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. 2.1k Downloads.AbstractTransitioning medical students are anxious about their readiness-for-internship, as are their residency program directors and teaching hospital leadership responsible for care quality and patient safety. A readiness-for-internship assessment program could contribute to ensuring optimal quality and safety and be a key element in implementing competency-based, time-variable medical education. In this paper, we describe the development of the Night-onCall program (NOC), a 4-h readiness-for-internship multi-instructional method simulation event.
NOC was designed and implemented over the course of 3 years to provide an authentic “night on call” experience for near graduating students and build measurements of students’ readiness for this transition framed by the Association of American Medical College’s Core Entrustable Professional Activities for Entering Residency. The NOC is a product of a program of research focused on questions related to enabling individualized pathways through medical training. The lessons learned and modifications made to create a feasible, acceptable, flexible, and educationally rich NOC are shared to inform the discussion about transition to residency curriculum and best practices regarding educational handoffs from undergraduate to graduate education. A competency-based readiness-for-internship assessment program is both timely and critical to the UME-GME continuum.In recent years, patient safety and quality assurance committees of hospitals and residency program directors have been called upon by accrediting agencies, malpractice insurance companies, and the general public to demonstrate that trained residents are capable of providing the level of care for which they have been assigned. Residency Review Committees, the clinical discipline specific accreditation bodies of the US Accreditation Council for Graduate Medical Education (ACGME), have provided guidelines outlining what a first-year resident can and cannot do without direct supervision until competency has been documented. In 2014, the Association of American Medical Colleges (AAMC), responsible for accrediting medical schools in the USA, released a set of 13 core Entrustable Professional Activities (EPAs) for entering residency (Core EPAs) (see Fig. EPAs are units of professional practice a trainee can be trusted to accomplish unsupervised once he or she has demonstrated sufficient and specific competence.
Authors of the core EPAs provided detailed guidance meant to drive the community toward refining, measuring, and benchmarking the minimal level of competence expected of a medical school graduate. As of yet, there is little consensus on how to assess the Core EPAs of new residents or what type of transition documentation (or “handoff”) to residency programs would be meaningful ,. 1The 2016 NOC activities were tailored to capture and assess the 13 core EPAs for medical students transitioning to residency. For a complete version of the Core Entrustable Professional Activities for Entering Residency please go to:Although ensuring readiness-for-internship is challenging, there are unacceptable negative consequences for patients, institutions, programs, and for the individual professional if “onboarding” is not done effectively.
Simulation has a critical role to play in both reducing the risk of iatrogenic harm to patients and assessing fundamental clinical competence critical to creating an institutional culture of safety ,. Ideally, with the implementation of a meaningful simulation-based assessment program just prior to medical school graduation, actionable formative feedback can be provided to both the learner and GME Program Directors to achieve these goals.In this paper, we describe in detail the development of a complex, immersive simulated, Night-onCall (NOC). We believe that NOC is an innovative program for a number of reasons including the fact that it (1) was designed iteratively and in response to specific local needs and evolving research questions, (2) it can be reproduced at most medical schools without need of sophisticated simulation facilities, and (3) it provides both an authentic educational experience for and is likely to enable high value core EPAs assessment of transitioning medical students. Developing NOC.
Conceptual framework underlying NOCNOC is a multi-station experience in an Objective Structured Clinical Exams (OSCEs) format ,. Since the 1960’s OSCEs utilizing standardized (a.k.a. “programed,” “simulated”) patients to assess core clinical skills have become a ubiquitous part of medical education assessment programs—used worldwide in a vast array of formats and for a variety of purposes including physicians’ licensing examinations. NOC aligns with literature that supports the utility of a well-designed OSCE as an assessment of clinical competence, assuming careful attention is paid to “contextual fidelity,” which includes the interprofessional nature of most medical work and accurate “professional role reproduction”. NOC is the current focus of a research program in which we explore the measurement of clinical competence for the purpose of supporting increasingly individualized pathways through medical training. The teamNOC was developed by a multidisciplinary and inter-professional team consisting of physician, nurse, medical librarian, and PhD-prepared educators from Emergency Medicine, Internal Medicine and Surgery and Obstetrics and Gynecology.
Our team, as whole, has extensive expertise in using simulation in undergraduate and graduate medical and nursing education. Development year over year16 (Night-onCall)Clinical cases/mixed modalityCase 1: Oliguria “I am calling about Mr. Jackson, 64-year-old man S/P Elective endovascular repair of AAA, post-operative day 3. His urine output has dropped and he has mild abdominal pain” (Has urinary retention, BPH).WISE-onCall module with 3 practice cases.Case 2: Oliguria “I am calling about Mr. 57-year-old man here for observation to rule out acute cardiac ischemia and pulmonary embolism.
His urine output has dropped and he remains without chest pain” (received contrast for a cat scan).Case 1: Oliguria (same).WISE-onCall module with three practice cases.Case 2: Oliguria (same).Case 3: headache “I’m calling about Mr. Johnson, 64-year-old man S/P a AAA repair day 3, and is complaining of a severe headache” (has a blood pressure of 195/99 and a history of HTN).Case 4: headache: “Hi. Are you covering for Mr. Kolinsky, 62-year-old man S/P internal fixation of an ankle fractureI wanted to let you know that he is having a severe headache” (history of migraines on propranolol for prevention).Form clinical question and retrieve evidence to advance clinical care.Culture of safety analysis of a paper case: vignette describing pre-entrustable peer on internal medicine clerkship-structured response identifying evidence of behaviors and assessment of entrustment.Handoff all two cases to fellow intern (standardized): prioritize based on urgency. Assessment of entrustment.Case 1: Oliguria (same).Plus: oral presentation to attending.WISE-onCall module with three practice cases.Case 2: Oliguria (same)Case 3r: headache (revised) “Hi. Are you covering for Mr.
Brooks, 60-year-old man being treated for Diverticulosis, I wanted to let you know his blood pressure is really high” (195/99 currently, non-focal neuro-exam, history of migraine headaches on propranolol for prevention)?Form clinical question and retrieve evidence to advance clinical care (same).Case 4r: Go “get” consent (revised): “Hi. This is Randy, your second year resident. You are covering Mr. Smith a 40 y/o with a cough, fever and pleural effusion. You need to go consent him for a thoracentesis. I will meet you at the bedside in 1 h.” (The resident will explain the procedure if asked, patient’s husband is in the room).Culture of safety analysis of a paper case: same.Handoff all four cases to fellow intern (standardized): prioritize based on urgency. 2The Night-onCall experience from the student’s perspective Types of NOC assessments Web-based multimedia moduleIn response to the increasing focus on medical students’ readiness for residency, and based on 10 years of experience building and studying WISE-MD—a web-based core surgery clerkship curriculum , our team created WISE-onCall—a set of web-based, multimedia modules targeted at enhancing the ability of novices to address common clinical coverage issues.
The modules are designed as a cognitive apprenticeship framework , starting with two “partially worked” case examples including video demonstration of inter-professional interaction, utilizing the instructional strategies of modeling, coaching, scaffolding, and fading of instructional guidance and then three text-based practice cases where the learner applies diagnostic skills and obtains feedback. To date, eight WISE-onCall modules have been completed with plans to build at least five more in the next 2 years. For NOC, we selected the Oliguria (low urine output) WISE-onCall module because it is a topic that all students are likely to have basic familiarity with by the end of medical school and it is a condition interns in all clinical disciplines can expect to encounter during a typical night on inpatient call. (Addresses EPAs #1,2,3,4,9,10,12). Performance-based assessment (PBA)Initially, in 2014, we designed two standardized patient (SP) and standardized nurse (SN) cases of relatively equal difficulty (case no.
2) for pre and post of the WISE-onCall module. In 2015, we developed two additional SP/SN cases, (case no. 4) in order to explore how clinical case content concordance and sequencing of PBA and WISE-onCall, impacted performance across the simulation activities.In 2016, we revised case numbers 3r and 4r to enable us to address, assess, and align PBAs to the core EPAs (see Table for details).Learners’ clinical skills including inter-professional teamwork were assessed using SP/SN completed checklists developed based on extensive/prior research. Clinical reasoning was assessed based on student-completed patient coverage notes and scored by a clinician based on a rubric ,. Rigorous methods were employed to develop SP/SN roles and checklists, as well as recruit, train, and calibrate actors for both case portrayal (3 h) and rater reliability (3 h) (Addresses EPAs 1,2,3,4,5,9,10,12). Oral presentationExperienced physicians from the study team played the role of a standardized attending (SA) for case number 1. The SA received a phone call from the study participants following the case number 1 clinical encounter.
A detailed guide to the case and the task were provided. Specifically, the guide included the clinical details of the case and a set of standardized prompts to be used to encourage the learner to share their clinical reasoning and establish a management plan. The SA was also responsible to assess the quality of the oral presentation using a checklist designed based on the detailed description of core EPA no. 6 and make an entrustment judgment. Evidence-based medicine activityFollowing case no. 3 learners, seated in front of a computer with an Internet access, were given 10 min to define a clinical question based on this case and instructed to use Web-based resources to find the best answer to a clinical questions provided to them (e.g., “What is the best initial management for urgent hypertension?”). A computer program was used to allow a medical librarian to remotely observe the learner’s progression through the activity both in real time and based on a recording.
Using this approach, the medical librarian was also able to assess the learner’s ability to formulate a clinical question and use digital resources to identify high quality evidence to guide the patient’s care as described by EPA no. Patient handoffWe recruited senior medical students to play the role of the standardized intern (SI) taking over the clinical service. Each SI was trained to use a structured evaluation instrument, modified from a published instrument, to assess the quality of the handoff as well as provide an entrustment judgement (EPA no. Culture of safety exerciseParticipants were first given time to read a detailed vignette describing a pre-entrustable intern’s approach to a series of common quality and safety challenges on an inpatient ward.
Then, in written responses to open-ended prompts, the participants listed both the interns’ behaviors and attitudes that interfered with a culture of safety and suggested actions needed for systems improvement. A faculty member (GN) assessed students’ written responses based on a rubric designed based on the description of the AAMC’s EPA no. Recruitment of studentsFor all phases of NOC, we recruited near-graduate medical students by email. If the student agreed to participate, he or she could sign up for a scheduled slot in the simulation center by clicking on a Universal Resource Locator (URL) embedded in the recruitment email. Study staff then confirmed the date with the participant and provided him/her background information regarding the study via email.
Participation was entirely voluntary, written informed consent was obtained and a financial incentive was provided. Resources needed to implement NOC. The NOC experience was hosted by the New York Simulation Center. We estimate our cost-per-student for NOC to be around $500 (US). This includes SP/SN salaries and staff time for planning and running the event, including SP training, student recruitment, and scheduling.
This estimated cost does not include a facility fee, the study incentive, case development time, patient note scoring, data entry and management, and physician preceptor time. Lessons learnedIn building this experience, we have learned many lessons that may be of interest to other’s seeking to build similar assessment events. While currently we do not share any assessment data with students, ultimately, we seek to use the competency assessments and entrustment judgments for feedback to students on their readiness and as a handoff to residency training program directors.
The following is what we learned so far. NOC is feasibleAs we have demonstrated, it is feasible to host a NOC for a large number of students. However, this can only be done with championship from leadership, adequate funding and committed professional and administrative personnel. The team met weekly for the 3 years; it took to develop materials, pilot, and refine the program.
The staging of the full NOC event required several months of planning which included scheduling space, recruiting and training actors, faculty and students playing roles, and recruiting and scheduling participants. Data entry, cleaning, analysis, and interpretation also required adequate resources. Advanced simulation facilities or equipment were not required to host the NOC. NOC is acceptableNOC is an immersive, complex, mixed-modality simulation experience, aimed at creating an authentic opportunity to rehearse being an Intern “on call.” Although it will require more work to establish the program as an effective means of measuring students’ readiness-for-internship for high-stakes purposes, the participants routinely expressed in debriefing portion of the NOC experience, that it helped them better understand their readiness and identify knowledge/skill gaps prior to their transition. NOC is a flexible structureDepending on local needs and resources, there are ways to modify the program to reduce cost and shorten the time needed, while at the same time, still achieving the same objectives. Based on our experience, we believe the EPA framework allows for a great deal of creativity and innovation.
For instance, we choose to assess EPA no. 13 using a written assessment of a paper case rather than a complex simulation others have used. Other schools prepare students for a night on call by integrating assessments into their required advanced clerkships. In the future, we plan to conduct head-to-head comparisons of various strategies to better understand relative educational and assessment value and costs. NOC will likely produce valuable informationOne goal of the analysis of our experience and data is to understand the educational value of the components of NOC. From the point of view of the students who have volunteered to participate, this low-stakes experience was almost uniformly seen as time well spent, educational, and anxiety-reducing.
This may change as we refine the competency measures and entrustment judgments and start providing detailed feedback. At our school, 12 years ago, we established a Comprehensive Clinical Skills Exam (CCSE), an 8-station Objective Structured Clinical Exam, to serve as a final performance exam for the core clinical clerkships. Similarly, we developed the CCSE as an assessment for learning or formative experience where it was very popular with and very much appreciated by students.
Once we transitioned the CCSE to an assessment of learning, (as defined by van der Vleuten et al. ) or summative, high-stakes experience where students were required to pass the exam, its popularity and the enthusiasm among students decreased. We suspect this may be an inevitable trade-off for some students, but we do hope to engage students in embracing the value of the data produced by NOC. Next steps for NOCWe are currently experimenting to find effective ways to visualize the NOC data and report it to students for the purposes of guiding them in preparation for internship. Despite desiring educational handoff information on their incoming interns, residency program directors are suspicious of assessments done in the undergraduate setting and do not yet “trust” evidence of readiness. If the AAMC EPAs are to become the standard by which we assess transitioning students’ preparedness for residency, we will need to assure all of our students reach those standards and continue to be able to perform at that level at the time they are transitioning to graduate level medical education.
Building programs, like NOC, will also enable medical schools to move toward a competency-based, time-variable curriculum that many now believe is the best way forward ,. We have described a program for achieving these goals that is feasible, acceptable, flexible, and likely to produce valuable information for learners, educational leaders and policy makers.
Availability of data and materialsAll materials needed to replicate the NOC Project, including standardized patient case materials and assessment instruments are available from the corresponding author on reasonable request. Authors’ contributionsAll individuals listed below have substantially contributed to the conception or design of the work and have participated in drafting the manuscript and/or revising critically for important intellectual content. In addition, each has given final approval of this version and has agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Specifically, AK is responsible for all aspects of this project. She has led the conception and design of the project, drafted and finalized the manuscript, designed and refined aspects of the project, and championed and supervised its implementation. SZ participated in overall conception of the project, designed SP/SN cases, recruited and trained actors, and participated in conceptualizing, editing, and finalizing the manuscript.
DS participated in overall conception of the project, designed SP/SN cases, and participated in manuscript editing and finalizing. SDY participated in design and implementation of NOC, data collection and management, and manuscript editing. HS participated in conception and design, sought and received IRB approval, and participated in manuscript editing. MN has participated in overall conception of the project, implemented the WISE-onCall module, designed data management and reporting components of the project, and participated in manuscript editing. GN has participated in overall conception of the project, in particular, the culture of safety activity, and participated in manuscript editing.
MVP participated in design and conception of the oral presentation component and manuscript conceptualization and editing. CD participated in design and conceptualization of the implementation of NOC. CB participated in design and conceptualization of the handoff and in manuscript editing. KLE contributed important intellectual content on educational theory and participated in manuscript editing. JN participated in conceptualization and design of evidence-based medicine component of the NOC and participated in manuscript editing. TSR participated in funding and championing the project and in conceptualizing and editing the manuscript.
All authors read and approved the final manuscript.
Case Based Pediatrics For Medical Students and Residents, 2nd Edition conversionSecond edition, Copyright 2013, 2014, 2015, Loren YamamotoFirst edition, Copyright 2004, Loren YamamotoAn Online Introductory Pediatrics Textbook - Currently transitioning from 1st edition to the 2nd editionBoth 1st edition and 2nd edition chapters are displayed below.Since the 2nd edition table of contents is different from the first edition, the 2004 first edition chapter numbers may not match the table of contents below.Department of Pediatrics, University of Hawaii John A. Burns School of MedicineKapiolani Medical Center For Women And Children1319 Punahou Street, Honolulu, HI 96826View this text online or download the entire 2004 first edition text for your tablet, computer, or mobile device. Second edition text will be available for download when it is completed in late 2015.This might take a long time to download. Please be patient.
The Word version will probably auto word wrap on the small tablet or mobile device screen, but it might incorrectly word wrap tables as well.This might take a long time to download. Please be patient. The PDF version will not auto word wrap so it will require you to scroll a small tablet or mobile device screen back and forth, but it will retain the correct alignment of the tables.Test your knowledge: Questions and answers at the end of each chapter from the 2004 first edition text.-First edition chapters are in light colors. New second edition chapters are in darker colors.Chapters are designated as MS3, MS4, and R as follows:MS3 - These are chapters designated as the curriculum content for the third year medical student pediatrics clerkship.MS4 - These chapters contain additional information that should be acquired by fourth year medical students destined for pediatrics residency.R - These chapters contain information that should be acquired by pediatric residents during their pediatrics residency.I. Office Primary Care: Section Editor - Vince K. Yamashiroya, MD- Melinda J.
Ashton, MD- Vince K. Yamashiroya, MD- Jeffrey K. Okamoto, MD- Dennis A.
Conrad, MD- Yusnita Weirather, AuD, CCC-A & Lynn M. Iwamoto, MD- Gretchen Kissel Foskett, MD- Jennifer R. King, DO- Jeffrey K. Okamoto, MD- Cindy W. Yang- Bryan D. Nutrition: Section Editor - Kyra A. Len, MD & Sheree Kuo, MD- Caron M.
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Iwamoto, MD- Sherry W.H. Loo, MD- Sheree Kuo, MD- Kelly S. Yamasato- Peter D. Eversen, MDIV. Genetics and Dysmorphology: Section Editor - Laurie H. Seaver, MD- Kirsty M.
McWalter, MS, CGC- Thomas P. Slavin, Jr., MD- Greigh I. Hirata, MD- Jennifer H. Boomsma, MS, CGC- Julie Won Ireland, MD- Sansan Lee, MS, CGC- Lianne E.
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Kosut, MD- Akaluck Thatayatikom, MD- M. Scott Hickman, MD- Akaluck Thatayatikom, MDVI. Infectious Disease: Section Editor - Jessica Kosut, MD & Venkataraman Balaraman, MBBS- Mary Rose Nino- Loren G. Yamamoto, MD, MPH, MBA- Marian E.
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