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Surgical subinternships: bridging the chiasm between medical school and residency
Accepted Manuscript Surgical Subinternships: Bridging The Chiasm Between Medical School And Residency Nabil Issa , Alan P. Ladd , Anne O. Lidor , Rebecca S. Sippel , Steve B. Goldin PII:
S0002-9610(14)00574-1
DOI:
10.1016/j.amjsurg.2014.10.006
Reference:
AJS 11343
To appear in:
The American Journal of Surgery
Received Date: 14 September 2014 Revised Date:
29 October 2014
Accepted Date: 30 October 2014
Please cite this article as: Issa N, Ladd AP, Lidor AO, Sippel RS, Goldin SB, Surgical Subinternships: Bridging The Chiasm Between Medical School And Residency, The American Journal of Surgery (2014), doi: 10.1016/j.amjsurg.2014.10.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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SURGICAL SUBINTERNSHIPS: BRIDGING THE CHIASM BETWEEN
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MEDICAL SCHOOL AND RESIDENCY A position paper prepared by the Subcommittee for Surgery Subinternship and the Curriculum Committee of the Association for Surgical Education (ASE)
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ABSTRACT
This effort is based on our observation that there is lack of good peer-reviewed
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literature and absence of published guidelines from national surgical organizations regarding the administrative structure and the curricular elements essential for evidence-based and educationally sound surgical subinternship rotations. Through synthesis of the literature, and by employing an iterative process among members of the Subcommittee for Surgery
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Subinternship and the Curriculum Committee of the Association for Surgical Education (ASE), it is the recommendation of the group that surgery subinternship rotations should evolve within
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five well-defined domains: administrative structure, goals and objectives, curricular elements, instructional methods and assessment tools. These recommendations provides a blue print for
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establishing a structured, educationally sound, and rewarding surgery subinternship rotation for medical students. The recommendation to create a separate administrative structure for the rotation should serve as an incentive for surgery department chairs to enhance the educational mission of their department and open additional leadership opportunities for faculty. It also provides means to recruit more students into the specialty. For the subinternship director, the rotation provides potential for career development as educators and opportunities for scholarly activities for academic advancement.
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SURGICAL SUBINTERNSHIPS: BRIDGING THE CHIASM BETWEEN MEDICAL SCHOOL AND RESIDENCY
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A position paper prepared by the Subcommittee for Surgery Subinternship and the Curriculum Committee of the Association for Surgical Education (ASE)
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Nabil Issa, Alan P Ladd, Anne O Lidor, Rebecca S Sippel, Steve B Goldin
INTRODUCTION
Subinternships are clinical rotations usually completed during the final year of medical school. Subinternships provide medical students with experiential exposure to patient care in
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the clinical setting with varying degrees of graded autonomy in evaluating patients, creating care plans, and getting involved in various clinical procedures. These rotations help students become familiar with the type of patients and the scope of clinical practice of a particular
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discipline. Such immersive exposure helps solidify the student’s interest in pursuing a career in that discipline through residency training. Undertaking a subinternship rotation can also
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provide students with close working relationships with faculty to provide recommendations and letters of support for residency application. BACKGROUND
Recent changes in graduate medical education rules and regulations, in physician financial compensation models, and medical legal issues have led to requirements of more
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direct involvement of faculty and more experienced residents in daily clinical activities, allowing fewer opportunities for medical students to be involved in direct patient care. [1] The
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diminishing opportunities for clinical experiences offered to medical students have been noted by residency program directors of various specialties. [2] When viewed through the six competencies advocated by the Accreditation Council for Graduate Medical Education
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(ACGME), program directors of different specialties including surgery, indicated that medical schools graduates had significant gaps in their clinical performance, and suggested that these
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gaps need to be bridged before new residents assume independent care of patients. [2-4] Residency program directors noted that students lacked skills in self-reflection and selfimprovement, were unfamiliar with the effective use of technology to review evidence-based guidelines, lacked advanced clinical reasoning when managing complex patients, found
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difficulties caring for multiple patients simultaneously, and lacked proper communications skills particularly during difficult communications with patients and families. [3, 4] Clinical subinternships provide great opportunities for medical students to take
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ownership of actual patients and increase their autonomy. However, unlike third-year clerkship
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rotations, subinternships in many institutions lack well-defined structure or explicit curriculum. Students on these rotations mainly shadow residents as they perform daily tasks of patient-care with variable degree of interactions with service faculty. [5] Most of these rotations do not comply with the basic tenants required for an educationally sound clinical experience including: explicit objectives, defined curriculum, and clear assessment tools. They also often lack opportunities to write orders and perform structured hand-offs of patient care. In addition, most of these rotations lack the administrative structure or didactic curriculum that would 2
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support meaningful educational experiences such as a dedicated coordinator for the educational activities or supervised meetings to discuss patient management concepts. [6]
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PROBLEM Several specialties including Internal Medicine, Family Medicine, Obstetrics and
Gynecology and Emergency Medicine, have developed evidence-based curricula for specialty-
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specific subinternship rotations and advocated for these rotations to adopt innovative
instructional strategies, and meaningful assessment methods that provide timely feedback to
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students. [7-10] There are no guidelines from national surgical societies to inform the development of similar educationally sound, surgical subinternships. STATE OF THE SURGERY SUBINTERNSHIP TODAY
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There is lack of good peer-reviewed literature and absence of published guidelines from national surgical organizations regarding curricular elements for surgical subinternships. Lindeman et al., surveyed more than 250 applicants to a surgical residency program who had
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enrolled in surgical subinternships prior to their application and concluded, “surgical
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subinternships lacked central organization or unifying curriculum”. [5] The study noted that while the majority of surgery subinternships provided students with opportunities for clinical case presentations and for taking call with junior residents, a significant number of these rotations lacked explicit goals and objectives, did not provide students with dedicated time with faculty to discuss common clinical problems and was devoid of technical and procedural skills laboratories. In a collaborative effort between three major national surgical organizations; the American College of Surgeons (ACS), the Association for Program Directors in Surgery (APDS) 3
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and the Association for Surgical Education (ASE), a needs assessment survey was conducted among interns, chief surgery residents, and surgical faculty from 11 medical institutions. The
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survey provided cognitive and procedural elements to create a national four-week curriculum with summative assessments for a surgery boot camp designed to achieve a set of competencybased goals and objectives targeting critical cognitive and procedural skills essential to all
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incoming surgery residents. Recognizing the limited impact a single boot camp could exert on student’s development, the curriculum committee for the surgery collaborative called for a
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more comprehensive redesign of medical schools curricula, specifically the structure and goals for the final year of school to promote better transition of student graduates into their roles as new residents. [11]
The Subcommittee for Surgery Subinternship and the Curriculum Committee at the ASE
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noted that the findings from the surgical collaborative group needs assessment survey and those from the Lindeman et al. study provides appropriate bases to inform the development of
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a well-structured surgery subinternship rotation. SUGGESTED EVOLUTION OF THE SURGERY SUBINTERNSHIP
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Through synthesis of the literature, and by employing an iterative process among
members of the Subcommittee for Surgery Subinternship and the Curriculum Committee of the Association for Surgical Education (ASE), it is the recommendation of the group that surgery subinternship rotations should evolve within five well-defined domains: administrative structure, goals and objectives, curricular elements, instructional methods and assessment tools. 4
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Administrative Structure A pivotal component for developing a robust surgical subinternship experience is the
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creation of a financial and administrative structure for the rotation that is collaborative but separate from that of the M3 surgery clerkship. The separation of the two positions allows for specialization and encourages innovation; provides senior medical students with opportunities
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for personalized mentorship and targeted career advice which is particularly important during the residency application process; and finally it provides additional educational leadership
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positions for faculty in the department of surgery. Surgery subinternship directors should petition the Medical School as well as the Department of Surgery at their institutions to help fund and coordinate the educational activities on the rotation and to ensure a meaningful educational experience for medical students attending surgery subinternship rotations. The
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administrative structure may be through one of three designs. The first design calls for the creation of a separate leadership position of a Subinternship Director, with a separate position for a dedicated administrative coordinator. An alternative proposal is that the M3 Clerkship
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Director and the M4 Subinternship Director share a single administrative coordinator. A third
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suggestion would be to maintain one director for both M3 Clerkship and M4 Subinternship with two separate administrative coordinators. There are merits, as well as downfalls, to each of these combinations depending on the logistics, finances, time commitments, and structural considerations within specific institutions. Figure 1 depicts three proposals for administrative structure for the surgery subinternship in relation to the Surgery Clerkship.
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The surgery subinternship director will need to create a curriculum that emphasizes the clinical application of medical knowledge within the context of actual patient care. The
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curriculum should build on but not duplicate M3 clerkship goals and experiences as outlined by the ASE publication “Manual for Surgical Objectives.” [12] The director for the rotation should work closely with residency program leadership, clinical faculty, residents, and allied healthcare
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professionals to define expectations and promote the integration of subinterns into clinical care teams where students can develop their own independent clinical skills under direct and
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indirect supervision and exhibit commitment and ownership to their patients. The choice of clinical rotations should ensure optimal experiences for the subinterns, taking into account the patient population and pathology encountered through the different clinical services and the number of other learners simultaneously present on the rotation e.g.
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junior residents, M3 students, PA students and others.
A formal orientation session should introduce students to the goals and objectives of
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the rotation including administrative tasks and rules. The orientation should also indicate the educational syllabus and time schedules, the reading assignments and finally the assessment
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methods and grading policies. During orientation, it is important to emphasize professionalism traits expected of the students, including ownership of patient care, compassion, and integrity during interactions with patients, their families and with other healthcare providers. To monitor the student’s educational performance, it is also important to create case and procedure logs that help both students and rotation director identify gaps in clinical experiences and provide practical remedies to address such deficiencies. Mid-rotation
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feedback sessions and end of rotation evaluation meetings will help the director to track progress and address pitfalls in a timely fashion.
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The Subinternship Director will also act as a surgery career advisor, and a coach for students interested in pursuing careers in surgery. This includes providing advice on choosing mentors, identifying research and leadership opportunities, assisting with personal statement
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writing, choosing institutional and away clinical rotations, assisting with the residency
application process, developing mock interviews and interview coaching, among other tasks
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deemed important for student placement into surgical residency programs. Goals and Objectives
The surgical subinternship should have distinct sets of knowledge, skills, and attitudes that build
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on but are distinct from those of the surgery clerkship. The surgery clerkship goals provide undifferentiated students with basic knowledge of surgical diseases and conditions. The surgery clerkship introduces undifferentiated students to the role the surgeon plays in the
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multidisciplinary care of patients. The clerkship also fosters interest in medical students to pursue surgical careers through mentorship and inclusion into the daily lives and practice of
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surgeons. [13] On the other hand, the surgery subinternship emphasizes the clinical application of medical knowledge within the context of actual patient care. The goal for surgery subinternships is to prepare students with the attitudinal, cognitive, and procedural skills required to make the transition into their future roles as residents capable of providing safe and efficient care for patients on day one of residency. To increase the clinical autonomy of the subinterns and to increase their sense of ownership, it would be helpful to assign subinterns to 7
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those clinical services that lack an intern. Otherwise, it would be important to ensure that they are assigned clinical loads that are similar to those expected of the intern on the service. In this
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situation, it is important for faculty and senior residents on the service to define the expectations and maintain the separation of roles between interns and subinterns. Explicit competency-based objectives should be developed and implemented to ensure the best
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educational outcomes for students. Additionally, competency-based goals and objectives of the rotation should preferably map into the six core competency structure proposed by the
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Accreditation council of Graduate Medical Education (ACGME); patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and system-based practice. More recently, The Association of American Medical Colleges (AAMC) introduced the Core Entrustable Professional Activities to Entering
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Residency (CEPAER). [14] The core Entrustable Professional Activities (EPA)’s are defined behaviors and activities that should be expected of all students graduating from medical schools and entering into residency programs regardless of the chosen specialty. The AAMC
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encouraged medical schools to adopt these EPA’s as competency outcomes for their graduates. Surgical subinternships should incorporate these within their goals and objectives. See table 1
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for Surgery Subinternship objectives incorporating the Association of American Medical Schools (AAMC) Entrustable Professional Activities (EPA)’s and mapped to the 6 ACGME core competencies with suggested instructional strategies and assessment methods. Curricular Elements Curricular elements for the surgery subinternship should address the Accreditation Council for Graduate Medical Education (ACGME) published competencies. Clinical tasks for 8
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subinterns should promote clinical decision-making in addition to simple knowledge recall. The rotation should provide subinterns with opportunities to independently evaluate patients and
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construct evidence-based management plans utilizing informatics and electronic resources. Students should demonstrate the ability to write orders, present cases concisely and efficiently, and discuss plans with faculty and care teams to gain timely feedback. The rotation should
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develop a student’s sense of ownership during transitions of care through instruction in and performance of safe patient hand-offs. Basic understanding of patient safety issues and quality
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control systems within healthcare institutions are also important curricular elements for the rotation. The subinternship rotation should promote communication skills essential for the daily care of patients, including calling for consultations, timely follow-up on daily care plans, answering pages, triaging multiple simultaneous patients and managing patients that are
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unfamiliar to them. They should become aware of essential communication skills to participate in difficult conversations with patients and families. The rotations should provide students with opportunities to develop essential procedural skills including bedside wound management, care
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for tubes and drains, suturing and knot tying, tube thoracostomy insertion, central line placement, and the use of bedside ultrasound for line placement and for Focused Assessment
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with Sonography for Trauma (FAST). Instructional Strategies
There should exist weekly protected time for educational activities under the direct
supervision of the rotation director. Educational activities should include professor rounds e.g. bedside rounds or meeting within a protected environment for in-depth discussion of patient
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assessment and plan of care development. The format for these rounds should be case-based discussions of patient-centered care to promote higher thinking skills for subinterns in a relaxed
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non-judgmental atmosphere. A detailed, but not lengthy, list for independent readings for nonclinical topics should be available and include topics on patient safety, quality
methodologies, and the principles of evidence-based practice. Web-based learning modules
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should be encouraged for communication topics, discharge planning, and patient handoff skills. The rotation should also provide access to a technical skills laboratory where students are
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provided with proctored practice and timely feedback. Clinical proctors should also directly observe student history and physical examination (H&P) skills and provide them with timely feedback to improve their performance. Proctors should also discuss and critique management plans with an emphasis on evidence-based guidelines. Finally, utilizing simulations, when
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available, would allow for focused training on isolated patient care issues with increased reproducibility and assurance of exposure to defined curricular elements that may not be
Assessment tools
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readily available during daily service.
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Assessment of subinterns should be comprehensive and targeted to provide meaningful feedback. This can be done through a composite scoring system that is made open and clear to students at the beginning of the rotation. The composite score should include clinical appraisals by faculty, 360o appraisals by residents and nursing staff involved in patient care on the services they rotate through, performance evaluations of procedural skills, professionalism points for the timely completion of reading and project assignments. It is also valuable to
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include an end of rotation essay that would demonstrate the student’s adaptive thinking regarding the application of patient safety concepts to daily patient care practices, or the
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implementation of quality control systems within healthcare institutions, or the institution of evidence-based practice protocols to improve patient outcomes. The condensed time of a 4week rotation may not be ideal for comprehensive summative assessments for cognitive and
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procedural skills among subinterns and the limited time would not allow for meaningful
remediation. In addition, such tests may divert the attention and efforts of subinterns away
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from the required tasks. The subinternship should be viewed as a venue for "deliberative practice" and "reflective practice" of clinical skills that builds to a finishing course like the residency preparatory curriculum or a capstone course with a preparatory curriculum layered around it. We encourage medical schools to adopt a “Capstone” course or an end of year “Boot
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Camp” including the ACS/ASE/APDS Surgical Residency Preparatory Curriculum where summative assessments are applied [15] The implementation of these end of year course allows medical schools to assess student’s competencies and achievement of entrustment
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graduation.
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behaviors, while providing ample time for remediation strategies closer to student’s
EVALUATING THE SUBINTERNSHIP It is important to design meaningful evaluation strategies to ensure that the goals and objectives of the rotation are accomplished. Reviewing student’s clinical and procedural logs during and at the completion of the rotation as well as generating an end of year categorized summary of these resources can identify pitfalls and inform further development of the
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curricular elements for the subinternship. End of rotation evaluation surveys to students, and end of year surveys to residents, and faculty can provide good insights on the administrative
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and educational strategies of the rotation. Surveying graduates and program directors at residency programs to which they match would assess their preparation for their roles as residents. Surgery subinternships should be a vibrant and relevant experience that is
dependable residents.
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EXPECTED BARRIERS AND POTENTIAL SOLUTIONS
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continuously evolving to address the needs of the students and help them be productive and
The creation of a structured surgical subinternship rotation is a major institutional change that requires commitment and vision by departmental leadership, innovation and ownership by faculty, as well as commitment of financial and administrative resources by the medical school.
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Faculty’s time and the availability of financial resources remain the major two barriers for the creation and maintenance of an educationally sound surgery subinternship clerkship.
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Innovative approaches are required to address these two important issues based on the local institutional structure and culture for each institution. While we do acknowledge that financial
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constraints and emphasis on clinical productivity are global barriers facing faculty recruitment, it is important to emphasis that incentives can be in the form of acknowledgement of efforts, creation of leadership positions, improving academic and research productivity as well as academic promotion. When petitioning the department of surgery and the medical school to provide a steady stream of financial and administrative support it would be helpful to indicate the value added by the new structured rotation, in the form of increasing student recruitment
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into the specialty and improving student education and preparedness for residency which would ultimately add to the positive reputation of both the department and the medical school.
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Moreover, the thrust for the creation of relevant modules and well defined experiences through a national standardized subinternship curriculum could provide a shared platform of resources that would help offset the costs that any one program may be required to invest for
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this endeavor.
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SUMMARY
The surgery subinternship should be viewed as a venue to ensure students are given graded responsibilities, are developing their higher thinking skills and are made aware of patient safety principles & application of evidence-based practices. This effort by the Surgery Subinternship
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Subcommittee and the Curriculum Committee at the ASE provides a blue print for establishing a structured, educationally sound, and rewarding surgery subinternship rotation for medical
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students. The recommendation to create a separate administrative structure for the rotation should serve as an incentive for surgery department chairs to enhance the educational mission
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of their department and open additional leadership opportunities for faculty. It also provides means to recruit more students into the specialty. For the sub-internship director, the rotation provides potential for career development as educators and opportunities for scholarly activities for academic advancement.
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REFERENCES [1] White, Casey B., Hilary M. Haftel, Joel A. Purkiss, Amy S. Schigelone, and Maya M.
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Hammoud. "Multidimensional effects of the 80-hour work week at the University of Michigan Medical School." Academic Medicine 81, no. 1 (2006): 57-62.
[2] Lyss-Lerman, Pamela, Arianne Teherani, Eva Aagaard, Helen Loeser, Molly Cooke, and G.
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Michael Harper. "What training is needed in the fourth year of medical school? Views of
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residency program directors." Academic Medicine 84, no. 7 (2009): 823-829. [3] Paolo, Anthony M., and Giulia A. Bonaminio. "Measuring outcomes of undergraduate medical education: residency directors' ratings of first-year residents." Academic Medicine 78, no. 1 (2003): 90-95.
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[4] Langdale, Lorrie A., Doug Schaad, Joyce Wipf, Susan Marshall, Louis Vontver, and Craig S. Scott. "Preparing graduates for the first year of residency: are medical schools
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meeting the need?." Academic Medicine 78, no. 1 (2003): 39-44. [5] Lindeman, Brenessa M., Pamela A. Lipsett, Adnan Alseidi, and Anne O. Lidor. "Medical
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student subinternships in surgery: characterization and needs assessment." The American Journal of Surgery 205, no. 2 (2013): 175-181.
[6] Fagan, Mark J., Raymond H. Curry, and Susan J. Gallagher. "The evolving role of the acting internship in the medical school curriculum." The American journal of medicine 104, no. 5 (1998): 409.
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[7] Sidlow, Robert. "The structure and content of the medical subinternship."Journal of general internal medicine 16, no. 8 (2001): 550-553.
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[8] Hueston, William J., Richelle J. Koopman, and Alexander W. Chessman. "A suggested fourth-year curriculum for medical students planning on entering family medicine." FAMILY MEDICINE-KANSAS CITY- 36, no. 2 (2004): 118-122.
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[9] Walton, Leslie A., Dee E. Fenner, Vicki L. Seltzer, George D. Wilbanks, Douglas W. Laube, M. Carlyle Crenshaw, Robert H. Messer, and Ralph H. Hale. "The fourth-year medical
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school curriculum: recommendations of the Association of Professors of Gynecology and Obstetrics and the Council on Resident Education in Obstetrics and Gynecology." American journal of obstetrics and gynecology 169, no. 1 (1993): 13-16. Coates, Wendy C. "The emergency medicine subinternship—an educator's guide
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[10]
to planning and administration." Academic Emergency Medicine 12, no. 2 (2005): 129-
[11]
Minter RM, Amos KD, Bentz ML, et al. “Transition to Surgical Residency: A Multi-
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129.
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institutional Study of the Effect of Formal Preparatory Curricula in the Fourth Year of Medical School.” Accessed at: https://www.facs.org/~/media/files/education/acsapdsasebrochure.ashx. And
Academic Medicine (in press).
[12]
Curriculum Committee Association for Surgical Education. Manual of surgical
objectives. 4th ed. Springfield (IL): the Association; 1988
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[13]
Reid, Chris M., Dennis Y. Kim, Jess Mandel, Alan Smith, Mark A. Talamini, and
Vishal Bansal. "Impact of a Third-Year Surgical Apprenticeship Model: Perceptions and
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Attitudes Compared with the Traditional Medical Student Clerkship Experience." Journal of the American College of Surgeons 218, no. 5 (2014): 1032-1037. www.aamc.org/cepaer
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[14]
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Table 1- Surgery subintership objectives mapped to the ACGME 6 core competencies and the AAMC’s core Entrustable activities for entering Residency (CEPAER) with suggested instructional strategies and assessment methods.
Instructional Strategies
1. Perform and present concise history and physical exam (EPA 1/ EPA 6) 2. Develop and prioritize differential diagnosis and select working diagnosis following a patient encounter (EPA 2) 3. Recommend and interpret common diagnostic and screening tests (EPA 3) 4. Discuss patient orders/ prescriptions and construct evidence-based management plans (EPA 4) 5. Provide documentation of clinical encounters in written or electronic format (EPA 5) 6. Triage and manage multiple patients 7. Perform bedside procedures: wound care, laceration repair, care for drains and tubes, central lines, chest tubes, ultrasound utilization, suturing and knot tying (EPA 12)
Daily rounds, case-based discussions, web-based modules, chart audits, simulation
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Patient Care
Surgery Subinternship Objective
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ACGME Core Competency
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1. Identify and manage unstable and critically ill patient (equivalent to EPA 10) 2. Manage common perioperative patient problems 3. Demonstrate understanding of the pharmacology of common meds: analgesia, nausea/vomiting meds, antibiotic groups 4. Demonstrate understanding of the relevant anatomy for common surgical procedures 5. Demonstrate the understanding of common surgical equipment and materials e.g. The electro-surgical unit, Types of mesh and suture materials 1. Identify strengths, deficiencies, and limits in one’s knowledge and expertise 2. Set learning and improvement goals 3. Demonstrate effective use of electronic resources into daily practice and personal improvement (equivalent to EPA 7)
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Practice-based learning and improvement
Direct Observation Forms and Professor rounds, Clinical appraisals, Simulation
Videos, skills lab, OR teaching Skills lab, clinical appraisals
Independent readings, didactics, web modules, simulation
Multiple choice questions, simulation Mock pages, small group presentations
Daily rounds, Professor rounds, attending morbidity and mortality (M&M) conferences
Clinical appraisals, writing an essay
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Medical Knowledge
Assessment Methods
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4. Incorporate feedback, self-reflection and improvement into daily practice
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Table 1- Surgery subintership objectives mapped to the ACGME 6 core competencies and the AAMC’s core Entrustable activities for entering Residency (CEPAER) with suggested instructional strategies and assessment methods.
Didactic, role-play, web-based modules, simulation
Mock pages, simulation
Professionalism 1. Demonstrate timely completion of administrative tasks 2. Demonstrate compassion, integrity, and respect for others 3. Demonstrate responsiveness to patient needs that supersedes selfinterest 4. Demonstrate accountability to patients, society and the profession 5. Seek and apply modifications to improve own efforts and demeanor based on feedback
Orientation session
Log review, clinical appraisals
Didactic, independent readings, web-based modules
Multiple choice questions, writing essay
System-based practice
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Interpersonal 1. Communicate effectively with patients and families respecting cultural and socio-economic backgrounds and communication 2. Work effectively as a productive and dependable member of the healthcare team (equivalent to EPA 9) skills 3. Demonstrate structured and effective communication skills when answering pages 4. Perform structured sign-outs during transitions of care (equivalent to EPA 8) 5. Obtain informed consent for tests and/ or procedures (EPA 11) 6. Demonstrate effective and efficient communication skills during interactions with healthcare professionals 7. Demonstrate sensitivity and empathy during difficult communications
1. Demonstrate understanding for principles of patient safety practices (EPA 13) 2. Demonstrate understanding for principles of quality improvements within the healthcare system (EPA 13)
EPA= Entrustable Professional Activities
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Figure 1 Suggested administrative structures for the Surgery Subinternship in Relation to the Surgery
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Clerkship. 1 – Different directors and administrative assistants, 2 - different directors and same administrative assistants, 3 – same director and different administrative assistants.
Subinternship Director
Clerkship Director
Subinternship
Clerkship
Administrative Assistant
Administrative Assistant
Subinternship Director
Clerkship Director
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(2)
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(1)
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Subinternship & Clerkship
(3)
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Administrative Assistant
Clerkship &
Subinternship Director
Subinternship
Clerkship
Administrative Assistant
Administrative Assistant
S0002-9610(14)00574-1
DOI:
10.1016/j.amjsurg.2014.10.006
Reference:
AJS 11343
To appear in:
The American Journal of Surgery
Received Date: 14 September 2014 Revised Date:
29 October 2014
Accepted Date: 30 October 2014
Please cite this article as: Issa N, Ladd AP, Lidor AO, Sippel RS, Goldin SB, Surgical Subinternships: Bridging The Chiasm Between Medical School And Residency, The American Journal of Surgery (2014), doi: 10.1016/j.amjsurg.2014.10.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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SURGICAL SUBINTERNSHIPS: BRIDGING THE CHIASM BETWEEN
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MEDICAL SCHOOL AND RESIDENCY A position paper prepared by the Subcommittee for Surgery Subinternship and the Curriculum Committee of the Association for Surgical Education (ASE)
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ABSTRACT
This effort is based on our observation that there is lack of good peer-reviewed
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literature and absence of published guidelines from national surgical organizations regarding the administrative structure and the curricular elements essential for evidence-based and educationally sound surgical subinternship rotations. Through synthesis of the literature, and by employing an iterative process among members of the Subcommittee for Surgery
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Subinternship and the Curriculum Committee of the Association for Surgical Education (ASE), it is the recommendation of the group that surgery subinternship rotations should evolve within
EP
five well-defined domains: administrative structure, goals and objectives, curricular elements, instructional methods and assessment tools. These recommendations provides a blue print for
AC C
establishing a structured, educationally sound, and rewarding surgery subinternship rotation for medical students. The recommendation to create a separate administrative structure for the rotation should serve as an incentive for surgery department chairs to enhance the educational mission of their department and open additional leadership opportunities for faculty. It also provides means to recruit more students into the specialty. For the subinternship director, the rotation provides potential for career development as educators and opportunities for scholarly activities for academic advancement.
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SURGICAL SUBINTERNSHIPS: BRIDGING THE CHIASM BETWEEN MEDICAL SCHOOL AND RESIDENCY
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A position paper prepared by the Subcommittee for Surgery Subinternship and the Curriculum Committee of the Association for Surgical Education (ASE)
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Nabil Issa, Alan P Ladd, Anne O Lidor, Rebecca S Sippel, Steve B Goldin
INTRODUCTION
Subinternships are clinical rotations usually completed during the final year of medical school. Subinternships provide medical students with experiential exposure to patient care in
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the clinical setting with varying degrees of graded autonomy in evaluating patients, creating care plans, and getting involved in various clinical procedures. These rotations help students become familiar with the type of patients and the scope of clinical practice of a particular
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discipline. Such immersive exposure helps solidify the student’s interest in pursuing a career in that discipline through residency training. Undertaking a subinternship rotation can also
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provide students with close working relationships with faculty to provide recommendations and letters of support for residency application. BACKGROUND
Recent changes in graduate medical education rules and regulations, in physician financial compensation models, and medical legal issues have led to requirements of more
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direct involvement of faculty and more experienced residents in daily clinical activities, allowing fewer opportunities for medical students to be involved in direct patient care. [1] The
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diminishing opportunities for clinical experiences offered to medical students have been noted by residency program directors of various specialties. [2] When viewed through the six competencies advocated by the Accreditation Council for Graduate Medical Education
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(ACGME), program directors of different specialties including surgery, indicated that medical schools graduates had significant gaps in their clinical performance, and suggested that these
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gaps need to be bridged before new residents assume independent care of patients. [2-4] Residency program directors noted that students lacked skills in self-reflection and selfimprovement, were unfamiliar with the effective use of technology to review evidence-based guidelines, lacked advanced clinical reasoning when managing complex patients, found
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difficulties caring for multiple patients simultaneously, and lacked proper communications skills particularly during difficult communications with patients and families. [3, 4] Clinical subinternships provide great opportunities for medical students to take
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ownership of actual patients and increase their autonomy. However, unlike third-year clerkship
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rotations, subinternships in many institutions lack well-defined structure or explicit curriculum. Students on these rotations mainly shadow residents as they perform daily tasks of patient-care with variable degree of interactions with service faculty. [5] Most of these rotations do not comply with the basic tenants required for an educationally sound clinical experience including: explicit objectives, defined curriculum, and clear assessment tools. They also often lack opportunities to write orders and perform structured hand-offs of patient care. In addition, most of these rotations lack the administrative structure or didactic curriculum that would 2
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support meaningful educational experiences such as a dedicated coordinator for the educational activities or supervised meetings to discuss patient management concepts. [6]
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PROBLEM Several specialties including Internal Medicine, Family Medicine, Obstetrics and
Gynecology and Emergency Medicine, have developed evidence-based curricula for specialty-
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specific subinternship rotations and advocated for these rotations to adopt innovative
instructional strategies, and meaningful assessment methods that provide timely feedback to
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students. [7-10] There are no guidelines from national surgical societies to inform the development of similar educationally sound, surgical subinternships. STATE OF THE SURGERY SUBINTERNSHIP TODAY
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There is lack of good peer-reviewed literature and absence of published guidelines from national surgical organizations regarding curricular elements for surgical subinternships. Lindeman et al., surveyed more than 250 applicants to a surgical residency program who had
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enrolled in surgical subinternships prior to their application and concluded, “surgical
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subinternships lacked central organization or unifying curriculum”. [5] The study noted that while the majority of surgery subinternships provided students with opportunities for clinical case presentations and for taking call with junior residents, a significant number of these rotations lacked explicit goals and objectives, did not provide students with dedicated time with faculty to discuss common clinical problems and was devoid of technical and procedural skills laboratories. In a collaborative effort between three major national surgical organizations; the American College of Surgeons (ACS), the Association for Program Directors in Surgery (APDS) 3
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and the Association for Surgical Education (ASE), a needs assessment survey was conducted among interns, chief surgery residents, and surgical faculty from 11 medical institutions. The
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survey provided cognitive and procedural elements to create a national four-week curriculum with summative assessments for a surgery boot camp designed to achieve a set of competencybased goals and objectives targeting critical cognitive and procedural skills essential to all
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incoming surgery residents. Recognizing the limited impact a single boot camp could exert on student’s development, the curriculum committee for the surgery collaborative called for a
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more comprehensive redesign of medical schools curricula, specifically the structure and goals for the final year of school to promote better transition of student graduates into their roles as new residents. [11]
The Subcommittee for Surgery Subinternship and the Curriculum Committee at the ASE
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noted that the findings from the surgical collaborative group needs assessment survey and those from the Lindeman et al. study provides appropriate bases to inform the development of
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a well-structured surgery subinternship rotation. SUGGESTED EVOLUTION OF THE SURGERY SUBINTERNSHIP
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Through synthesis of the literature, and by employing an iterative process among
members of the Subcommittee for Surgery Subinternship and the Curriculum Committee of the Association for Surgical Education (ASE), it is the recommendation of the group that surgery subinternship rotations should evolve within five well-defined domains: administrative structure, goals and objectives, curricular elements, instructional methods and assessment tools. 4
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Administrative Structure A pivotal component for developing a robust surgical subinternship experience is the
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creation of a financial and administrative structure for the rotation that is collaborative but separate from that of the M3 surgery clerkship. The separation of the two positions allows for specialization and encourages innovation; provides senior medical students with opportunities
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for personalized mentorship and targeted career advice which is particularly important during the residency application process; and finally it provides additional educational leadership
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positions for faculty in the department of surgery. Surgery subinternship directors should petition the Medical School as well as the Department of Surgery at their institutions to help fund and coordinate the educational activities on the rotation and to ensure a meaningful educational experience for medical students attending surgery subinternship rotations. The
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administrative structure may be through one of three designs. The first design calls for the creation of a separate leadership position of a Subinternship Director, with a separate position for a dedicated administrative coordinator. An alternative proposal is that the M3 Clerkship
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Director and the M4 Subinternship Director share a single administrative coordinator. A third
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suggestion would be to maintain one director for both M3 Clerkship and M4 Subinternship with two separate administrative coordinators. There are merits, as well as downfalls, to each of these combinations depending on the logistics, finances, time commitments, and structural considerations within specific institutions. Figure 1 depicts three proposals for administrative structure for the surgery subinternship in relation to the Surgery Clerkship.
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The surgery subinternship director will need to create a curriculum that emphasizes the clinical application of medical knowledge within the context of actual patient care. The
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curriculum should build on but not duplicate M3 clerkship goals and experiences as outlined by the ASE publication “Manual for Surgical Objectives.” [12] The director for the rotation should work closely with residency program leadership, clinical faculty, residents, and allied healthcare
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professionals to define expectations and promote the integration of subinterns into clinical care teams where students can develop their own independent clinical skills under direct and
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indirect supervision and exhibit commitment and ownership to their patients. The choice of clinical rotations should ensure optimal experiences for the subinterns, taking into account the patient population and pathology encountered through the different clinical services and the number of other learners simultaneously present on the rotation e.g.
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junior residents, M3 students, PA students and others.
A formal orientation session should introduce students to the goals and objectives of
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the rotation including administrative tasks and rules. The orientation should also indicate the educational syllabus and time schedules, the reading assignments and finally the assessment
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methods and grading policies. During orientation, it is important to emphasize professionalism traits expected of the students, including ownership of patient care, compassion, and integrity during interactions with patients, their families and with other healthcare providers. To monitor the student’s educational performance, it is also important to create case and procedure logs that help both students and rotation director identify gaps in clinical experiences and provide practical remedies to address such deficiencies. Mid-rotation
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feedback sessions and end of rotation evaluation meetings will help the director to track progress and address pitfalls in a timely fashion.
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The Subinternship Director will also act as a surgery career advisor, and a coach for students interested in pursuing careers in surgery. This includes providing advice on choosing mentors, identifying research and leadership opportunities, assisting with personal statement
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writing, choosing institutional and away clinical rotations, assisting with the residency
application process, developing mock interviews and interview coaching, among other tasks
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deemed important for student placement into surgical residency programs. Goals and Objectives
The surgical subinternship should have distinct sets of knowledge, skills, and attitudes that build
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on but are distinct from those of the surgery clerkship. The surgery clerkship goals provide undifferentiated students with basic knowledge of surgical diseases and conditions. The surgery clerkship introduces undifferentiated students to the role the surgeon plays in the
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multidisciplinary care of patients. The clerkship also fosters interest in medical students to pursue surgical careers through mentorship and inclusion into the daily lives and practice of
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surgeons. [13] On the other hand, the surgery subinternship emphasizes the clinical application of medical knowledge within the context of actual patient care. The goal for surgery subinternships is to prepare students with the attitudinal, cognitive, and procedural skills required to make the transition into their future roles as residents capable of providing safe and efficient care for patients on day one of residency. To increase the clinical autonomy of the subinterns and to increase their sense of ownership, it would be helpful to assign subinterns to 7
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those clinical services that lack an intern. Otherwise, it would be important to ensure that they are assigned clinical loads that are similar to those expected of the intern on the service. In this
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situation, it is important for faculty and senior residents on the service to define the expectations and maintain the separation of roles between interns and subinterns. Explicit competency-based objectives should be developed and implemented to ensure the best
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educational outcomes for students. Additionally, competency-based goals and objectives of the rotation should preferably map into the six core competency structure proposed by the
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Accreditation council of Graduate Medical Education (ACGME); patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and system-based practice. More recently, The Association of American Medical Colleges (AAMC) introduced the Core Entrustable Professional Activities to Entering
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Residency (CEPAER). [14] The core Entrustable Professional Activities (EPA)’s are defined behaviors and activities that should be expected of all students graduating from medical schools and entering into residency programs regardless of the chosen specialty. The AAMC
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encouraged medical schools to adopt these EPA’s as competency outcomes for their graduates. Surgical subinternships should incorporate these within their goals and objectives. See table 1
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for Surgery Subinternship objectives incorporating the Association of American Medical Schools (AAMC) Entrustable Professional Activities (EPA)’s and mapped to the 6 ACGME core competencies with suggested instructional strategies and assessment methods. Curricular Elements Curricular elements for the surgery subinternship should address the Accreditation Council for Graduate Medical Education (ACGME) published competencies. Clinical tasks for 8
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subinterns should promote clinical decision-making in addition to simple knowledge recall. The rotation should provide subinterns with opportunities to independently evaluate patients and
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construct evidence-based management plans utilizing informatics and electronic resources. Students should demonstrate the ability to write orders, present cases concisely and efficiently, and discuss plans with faculty and care teams to gain timely feedback. The rotation should
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develop a student’s sense of ownership during transitions of care through instruction in and performance of safe patient hand-offs. Basic understanding of patient safety issues and quality
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control systems within healthcare institutions are also important curricular elements for the rotation. The subinternship rotation should promote communication skills essential for the daily care of patients, including calling for consultations, timely follow-up on daily care plans, answering pages, triaging multiple simultaneous patients and managing patients that are
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unfamiliar to them. They should become aware of essential communication skills to participate in difficult conversations with patients and families. The rotations should provide students with opportunities to develop essential procedural skills including bedside wound management, care
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for tubes and drains, suturing and knot tying, tube thoracostomy insertion, central line placement, and the use of bedside ultrasound for line placement and for Focused Assessment
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with Sonography for Trauma (FAST). Instructional Strategies
There should exist weekly protected time for educational activities under the direct
supervision of the rotation director. Educational activities should include professor rounds e.g. bedside rounds or meeting within a protected environment for in-depth discussion of patient
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assessment and plan of care development. The format for these rounds should be case-based discussions of patient-centered care to promote higher thinking skills for subinterns in a relaxed
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non-judgmental atmosphere. A detailed, but not lengthy, list for independent readings for nonclinical topics should be available and include topics on patient safety, quality
methodologies, and the principles of evidence-based practice. Web-based learning modules
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should be encouraged for communication topics, discharge planning, and patient handoff skills. The rotation should also provide access to a technical skills laboratory where students are
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provided with proctored practice and timely feedback. Clinical proctors should also directly observe student history and physical examination (H&P) skills and provide them with timely feedback to improve their performance. Proctors should also discuss and critique management plans with an emphasis on evidence-based guidelines. Finally, utilizing simulations, when
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available, would allow for focused training on isolated patient care issues with increased reproducibility and assurance of exposure to defined curricular elements that may not be
Assessment tools
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readily available during daily service.
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Assessment of subinterns should be comprehensive and targeted to provide meaningful feedback. This can be done through a composite scoring system that is made open and clear to students at the beginning of the rotation. The composite score should include clinical appraisals by faculty, 360o appraisals by residents and nursing staff involved in patient care on the services they rotate through, performance evaluations of procedural skills, professionalism points for the timely completion of reading and project assignments. It is also valuable to
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include an end of rotation essay that would demonstrate the student’s adaptive thinking regarding the application of patient safety concepts to daily patient care practices, or the
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implementation of quality control systems within healthcare institutions, or the institution of evidence-based practice protocols to improve patient outcomes. The condensed time of a 4week rotation may not be ideal for comprehensive summative assessments for cognitive and
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procedural skills among subinterns and the limited time would not allow for meaningful
remediation. In addition, such tests may divert the attention and efforts of subinterns away
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from the required tasks. The subinternship should be viewed as a venue for "deliberative practice" and "reflective practice" of clinical skills that builds to a finishing course like the residency preparatory curriculum or a capstone course with a preparatory curriculum layered around it. We encourage medical schools to adopt a “Capstone” course or an end of year “Boot
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Camp” including the ACS/ASE/APDS Surgical Residency Preparatory Curriculum where summative assessments are applied [15] The implementation of these end of year course allows medical schools to assess student’s competencies and achievement of entrustment
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graduation.
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behaviors, while providing ample time for remediation strategies closer to student’s
EVALUATING THE SUBINTERNSHIP It is important to design meaningful evaluation strategies to ensure that the goals and objectives of the rotation are accomplished. Reviewing student’s clinical and procedural logs during and at the completion of the rotation as well as generating an end of year categorized summary of these resources can identify pitfalls and inform further development of the
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curricular elements for the subinternship. End of rotation evaluation surveys to students, and end of year surveys to residents, and faculty can provide good insights on the administrative
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and educational strategies of the rotation. Surveying graduates and program directors at residency programs to which they match would assess their preparation for their roles as residents. Surgery subinternships should be a vibrant and relevant experience that is
dependable residents.
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EXPECTED BARRIERS AND POTENTIAL SOLUTIONS
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continuously evolving to address the needs of the students and help them be productive and
The creation of a structured surgical subinternship rotation is a major institutional change that requires commitment and vision by departmental leadership, innovation and ownership by faculty, as well as commitment of financial and administrative resources by the medical school.
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Faculty’s time and the availability of financial resources remain the major two barriers for the creation and maintenance of an educationally sound surgery subinternship clerkship.
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Innovative approaches are required to address these two important issues based on the local institutional structure and culture for each institution. While we do acknowledge that financial
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constraints and emphasis on clinical productivity are global barriers facing faculty recruitment, it is important to emphasis that incentives can be in the form of acknowledgement of efforts, creation of leadership positions, improving academic and research productivity as well as academic promotion. When petitioning the department of surgery and the medical school to provide a steady stream of financial and administrative support it would be helpful to indicate the value added by the new structured rotation, in the form of increasing student recruitment
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into the specialty and improving student education and preparedness for residency which would ultimately add to the positive reputation of both the department and the medical school.
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Moreover, the thrust for the creation of relevant modules and well defined experiences through a national standardized subinternship curriculum could provide a shared platform of resources that would help offset the costs that any one program may be required to invest for
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this endeavor.
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SUMMARY
The surgery subinternship should be viewed as a venue to ensure students are given graded responsibilities, are developing their higher thinking skills and are made aware of patient safety principles & application of evidence-based practices. This effort by the Surgery Subinternship
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Subcommittee and the Curriculum Committee at the ASE provides a blue print for establishing a structured, educationally sound, and rewarding surgery subinternship rotation for medical
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students. The recommendation to create a separate administrative structure for the rotation should serve as an incentive for surgery department chairs to enhance the educational mission
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of their department and open additional leadership opportunities for faculty. It also provides means to recruit more students into the specialty. For the sub-internship director, the rotation provides potential for career development as educators and opportunities for scholarly activities for academic advancement.
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REFERENCES [1] White, Casey B., Hilary M. Haftel, Joel A. Purkiss, Amy S. Schigelone, and Maya M.
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Hammoud. "Multidimensional effects of the 80-hour work week at the University of Michigan Medical School." Academic Medicine 81, no. 1 (2006): 57-62.
[2] Lyss-Lerman, Pamela, Arianne Teherani, Eva Aagaard, Helen Loeser, Molly Cooke, and G.
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Michael Harper. "What training is needed in the fourth year of medical school? Views of
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residency program directors." Academic Medicine 84, no. 7 (2009): 823-829. [3] Paolo, Anthony M., and Giulia A. Bonaminio. "Measuring outcomes of undergraduate medical education: residency directors' ratings of first-year residents." Academic Medicine 78, no. 1 (2003): 90-95.
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[4] Langdale, Lorrie A., Doug Schaad, Joyce Wipf, Susan Marshall, Louis Vontver, and Craig S. Scott. "Preparing graduates for the first year of residency: are medical schools
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meeting the need?." Academic Medicine 78, no. 1 (2003): 39-44. [5] Lindeman, Brenessa M., Pamela A. Lipsett, Adnan Alseidi, and Anne O. Lidor. "Medical
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student subinternships in surgery: characterization and needs assessment." The American Journal of Surgery 205, no. 2 (2013): 175-181.
[6] Fagan, Mark J., Raymond H. Curry, and Susan J. Gallagher. "The evolving role of the acting internship in the medical school curriculum." The American journal of medicine 104, no. 5 (1998): 409.
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[7] Sidlow, Robert. "The structure and content of the medical subinternship."Journal of general internal medicine 16, no. 8 (2001): 550-553.
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[8] Hueston, William J., Richelle J. Koopman, and Alexander W. Chessman. "A suggested fourth-year curriculum for medical students planning on entering family medicine." FAMILY MEDICINE-KANSAS CITY- 36, no. 2 (2004): 118-122.
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[9] Walton, Leslie A., Dee E. Fenner, Vicki L. Seltzer, George D. Wilbanks, Douglas W. Laube, M. Carlyle Crenshaw, Robert H. Messer, and Ralph H. Hale. "The fourth-year medical
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school curriculum: recommendations of the Association of Professors of Gynecology and Obstetrics and the Council on Resident Education in Obstetrics and Gynecology." American journal of obstetrics and gynecology 169, no. 1 (1993): 13-16. Coates, Wendy C. "The emergency medicine subinternship—an educator's guide
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[10]
to planning and administration." Academic Emergency Medicine 12, no. 2 (2005): 129-
[11]
Minter RM, Amos KD, Bentz ML, et al. “Transition to Surgical Residency: A Multi-
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129.
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institutional Study of the Effect of Formal Preparatory Curricula in the Fourth Year of Medical School.” Accessed at: https://www.facs.org/~/media/files/education/acsapdsasebrochure.ashx. And
Academic Medicine (in press).
[12]
Curriculum Committee Association for Surgical Education. Manual of surgical
objectives. 4th ed. Springfield (IL): the Association; 1988
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[13]
Reid, Chris M., Dennis Y. Kim, Jess Mandel, Alan Smith, Mark A. Talamini, and
Vishal Bansal. "Impact of a Third-Year Surgical Apprenticeship Model: Perceptions and
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Attitudes Compared with the Traditional Medical Student Clerkship Experience." Journal of the American College of Surgeons 218, no. 5 (2014): 1032-1037. www.aamc.org/cepaer
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[14]
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Table 1- Surgery subintership objectives mapped to the ACGME 6 core competencies and the AAMC’s core Entrustable activities for entering Residency (CEPAER) with suggested instructional strategies and assessment methods.
Instructional Strategies
1. Perform and present concise history and physical exam (EPA 1/ EPA 6) 2. Develop and prioritize differential diagnosis and select working diagnosis following a patient encounter (EPA 2) 3. Recommend and interpret common diagnostic and screening tests (EPA 3) 4. Discuss patient orders/ prescriptions and construct evidence-based management plans (EPA 4) 5. Provide documentation of clinical encounters in written or electronic format (EPA 5) 6. Triage and manage multiple patients 7. Perform bedside procedures: wound care, laceration repair, care for drains and tubes, central lines, chest tubes, ultrasound utilization, suturing and knot tying (EPA 12)
Daily rounds, case-based discussions, web-based modules, chart audits, simulation
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Patient Care
Surgery Subinternship Objective
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ACGME Core Competency
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1. Identify and manage unstable and critically ill patient (equivalent to EPA 10) 2. Manage common perioperative patient problems 3. Demonstrate understanding of the pharmacology of common meds: analgesia, nausea/vomiting meds, antibiotic groups 4. Demonstrate understanding of the relevant anatomy for common surgical procedures 5. Demonstrate the understanding of common surgical equipment and materials e.g. The electro-surgical unit, Types of mesh and suture materials 1. Identify strengths, deficiencies, and limits in one’s knowledge and expertise 2. Set learning and improvement goals 3. Demonstrate effective use of electronic resources into daily practice and personal improvement (equivalent to EPA 7)
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Practice-based learning and improvement
Direct Observation Forms and Professor rounds, Clinical appraisals, Simulation
Videos, skills lab, OR teaching Skills lab, clinical appraisals
Independent readings, didactics, web modules, simulation
Multiple choice questions, simulation Mock pages, small group presentations
Daily rounds, Professor rounds, attending morbidity and mortality (M&M) conferences
Clinical appraisals, writing an essay
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Medical Knowledge
Assessment Methods
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4. Incorporate feedback, self-reflection and improvement into daily practice
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Table 1- Surgery subintership objectives mapped to the ACGME 6 core competencies and the AAMC’s core Entrustable activities for entering Residency (CEPAER) with suggested instructional strategies and assessment methods.
Didactic, role-play, web-based modules, simulation
Mock pages, simulation
Professionalism 1. Demonstrate timely completion of administrative tasks 2. Demonstrate compassion, integrity, and respect for others 3. Demonstrate responsiveness to patient needs that supersedes selfinterest 4. Demonstrate accountability to patients, society and the profession 5. Seek and apply modifications to improve own efforts and demeanor based on feedback
Orientation session
Log review, clinical appraisals
Didactic, independent readings, web-based modules
Multiple choice questions, writing essay
System-based practice
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Interpersonal 1. Communicate effectively with patients and families respecting cultural and socio-economic backgrounds and communication 2. Work effectively as a productive and dependable member of the healthcare team (equivalent to EPA 9) skills 3. Demonstrate structured and effective communication skills when answering pages 4. Perform structured sign-outs during transitions of care (equivalent to EPA 8) 5. Obtain informed consent for tests and/ or procedures (EPA 11) 6. Demonstrate effective and efficient communication skills during interactions with healthcare professionals 7. Demonstrate sensitivity and empathy during difficult communications
1. Demonstrate understanding for principles of patient safety practices (EPA 13) 2. Demonstrate understanding for principles of quality improvements within the healthcare system (EPA 13)
EPA= Entrustable Professional Activities
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Figure 1 Suggested administrative structures for the Surgery Subinternship in Relation to the Surgery
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Clerkship. 1 – Different directors and administrative assistants, 2 - different directors and same administrative assistants, 3 – same director and different administrative assistants.
Subinternship Director
Clerkship Director
Subinternship
Clerkship
Administrative Assistant
Administrative Assistant
Subinternship Director
Clerkship Director
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(2)
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Subinternship & Clerkship
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Administrative Assistant
Clerkship &
Subinternship Director
Subinternship
Clerkship
Administrative Assistant
Administrative Assistant