Bridging the Continuum Between UME and GME

Bridging the Continuum Between
Undergraduate and Graduate Medical
Education: A Feedforward Mechanism for
Graduating Medical Students
Helen Morgan MD, Nicholas Kman MD, Jennifer McCallister MD, Sally Santen MD, PhD

AMA Accelerating Change in Medical Education
Disclosures

Objectives
1. Review background literature on:
– Undergraduate Medical Education (UME) to Graduate Medical Education (GME)
continuum
– Competency based medical education
– Current state of the 4th year of medical school
2. Describe how a clinical track based on ACGME
competencies could bridge the chasm between UME and GME.
3. Identify strategies for creating specialty specific milestones
reports at your institutions.
4. Identify barriers and derive solutions to these “feedforward”
concepts.

Undergraduate Medical
Education (UME)
Graduate Medical Education
(GME)

MK ,PC, Prof, SBP, PBLI,
ISC
Education (UME)
(GME)
Competency Based Medical Education

MK ,PC, Prof, SBP, PBLI, ISC
Education (UME)
(GME)
Competency Based Medical Education
+ACGME Milestones Project

What are
the current
issues of the
M4 year?
In an ideal
world, what
would be the
core objectives
of the M4 year?

Current State of the Senior Medical School
Experience

Issues We All Face
▪ Only 4th year constants across institutions:
▪ Expectation that students will take USMLE Step 2 CS
and CK
▪ Select a specialty
▪ Interview for residency positions.
Cosgrove, E M (02/19/2014). "Empowering Fourth-Year
Medical Students: The Value of the Senior Year". Academic
medicine (1040-2446), p. 1.

Course offerings in 4th Year
▪ Subinternships were required by 122/136 (90%).
▪ Capstone courses used to fill curricular gaps.
▪ Revisiting basic sciences.
▪ Many schools require rotations in specific settings (EM,
ICU, Ambulatory).
▪ A growing number of schools require participation in
research.
▪ Students work with underserved populations or seek
experiences that will be henceforth unavailable
▪ Electives to "audition" at desired residency sites.
13
Course Offerings in the Fourth Year of Medical School: How U.S. Medical Schools Are Preparing Students for Internship.
Elnicki, et al for the CDIM/Association of Program Directors in Internal Medicine Committee on Transition to Internship
Academic Medicine 2015

Course offerings in 4th Year
▪ Subinternships were required by 122/136 (90%).
▪ Capstone courses used to fill curricular gaps (80/136 (59%)).
▪ Revisiting basic sciences.
▪ Many schools require rotations in specific settings (EM (45%),
ICU (34%), Ambulatory (35%)).
▪ A growing number of schools require participation in research
(51/136 (38%)).
▪ Students work with underserved populations or seek
experiences that will be henceforth unavailable
▪ Electives to "audition" at desired residency sites.
14
Course Offerings in the Fourth Year of Medical School: How U.S. Medical Schools Are Preparing Students for Internship.
Elnicki, et al for the CDIM/Association of Program Directors in Internal Medicine Committee on Transition to Internship
Academic Medicine 2015

Lyss-Lerman P, et al. What training is needed in the fourth
year of medical school? Views of residency program
directors. Acad Med. 2009 Jul;84(7):823-9.
▪ Common struggles of interns:
▪ Lack of self-reflection and improvement
▪ Poor organizational skills
▪ Underdeveloped professionalism
▪ Weak medical knowledge
▪ Competencies MS IV students should gain before
starting residency
▪ Advanced clinical reasoning
▪ Near intern level independence
▪ Ownership of patient care
15

Lyss-Lerman P, et al. What training is needed in the fourth
year of medical school? Views of residency program
directors. Acad Med. 2009 Jul;84(7):823-9.
▪ “Organizing the curriculum with specialty-specific
tracks could be explored by looking at specialty-
specific data and expanding the interviews to
include more PDs.”
16

Walling A, Merando A. The fourth year of medical
education: a literature review. Acad Med. 2010
Nov;85(11):1698-704.
▪ Three recurring themes:
▪ Lack of clarity about the educational purpose
▪ Problems in curricular content and organization
▪ Concerns about the educational quality of courses
17

Walling A, Merando A. The fourth year of medical
education: a literature review. Acad Med. 2010
Nov;85(11):1698-704.
▪ ACGME policies and practices will increasingly
influence medical student education
▪ 4th year as capstone for medical school versus
preparation year for residency
▪ Turned in favor of the pre-residency viewpoint
▪ Other factors that increase the pressure towards
using the fourth year to prepare for residency are
student debt and the growing specter
of unmatched US graduates
18

What is the 4th Year? What Can it Be?
19

Reddy ST, et al. ACE perspective paper: recommendations for
redesigning the "final year" of medical school. Teach Learn Med.
2014;26(4):420-7.
▪ Demonstrate that they have mastered objectives
(based on 6 ACGME Core Clinical Competencies)
▪ Complete a required capstone course prepares
students for residency.
▪ Structure their 4th year schedules to accomplish
specialty-specific objectives that prepare them for
their intended specialty.
▪ Engage in thoughtful inventory of training. Identified
gaps should be addressed through deliberate
participation in rotations that address identified
areas.
20

2014;26(4):420-7.
▪ Demonstrate that they have mastered objectives
(based on 6 ACGME Core Clinical Competencies)
▪ Complete a required capstone course prepares
students for residency.
▪ Structure their 4th year schedules to accomplish
specialty-specific objectives that prepare them
for their intended specialty.
▪ Engage in thoughtful inventory of their medical
school training. Identified gaps should be addressed
through the deliberate participation in rotations that
address the identified areas.
21

2014;26(4):420-7.
▪ 4th year is a bridge between medical school and
Residency: ACGME Competencies and AAMC Core
Entrustable Professional Activities (EPAs) should be
used to guide curriculum development.
▪ These competencies and specialty-specific
milestones and EPAs provide guidance to medical
schools for the minimum level of competency for
starting intern and can be used to design 4th-year
curricula.
22

What are some potential solutions to
bridge the gap between UME and
GME?
Discussion

Potential Solution: Clinical
Tracks

Advanced Management in
Hospital Based Care
Advanced Management in
Relationship Centered Care
Advanced Competency Elective
Clinical Tracks:
A longitudinal
experience in a
specialty or
subspecialty designed
to prepare students to
be an intern/incoming
resident by meeting
entry level milestones
in that field.
Other Electives (4 total required
including Advanced Competency)
Flex
Gateway Activities
Part Three
Advanced
Clinical
Management
HSIQ Project
What is a Clinical Track?

Required rotations Recommended
rotations
Supplemental
activities
Clinical Tracks—requirements

How long should a Clinical Track be?
▪ Not fulfilled by a required number of clinical
rotations
▪ Represent a combination of clinical rotations &
experiences
▪ Allow student to develop necessary skills

Clinical Tracks—evaluation
ACGME
Milestone-based
assessments
Competency based evaluations

Currently available Clinical Tracks
▪ Anesthesiology
▪ Emergency Medicine
▪ Family Medicine
▪ Internal Medicine (Preliminary Medicine included)
▪ Internal Medicine-Pediatrics
▪ Obstetrics/Gynecology
▪ Pediatrics
▪ Psychiatry
▪ Neurology
▪ Radiology
▪ Surgery/Surgical Subspecialties (Preliminary Surgery
included)

Description of the EM Clinical Track
Recommended Courses
▪ EM at OSUWMC
▪ MICU, SICU, Cardiology, or Pulmonary.
▪ Chronic Care
▪ Geriatrics, HIV Patient Care, CHF, Adult Kidney Disease, Child
Abuse/Child Advocacy, Alcohol & Drug Abuse.
▪ Clinical Track Electives
▪ Advanced Topics in Emergency Medicine (ATEM), Away Elective in EM
(Tox, Ultrasound, EMS, Peds EM), Ultrasound Advanced Competency,
Emergency Preparedness Advanced Competency, Radiology,
Anesthesia, Sports Medicine, Dermatology, Plastics, ENT/Ophtho (two
2-week electives if possible), Hand Surgery, Orthopedics.
30

Description of the IM Clinical Track
Recommended Courses
▪ Emergency Medicine adult, any site
▪ Any IM mini-internship- at OSU
▪ Any two different ambulatory practice environments, at least
one must be IM
▪ Electives
▪ Consider two sub-internships in IM (one early, one late), consult
experience in a specialty of interest. Consider the 2- week
Medicine Boot Camp (general intern survival skills) and the 4-
week “Advanced Competency in Procedural Skills”.
32

Assessments—IM Clinical Track
Assessment Items Data PC
1
PC
2
PC
3
PC
4
PC
5
MK
1
MK
2
SB
P1
SB
P2
SB
P3
Mini I—Patient Care (CEO 1.2.1)
Obtained accurate and pertinent histories
x
Demonstrated physical exam skills and identified
exam findings
x
Assessed and managed undiagnosed problems
x x x
Interpreted clinical situations and diagnostic tests
x x
Min I—Procedures (CEO 2.4)
Performed general procedures of a physician
x
Mini I—Medical knowledge (CEO 2.1.2)
Applied knowledge to understand patient care
x x
Mini I—Systems-based Practice (CEO 5.1)
Facilitated an interdisciplinary and team approach to
coordinate care
x
Mini I—Systems-based Practice (CEO 5.2)
Utilized healthcare resources effectively
x

M3 Clerkship
Experiences
ResidencyVariable fourth year experiences

M3 Clerkship
Experiences
ResidencyVariable fourth year experiences
Specialty Specific
Residency
Preparation
Electives
(bootcamps)

Clerkship
Experiences
Residency
Surgery (2008)
Obstetrics and Gynecology (2013)
Pediatrics (2015)
Variable fourth year experiences
Specialty Specific
Residency
Preparation
Electives
(bootcamps)

Advanced Clinical Skills in Obstetrics and
Gynecology Curriculum
15 hours: Embalmed
cadaver and fresh frozen
operative cadaver
sessions
14 hours: Case based
obstetric and gynecologic
cases
17 hours: Laparoscopic
and open skills testing
and teaching
17 hours: Flipped
classroom sessions with
case-based discussions
10 hours: Pre-operative simulation
based curriculum
Decision to
Incision
Case
discussions
Anatomy
Simulation
Lecture
Surgical skills

APGO Test
Decision
to
Incision
Pelvic
Exam
with
GTA
Pelvic
Anatomy
Literature
Assessment
Paging
Suture
Skills
Antepartum Care and Complications of Pregnancy X
Care of Patients in the Intrapartum Period X
Care of Patients in the Postpartum Period X
Obstetrical Technical Skills X X
Immediate Care of the Newborn
Gynecology Technical Skills: Laparotomy X X
Gynecology Technical Skills: Vaginal X X
Gynecology Technical Skills: Endoscopy X X
Peri-Operative Care X
Family Planning X
Ambulatory Gynecology X
Care of the Patient with Non-Reproductive Medical
Disorders
X
Abdominal/Pelvic Pain X X
Abnormal Uterine Bleeding X
Pelvic Mass X
Pelvic Floor Disorders X X
First Trimester Bleeding X
Patient Safety and Systems Approach to Medical
Errors
X
Cost-effective Care and Patient Advocacy X
Self-Directed Learning/Critical Appraisal of the
Medical Literature X
QI Process: Systematically analyze practice using
quality improvement methods and implement
changes with the goal of practice
improvement
Compassion, Integrity and Respect for Others X
Accountability and Responsiveness to the Needs of
Patients, Society, and the Profession X
Respect of Privacy, Autonomy and Pt/Physician
Relationship
X
Communication with Patients and Families X
Communication with Physicians and Other Health
Professionals
X
Informed Consent and Shared Decision Making X
Interpersonal and
Communication
Skills
Competency
Assessment Method
Topic
Patient Care
Medical
Knowledge
Systems Based
Practice
Problem Based
Learning and
Improvement
Professionalism
Not assessed
Not assessed
Domain Competency

Post-Match Milestones-based Medical Student
Performance Evaluation (mMSPE)
Department of Obstetrics and Gynecology
L4001 University Hospital South
1500 E. Medical Center Drive, SPC 5276
Ann Arbor, MI 48109-5276
DATE
PD name
PD address
Dear Dr. PD,
(Student name) successfully completed an Advanced Clinical Skills in Obstetrics and Gynecology elective (ie
bootcamp) at the University of Michigan in March, 2016. The content of this four-week residency preparation
course was mapped to the ACGME OBGYN level one milestones (see appendix for a description of the course
curriculum). Assessments from this course, as well as high stakes assessments from the medical school
curriculum were utilized to determine whether (student name) met level one milestones for 25 of the 28
competencies. (Student name) met or exceeded level one milestones in ___ of the 25 competencies, and his/her
performance is detailed in the table on the following page. He/She stood out for_______________________.
We hope that this information is helpful to you, and can be utilized as you build your incoming PGY1 residents’
milestones portfolio.
Sincerely,
Helen Kang Morgan, MD & Anita Malone, MD
Co-Directors, Advanced Clinical Skills in Obstetrics and Gynecology Course

Domain Competency Level One Milestone Assessments
Did not
meet
Met Exceeded
Patient Care Antepartum Care and Complications of
Pregnancy
APGO Assessment, APGO Antepartum Teaching Case
Care of Patients in the Intrapartum Period APGO Assessment, APGO Abnormal Labor Teaching
Case, Shoulder Dystocia Simulation Case
Care of Patients in the Postpartum Period APGO Assessment, APGO Postpartum Teaching Case,
Postpartum Hemorrhage Simulation Case
Obstetrical Technical Skills Suture Skills, Pelvic Exam with GTA, Decision to
Incision
Immediate Care of the Newborn NA
Gynecology Technical Skills: Laparotomy APGO Assessment, Decision to Incision, Pelvic
Anatomy
Gynecology Technical Skills: Vaginal Decision to Incision, Pelvic Anatomy
Gynecology Technical Skills: Endoscopy APGO Assessment, Decision to Incision, Pelvic
Anatomy
Peri-Operative Care APGO Assessment, Pelvic Anatomy
Family Planning APGO Assessment, APGO Family Planning Teaching
Case
Ambulatory Gynecology APGO Assessment
Care of the Patient with Non-Reproductive
Medical Disorders
APGO Assessment, M4CCA, APGO Gynecological
Procedures Teaching Case
Medical
Knowledge
Health Care Maintenance and Disease
Prevention
APGO Assessment, APGO HME Teaching Case,
M4CCA EBM
Abdominal/Pelvic Pain APGO Assessment, APGO Endometriosis Teaching
Case
Abnormal Uterine Bleeding APGO Assessment, APGO Normal and Abnormal
Uterine Bleeding Case,
Pelvic Mass APGO Assessment, APGO Ovarian Neoplasms
Teaching Case, APGO Endometrial Hyperplasia
Teaching Case
Pelvic Floor Disorders APGO Assessment, Pelvic Anatomy
First Trimester Bleeding APGO Assessment, APGO Spontaneous Abortion
Teaching Case
Systems Based
Practice
Patient Safety and Systems Approach to
Medical Errors
M4 CCA, Paging Curriculum
Cost-effective Care and Patient Advocacy NA
Problem Based
Learning and
Improvement
Self-Directed Learning/Critical Appraisal of
the Medical Literature
Literature Assessment, M4CCA
QI Process: Systematically analyze
practice using quality improvement
methods and implement changes with the
goal of practice
improvement
NA
Professionalism Compassion, Integrity and Respect for
Others
Paging Curriculum, M4CCA
Accountability and Responsiveness to the
Needs of Patients, Society, and the
Profession
Respect of Privacy, Autonomy and
Pt/Physician Relationship
Paging Curriculum
Interpersonal and
Communication
Skills
Communication with Patients and Families M4 CCA, Paging Curriculum, Decision to Incision
Communication with Physicians and Other
Health Professionals
Paging Curriculum, Decision to Incision
Informed Consent and Shared Decision
Making
Paging Curriculum, M4CCA, Decision to Incision

Did not
meet
Met Exceeded
Pregnancy
Obstetrical Technical Skills Suture Skills, Pelvic Exam with GTA, Decision to
Incision
Gynecology Technical Skills: Laparotomy APGO Assessment, Decision to Incision, Pelvic
Anatomy
Gynecology Technical Skills: Endoscopy APGO Assessment, Decision to Incision, Pelvic
Anatomy
Family Planning APGO Assessment, APGO Family Planning Teaching
Case
Medical Disorders
Medical
Knowledge
Health Care Maintenance and Disease
Prevention
APGO Assessment, APGO HME Teaching Case,
M4CCA EBM
Abdominal/Pelvic Pain APGO Assessment, APGO Endometriosis Teaching
Case
Abnormal Uterine Bleeding APGO Assessment, APGO Normal and Abnormal
Uterine Bleeding Case,
Pelvic Mass APGO Assessment, APGO Ovarian Neoplasms
Teaching Case, APGO Endometrial Hyperplasia
Teaching Case
Pelvic Floor Disorders APGO Assessment, Pelvic Anatomy
First Trimester Bleeding APGO Assessment, APGO Spontaneous Abortion
Teaching Case
Systems Based
Practice
Patient Safety and Systems Approach to
Medical Errors
M4 CCA, Paging Curriculum
Cost-effective Care and Patient Advocacy NA
Problem Based
Learning and
Improvement
Self-Directed Learning/Critical Appraisal of
the Medical Literature
Literature Assessment, M4CCA
QI Process: Systematically analyze
practice using quality improvement
methods and implement changes with the
goal of practice
improvement
NA
Professionalism Compassion, Integrity and Respect for
Others
Accountability and Responsiveness to the
Needs of Patients, Society, and the
Profession
Respect of Privacy, Autonomy and
Pt/Physician Relationship
Paging Curriculum
Interpersonal and
Communication
Skills
Communication with Patients and Families M4 CCA, Paging Curriculum, Decision to Incision
Communication with Physicians and Other
Health Professionals
Paging Curriculum, Decision to Incision
Informed Consent and Shared Decision
Making
Paging Curriculum, M4CCA, Decision to Incision
Did not
meet
Met Exceeded
Pregnancy
Obstetrical Technical Skills Suture Skills, Pelvic Exam with GTA, Decision to Incision
Gynecology Technical Skills: Laparotomy APGO Assessment, Decision to Incision, Pelvic Anatomy
Gynecology Technical Skills: Endoscopy APGO Assessment, Decision to Incision, Pelvic Anatomy
Family Planning APGO Assessment, APGO Family Planning Teaching Case
Medical Disorders

Feedback
▪Student:
“it is always nice to have a snapshot
summary of your performance”
“I definitely think the letter is useful,
both for my PD and for me… I did
not realize that I was weak in
ambulatory gynecology”
▪Program Director:
“wow this is great”
“I found this very very helpful”
“it’s a great educational handoff”

“The majority thought the proposed assessment provided new
information not available on the traditional MSPE, and one concluded
that the proposed letter would allow for early intervention for areas of
weakness”

At your institution, how
would you bridge the gap
between UME and GME
(specifically what
information would you
use?)
Ideally how should we
handover information
about low performing
learners?

MK ,PC, Prof, SBP, PBLI, ISC
Education (UME)
(GME)

Bridging the Continuum Between UME and GME

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