Are they getting it? (continued)

By David Taylor, Ed.D.

Student tracking was on paper and did not lend itself to critical analysis, certainly not the kind of analysis available with a sophisticated computer database. And it was definitely not to the level of detail now required by the primary accrediting body, the Liaison Committee on Medical Education (LCME).

Role of the LCME

The major impetus for moving to a sophisticated, computerized tracking system came from the LCME a few years ago, notes Patricia Butler, M.D., associate dean of educational programs, whose office paved the way for implementing One45.

“There are lots of new rules, and we just didn’t have a way to follow them,” she says.

The horror stories of medical errors by exhausted residents working 100 hours at a stretch were making headlines, and it became clear that undergrads should be following the same rules as residents.

As Dr. Butler summarizes the clerkship situation, “We need to monitor the types of patients the students are seeing.”

She points out that rapid changes in health care today, which at first glance might not appear to be relevant, are changing students’ education. For example, consider the trend to shorter hospital stays. Cases that might have been admitted a few years ago are now handled on an outpatient basis. Short stays mean that students have fewer and briefer opportunities to see and follow a particular case, perhaps reducing the depth and continuity of care provided by students. As a corollary, students may care for a large and diverse number of increasingly ill patients in a brief period of time. Both of these trends have changed the students’ experiences of learning and care.

Allison DeGreeff, third-year medical student agrees. “I am not concerned that I will not receive adequate exposure.  There’s a vast array of pathologies seen in our institutions, and I have never felt as though I wasn’t experiencing enough.” A vast array, yes, but are they the right pathologies?

The core of learning

From Dr. Butler’s perspective, the combination of LCME regulations and the close tracking of student experiences made possible by One45, forces medical schools to carefully define their core curriculum.

Dr. Hormann spells it out: “They [LCME] want us to record what we’re doing, they want us to record what the students are doing, they want us to be able to prove that we know what the students are doing, and that they’re doing what we expect them to. The only way to do that really is to use some sort of computerized system, where we can track it.”

In his office, Dr. Hormann logs into One45, picks a random third-year student, and scrolls through her list. “OK, here’s OB-Gyn, which expects her to be there for caesarian delivery, perform a breast exam, be there for vaginal delivery. Internal medicine expects her to start an IV, do a parancentesis or a thoracentesis, get an arterial blood gas, get blood from an artery... each rotation has a different list of requirements for their clinical skills.”

The same goes for disease states. “We’ve established diagnoses we expect them to see, so we expect them to see a case of allergic rhinitis, allergies, gastroenteritis, or stomach flu, and we expect them to see asthma,” he explains.

What happens if they don’t see a crucial case or learn to perform some key skill on a patient? It turns out the LCME can be flexible on this score. “As far as the LCME is concerned, they’re happy if it’s a real patient or a simulated patient or a computer-simulated patient, or even if you sit down and talk extensively about it, as in a case discussion. They just want the student exposed to that diagnosis in some way. So we have a lot of flexibility in how we do that exposure,” Dr. Hormann says.

As useful as it may be, the new system has not been without its growing pains. Working 80-hour weeks for the first time, students often view documenting their time as a real chore – and learning the intricacies of One45 can be daunting.

“I feel that One45 has potential to be a very useful and helpful program,” notes student DeGreeff, “but in its current form, it is a burden to the students.  The forms are not very user-friendly, which encourages students to put off their documentation.” 

A paradigm shift

In his office, Dr. Hormann leans back from the screen and considers how the situation has changed. “For years, medical education assumed that as long as you were in the hospital, you must be learning. And of course that’s a good thing, but there were no real, specific expectations. We’re doing the same thing as with the residents, defining what those desired outcomes are, then developing the curriculum to get to those outcomes – rather than throwing them into an environment and hoping they will learn something.”

These two technologies represent a basic change in the approach to medical education. Just as the Turning Point ARS is transforming the lecture by giving feedback to the instructor, One45 informs the clerkship director so he can be sure the student’s hands-on learning experiences are complete. These are seismic shifts that span the entire educational experience of medical students – the type of change that future physicians might wonder how they ever did without.