randomly selected, de-identified FF tools from the 2018-2019 IM clerkship were analyzed for content and quality of student reflection. Results revealed that student reflection on feedback was insufficient, with transformative, thoughtful reflection seldom occurring. In response to these findings, the FF tool's instructions were augmented with a module to encourage critical reflection. Subsequently, a post-intervention study was conducted, in which randomly selected, de-identified FF tools from the 2020-2021 IM clerkship were analyzed in the same manner as the pre-intervention study. RESULTS: 149 feedback tips from 50 FF tools were included in the pre-intervention study, and 162 feedback tips from 54 FF tools were included in the post-intervention study for a total of 311 feedback tips from 104 FF tools analyzed. In both studies, most of the feedback tips aligned with established standards for resident and faculty evaluators. In addition, the mean scores for each REFLECT Rubric criterion were significantly higher in the post-intervention group than the pre-intervention group. CONCLUSION: The FF tool is an invaluable electronic feedback tool in the IM clerkship at UT Southwestern. It enables documentation of formative feedback and promotes critical student engagement, reflection upon feedback, and the development of plans to implement feedback for improvement. Study results demonstrate that students receive formative feedback from an attending, resident, or patient that is appropriate in content. Additionally, study results demonstrate that the intervention improved student engagement and quality of reflection on feedback using the FF tool.Item Improving Teamwork Competencies and Patient Handovers of Students in the Emergency Medicine Clinical Learning Environment(2024-05) Lokesh, Nidhish; Reed, W. Gary; Greilich, Philip; Pierce, Ava E.BACKGROUND: Communication failures contribute to significant teamwork failures causing adverse events for patients and providers, especially during patient handovers when providers transition care of patients to each other. Teamwork education has been shown to improve knowledge, skills, and communication in prelicensure learners. Despite knowledge of the problem and potential solutions, as well as requirements and recommendations by national medical accreditation and oversight agencies, there exists a gap in standardized teamwork education and assessment. The Emergency Department is a setting rife with inherent barriers to teamwork with a high frequency of patient handovers. LOCAL PROBLEM: At UT Southwestern, students used to have limited opportunities to improve teamwork in structured ways during their time on the clinical wards. In response, the institution developed and is implementing an educational quality enhancement plan - TeamFIRST - with the goal of developing a competency-based teamwork education (CBTE) strategy for students that is progressive, interprofessional, and continuous through the pre-clerkship, clerkship, and post-clerkship phases of medical school. Module 4 out of the 5 modules TeamFIRST developed focuses on improving teamwork competencies specifically in the clinical learning environment, i.e. during clinical rotations in most students' second years and beyond. This includes the Emergency Medicine clinical rotation, which most students undergo at Parkland Memorial Hospital, the busiest emergency department in the nation, as well as at other local Emergency Departments like Clements University Hospital and Presbyterian Dallas. Until now, the Emergency Medicine clinical rotation at UT Southwestern did not have any formal handover or teamwork education, despite being the clinical setting in which teamwork and handovers arguably provide the most value. METHODS: Continuous Quality Improvement (QI) and Implementation Science tools and methodologies were used in the study of the current state of handovers in the ED and in the design of interventions to implement effective handovers. Define-Measure-Analyze-Design-Verify methodology was used to iterate our interventions. Interviews with stakeholders were conducted to determine critical needs, learn about the main drivers for intervention, and map the current state of the ED clerkship rotation so that a suitable educational module could be developed. These stakeholders mainly included faculty, course directors, residents, and students in the Emergency Medicine rotation as well as members of TeamFIRST. Shared requirements from stakeholders included focusing on improving handovers, limiting time commitment due to already busy schedules, and mixing virtual with in-person education. Information was also gathered on the state of different handover types in the ED to design assessment tools that captured the critical components. TeamFIRST identified nine of the twelve Teamwork Competencies - Structured Communication, Closed Loop Communication, Asking Clarifying Questions, Sharing Unique Information, Mutual Trust, Team Mental Models, Mutual Performance Monitoring, Obstacles to Teamwork, and Psychological Safety - for the Module 4 interventions to address. Working in concert with TeamFIRST and the Emergency Medicine stakeholders, we developed a teamwork education curriculum that integrated into the existing Emergency Medicine clerkship rotation and focused specifically on improving patient handovers. Each teamwork competency was explored to differing degrees among the spectrum of inform, demonstrate, practice, and feedback. We selected various process, outcome, and balancing measures such as impact (effectiveness), fidelity of activities, acceptability and appropriateness, and feasibility. Impact of the curriculum was measured by assessing students' knowledge, confidence in skills, and attitudes on the teamwork competencies. Both quantitative and qualitative data was collected. Statistical methods such as Z test of proportion and Mann-Whitney U test were used to analyze pre- and post- data to determine any significant changes. INTERVENTIONS: The teamwork curriculum initially designed for the Emergency Medicine clerkship rotation (the "test" phase, designated "Curriculum 1.0") had three main aspects: a pre-orientation, asynchronous, virtual educational module on teamwork and handovers, integrated handover practice and assessment throughout the rotation, integrated teamwork participation/observation, reflection, and debriefing during the rotation. The pre-orientation module was designed with a pre-assessment to determine students' capacities before being exposed to the material and a post-assessment to measure changes in knowledge and receive feedback after going through the didactic curriculum that covered the teamwork competencies and dedicated a full section to patient handovers. The handover practice was scattered throughout teaching shifts, simulation center cases and a dedicated handover station, and while working on regular emergency department shifts with accompanying assessment tools made to allow residents and faculty to evaluate student handovers and provide learners feedback. Lastly, students participated in and observed teamwork instances throughout their rotation and were encouraged to note these experiences down in a Teamwork Competency Journal so they could reflect and debrief on them in a group session late in the rotation. Finally, an end-of-rotation assessment was administered to capture changes in knowledge, skills, and attitudes, as well as feedback on acceptability, appropriateness, and feasibility. Whereas feasibility data were derived from the qualitative feedback, fidelity to the learning activities were assessed quantitatively. These interventions were first tested with a non-representative student sample outside of the EM rotation at the end of the summer 2020 and during field tests in Spring 2021 to improve the process and optimize the interventions. The official, representative test within the clerkship, "Curriculum 1.0", began in June 2021 and ran through March 2023 (22 months total). "Curriculum 2.0", the more streamlined version, is our pilot phase, and has been running from April 2023 through the present. RESULTS: We had 124 students participate in the Curriculum 1.0 test over 13 rotation blocks and collected qualitative and quantitative data on acceptability, appropriateness, fidelity, feasibility, and impact. So far, the curriculum has shown to be effective in improving knowledge (significant in 5/8 categories, p<0.05) and confidence in teamwork skills (significant in 11/11 categories, p<0.05). Also, students have deemed the curriculum acceptable and appropriate (all average ratings >4/5). However, some learning activities were deemed less feasible, and the fidelity (completion as intended) of different activities was low (48% completion or less). Feedback was generally positive, with common themes being that the handover education and practice were useful and relevant, the teamwork debrief was excellent, and the course was unique. Negative feedback commonly addressed a lack of clarity in communication about the curriculum requirements and the need for more active student roles. CONCLUSION: Overall, the impact and acceptability/appropriateness of Curriculum 1.0 were high, feasibility of the curriculum was moderate, and fidelity was low. Some of the key takeaways include that our stakeholders found the education to be effective and valuable, a combination of asynchronous and synchronous learning seemed the most feasible and acceptable, and that the time pressures on our EM residents and faculty are high. Going forward, we will continue to pilot the streamlined "Curriculum 2.0", which has already shown to be more feasible and sustainable, to improve the experience for learners and instructors, improve data collection, and focus on getting students more practice on patient handovers.Item Lies, damned lies, and evaluations: the quest for "high value" feedback(2022-01-21) Scielzo, Shannon; Kazi, Salahuddin