New challenge for students and staff!

1. New challenge for students and staff! Marijke van Santen-Hoeufft ass. prof. internal medicine/rheumatology, consultant in clinical education, curriculum development and assessment Maastricht, the Netherlands Clinical phase

2. The ambulatory and clinical environment in a modern medical curriculum Clinical phase

3. The Maastricht Curriculum Hospital Educational buildings and laboratories Clinical phase

4. How do we prepare our future doctors best for the challenges of the 21st century? ‘The Maastricht experience’ Clinical phase

5. Outline of presentation • Motivation for curriculum change • Year 3 • Strenghts and weaknesses of clinical rotations • Conclusion Clinical phase

6. Many motivations for curriculum change in Maastricht 2001… The most important overall: The transition of preclinical to clinical phase is experienced as quite a shock of practice and… The transition of graduate to post-graduate training is experienced as… A tremendous ‘shock of practice’! Clinical phase

7. Why shock of practice? • Post-graduate training requires: • Working under time pressure • Facing larger responsibility • Dealing with more complex problems • Having insufficient competencies Clinical phase

8. How to prevent shock of practices? • Critical appraisal of current content year 4 - 6 • Better preparation for the ‘real work’ in year 3 • HOW TO DO THIS? • Start with real patient encounters in year 3 • Broadening of competencies other than medical expert Clinical phase

9. Year C o n t e n t 1 Emergency care and regulatory systems 2 Stages of life and diagnostics 3 Chronic disorders, ambulatory patient contacts 4 Internships, focus basic sciences 5 Internships 6 Participation in research and patient care Structure of the 2001 curriculum Theory Practice Clinical phase

10. Why early patient contacts? Clinical phase

11. How do we learn best ? Average Retention Rate1 Teach others 80% 75% Practicebydoing Discussiongroup 50% Demonstration 30% Audiovisual 20% Reading 10% Lecture 5% 1 National Training Laboratories, Bethel, Maine, USA Clinical phase

12. Educational objectives Integration theory & practice Patients are starting point for learning Variability in instructional methods in which students are required to be active Instructional methods Learner control Active learning Collaborative learning Self-directed learning Teachers Teachers ascoach Clinical phase

13. The learning cycle Patient vignette/case Preparation in tutorial group Self study Report to Tutorial group Activities around patient encounter Preparation with clinical supervisor Self study Patient encounter Evaluation & Formulation learning objectives Clinical phase

14. Tutorial group • 10 weak cycle • n = 10 • 1x per week 4 hours • presentation and discussion of patient problems (3 hours). • Preparing next patient encounter (1 hour) • staff member is coach Clinical phase

16. ‘SOEPEL’: Structured Consultation Report • Subjective • Objective • Evaluation • Planning • Elaboration: discussing learning goals with clinical supervisor, after patient encounter. Student formulates new learning goals • Learning goals: the new learning goals are the guide for further self study and for report in the base group Clinical phase

20. The learning cycle Patient vignette/case Preparation in tutorial group Self study Report to Tutorial group Activities around patient encounter Preparation with clinical supervisor Self study Patient encounter Evaluation & Formulation learning objectives Clinical phase

21. Formulating learning goals……. Clinical phase

22. heart / lungs / vessels abdomen locomotion brain and behaviour Year 3A students’ week Gastro-enterology Gynecology / Obstetrics Surgery Family medicine Urology Pediatrics Participating disciplines Clinical phase

23. Back to Brazil,back to the transition of students from the safe escola Pernambucana to the challenging IMIP environments…How to use PBL in a ambulatory and clinical context? Clinical phase

24. All medical faculties want to prepare their students the best they can for the 6th year and post graduate education But what is the best way? Evidence for ‘best practice’? Clinical phase

25. “It may not be a perfect wheel, but it’s a state-of-the-art wheel.”

26. Effectiveness of clinical rotations?? Clinical phase

27. Strenghts of internships • Learning in real, relevant context • Integration of theory and workplace learning • Active participation in practice • Coping with increasing complex and diversepatient problems • Increasing self-reliance success depends on length of internship! Clinical phase

28. Unfortunately all internships have their weaknesses too… Why are internships generally less effective than ideally possible? Clinical phase

29. The effectiveness of internships is hampered by problems regarding: • the teacher • the workplace • the students • the elements of good clinical teaching Clinical phase

30. Common problems in clinical phaseregarding the teacher(1): • Time pressures • Competing demands (clinical with parttime availability;administrative; research) • Teaching often opportunistic, making planningmore difficult • Often under-resourced • Rewards and recognition for teachers poor • Good teaching needs intrinsic motivation of teacher Clinical phase

31. Common problems in clinical phaseregarding the teacher(2): • Lack of knowledge about: • the effects of being a role model • motivating students • assessing competence • giving constructive feedback • the curriculum content, end-objectives… • etc. • Lack of training in: • educational skills • evaluating his own teaching and asking feedback (self reflection) Clinical phase

32. Common problems in clinical phaseregarding the workplace: • Increasing numbers and types of students • Fewer patients (shorter hospital stays; patients too ill or complex) • Competing demands (patient-care related actions come first) • Clinical environment not ‘teaching friendly’ (busy hospital ward; no suitable meetingplace with students;no learning climat) • Ambulatory care insufficiently involved in education Clinical phase

33. Common problems in clinical phaseregarding the teacher(1): • Time pressures • Competing demands (clinical with parttime availability;administrative; research) • Teaching often opportunistic, making planningmore difficult • Often under-resourced • Rewards and recognition for teachers poor • Good teaching needs intrinsic motivation of teacher Clinical phase

34. Common problems in clinical phaseregarding the teacher(2): • Lack of knowledge about: • the effects of being a role model • motivating students • assessing competence • giving constructive feedback • the curriculum content, end-objectives… • etc. • Lack of training in: • educational skills • evaluating his own teaching and asking feedback (self reflection) Clinical phase

35. Common problems in clinical phaseregarding the workplace: • Increasing numbers and types of students • Fewer patients (shorter hospital stays; patients too ill or complex) • Competing demands (patient-care related actions come first) • Clinical environment not ‘teaching friendly’ (busy hospital ward; no suitable meetingplace with students;no learning climat) • Ambulatory care insufficiently involved in education Clinical phase

36. Common problems in clinical phaseregarding the students: • Insufficiently prepared (knowledge, skills) • Don’t take the opportunities for examiningpatients independently • Stay passive observers in stead of active participants due to too short clerkships (no time for professional socialisation) Clinical phase

37. Common problems with clinical teaching(1): • Lack of clear objectives and expectations • Focus on factual recall rather than on developmentof problem solving skills and attitutes • Teaching pitched at the wrong level (too high or too specialistic) • Inadequate supervision and provision of feedback(due to lack of time, lack of skills or motivation, no continuity) Clinical phase

38. Isn’t it a wonder there are competent physicians anyway?!At least we think we are…. Clinical phase

39. Important determinantsof the effectiveness of student learningin a clinical environment: • Patient mix • Opportunities for examining patients independently • Received supervision and feedback • Organisational quality • Student being part of a team • Number of students at one time • Educational sessions • Positive attitude of staff towards students Clinical phase

40. Most important determinantsof the effectiveness of student learningin a clinical environment: 1- received supervision and feedback 2- opportunities for examining patients independently 3- patient mix Clinical phase

41. Measures to improve effectivenessof clerkships: • Clerkship study guides • Teach the teachers trainings • Create a positive learning environment • More direct observation and feedback • Include protected time for selfstudy • Integration of learning and assessing on the workplaceby using miniCEX, logbooks etc. Clinical phase

42. Integration of learning and assessing by: • Observing multiple events during clerkshipinvolving multiple people • Using mini CEX (Clinical Evaluation eXercise)or other ‘on the job assessment tools’ • Using the logbook in which structured clinical recordsare gathered of all patients seen by the student • Coaching • Critical incident analysis • Portfolio etc. Clinical phase

43. Integration in medical curricula Faculty of Medicine Universiteit Maastricht Clinical phase

44. Clinical phase

45. In summary, improvement of the effectiveness of the ambulatory and clinical phase can be achieved,but not without effort and lots of motivationof organisation, staff and students! Clinical phase

46. Thank you for your attention!

47. Traineeship year 6 • Participation in health care: • 20 weeks junior doctor in general practice or • hospital setting • Focus on doctor’s role of medical expert, • scientist, health care worker, person • Further development of competencies in: • medical acting • communication • cooperation • knowledge/science • social acting • organisation • professionalism Clinical phase