Lowell Tong

Development of a longitudinal integrated clerkship at an academic medical center

Abstract In 2005, medical educators at the University of California, San Francisco (UCSF), began developing the Parnassus Integrated Student Clinical Experiences (PISCES) program, a year-long longitudinal integrated clerkship at its academic medical center. The principles guiding this new clerkship were continuity with faculty preceptors, patients, and peers; a developmentally progressive curriculum with an emphasis on interdisciplinary teaching; and exposure to undiagnosed illness in acute and chronic care settings. Innovative elements included quarterly student evaluation sessions with all preceptors together, peer-to-peer evaluation, and oversight advising with an assigned faculty member. PISCES launched with eight medical students for the 2007/2008 academic year and expanded to 15 students for 2008/2009. Compared to UCSFs traditional core clerkships, evaluations from PISCES indicated significantly higher student satisfaction with faculty teaching, formal didactics, direct observation of clinical skills, and feedback. Student performance on discipline-specific examinations and United States Medical Licensing Examination step 2 CK was equivalent to and on standardized patient examinations was slightly superior to that of traditional peers. Participants’ career interests ranged from primary care to surgical subspecialties. These results demonstrate that a longitudinal integrated clerkship can be implemented successfully at a tertiary care academic medical center.

Perceptions of evaluation in longitudinal versus traditional clerkships

Medical Education 2011: 45: 464–470

Faculty verbal evaluations reveal strategies used to promote medical student performance

Abstract Background: Preceptors rarely follow medical students’ developing clinical performance over time and across disciplines. This study analyzes preceptors’ descriptions of longitudinal integrated clerkship (LIC) students’ clinical development and their identification of strategies to guide students’ progress. Methods: We used a common evaluation framework, reporter-interpreter-manager-educator, to guide multidisciplinary LIC preceptors’ discussions of students’ progress. We conducted thematic analysis of transcripts from preceptors’ (seven longitudinal ambulatory preceptors per student) quarterly group discussions of 15 students’ performance over one year. Results: All students’ clinical development progressed, although most experienced obstacles. Lack of structure in the history and physical exam commonly obstructed progression. Preceptors used templates for data gathering, and modeling or experiences in the inpatient setting to provide time and solidify structure. To advance students’ knowledge acquisition, many preceptors identified focused learning topics with their students; to promote application of knowledge, preceptors used reasoning strategies to teach the steps involved in synthesizing clinical data. Preceptors shared accountability for helping students advance as the LIC allowed them to follow students’ response to teaching strategies. Discussion: These results depict preceptors’ perceptions of LIC students’ developmental continuum and illustrate how multidisciplinary preceptors can use a common evaluation framework to identify strategies to improve performance and follow students’ performance longitudinally.

Development and Initial Testing of a Structured Clinical Observation Tool to Assess Pharmacotherapy Competence

ObjectiveThe authors developed and tested the feasibility and utility of a new direct-observation instrument to assess trainee performance of a medication management session.MethodsThe Psychopharmacotherapy-Structured Clinical Observation (P-SCO) instrument was developed based on multiple sources of expertise and then implemented in 4 university-based outpatient medication management clinics with 7 faculty supervising 17 third-year residents. After each observation by a faculty member of a medication management session, residents received feedback in writing (the completed P-SCO) and verbally in person. Targets were 8 P-SCO observations per academic year per resident (or 0.67 per month) and 16 observations per year completed by each faculty (or 1.3 per month). Qualitative thematic analysis was employed to compare the frequency, specificity, type (reinforcing vs. corrective), and content of comments documented on the P-SCO forms to midpoint and end of rotation global assessments by the same faculty for the same residents in the same rotation.ResultsFaculty completed 2.4 (SD=1,2) P-SCOs per month during the study period. Each resident received 1.1 (SD=0.53) P-SCO observations per month. Faculty and residents completed significantly more observations than targeted (p=0.03 and p=0.003, respectively). Two percent of the P-SCOs had no written comments. Less than 3% of the P-SCO comments were nonspecific compared with 43% for the global assessments. Residents received, on average, 3.3 times more total, 2.6 times more reinforcing, and 5.3 times more corrective patient care specific comments on the P-SCO than on the global assessment (p<0.001). For the numerical ratings, residents received an average of 4.2 “exceeds expectations” and 1.7 “below expectations” ratings on P-SCOs compared with 2.6 and 0, respectively, on global assessments (p<0.02).ConclusionFaculty can feasibly use the P-SCO instrument in a training clinic. Compared with traditional global assessment, the P-SCO provided much more specific feedback information, a better balance of corrective to re-enforcing comments, and a greater spread of ratings related to competency in pharmacodverbally

The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults

These Practice Guidelines for the Psychiatric Evaluation of Adults mark a transition in the American Psychiatric Association’s Practice Guidelines. Since the publication of the 2011 Institute of Medicine report Clinical Practice Guidelines We Can Trust, there has been an increasing focus on using clearly defined, transparent processes for rating the quality of evidence and the strength of the overall body of evidence in systematic reviews of the scientific literature. These guidelines were developed using a process intended to be consistent with the recommendations of the Institute of Medicine (2011), the Principles for theDevelopment of Specialty Society Clinical Guidelines of the Council of Medical Specialty Societies (2012), and the requirements of the Agency for Healthcare Research andQuality (AHRQ) for inclusion of a guideline in the National Guideline Clearinghouse. Parameters used for the guidelines’ systematic review are included with the full text of the guidelines; the development process is fully described in a document available on the APA website: http:// www.psychiatry.org/File%20Library/Practice/APA-GuidelineDevelopment-Process–updated-2011-.pdf. To supplement the expertise of members of the guideline work group, we used a “snowball” survey methodology to identify experts on psychiatric evaluation and solicit their input on aspects of the psychiatric evaluation that they saw as likely to improve specific patient outcomes (Yager 2014). Results of this expert survey are included with the full text of the practice guideline.

Legal and Ethical Changes in Consultation Psychiatry

To illustrate how legal and ethical issues have changed over the past decade for the psychiatric consultant, we thought it would be instructive to compare how consultations on equivalent patients were handled in 1980 and 1990.

The electroconvulsive therapy and anesthesia exercise (ECTAE): the creation of an interdisciplinary learning activity for medical students.

Objectives Demonstration of the effectiveness for medical student teaching of the electroconvulsive therapy (ECT)–anesthesia exercise (ECTAE). The ECTAE is a self-directed, interdisciplinary (psychiatry and anesthesia) learning exercise. Students are taught the assessment of mood and cognition using structured interviewing methods (psychiatry), basic airway and pharmacologic management (anesthesia), and informed consent and interdisciplinary communication (both). There are online pre-exercise and postexercise assessments. Methods Third-year medical students reviewed educational reference materials, participated in ECT clinical encounters with both psychiatry and anesthesia, and debriefed after completion of the interdisciplinary exercise. The impact of the exercise was evaluated through online pre- and postexercise assessments. Quantitative and qualitative results for 3 student cohorts (2007 through 2010) were analyzed. Results Thirty-eight students participated the study over 3 years. Mean scores for 21 true-false questions increased from 14.3 to 17.5 (n = 30) with P < 0.0001. Similarly, mean scores for 11 multiple choice questions increased from 6.8 to 8.9 (n = 22) with P < 0.0001. Thirty of 31 students who completed the program evaluation reported greater comfort level discussing and recommending ECT after participation in ECTAE. Conclusions The ECTAE is an effective learning activity for medical students, which incorporates cross-disciplinary learning objectives through self-directed exercises, online assessments, and actual clinical experience of ECT. It improves student knowledge of both psychiatry and anesthesia learning objectives, as well as increasing comfort about ECT. Further research could determine if this activity is easily transportable to other academic settings.

A Novel Department-Based Faculty Fellowship to Promote Scholarship in Medical Education

This report is a retrospective analysis of a novel departmentbased educational scholarship program for faculty. Its purpose is to stimulate other departments to consider replicating or adapting this modest-cost fellowship model to benefit their own faculty educators. Existing models for developing education scholarship amongst physician educators range from individual, informal reflective practices to formal longitudinal fellowships [1] and are organized at the levels of medical schools (academies, educator-scholar programs), hospitals (academies), national specialty organizations (educator-focused programs within specialty organizations), and national medical specialty educator organizations [2–7]. This report is the first known to describe a single department-based faculty fellowship in education scholarship and documents its education scholarship output and impact on academic careers.