Evaluating the third-year curriculum: Disparities in medical education among hospital sites

MEC Executive Committee Meeting July 13, 2007 David Geffen School of Medicine at UCLA

I.

INTRODUCTION

 Diverse clinical training opportunities  Advantages: Increased exposure  Disadvantages: Educational differences among sites  Lecture time  Attending interaction  Resident teaching

I.

INTRODUCTION

 Study Objectives:  Assess and compare the educational experience at training sites for different subspecialties  Receive student feedback regarding ways to improve the curriculum during the third year

II.

METHODS

 Participants- 3 rd and 4 th Year Medical Students invited to take confidential, anonymous online survey  Online survey- 130 questions assessing individual clerkship experiences  Design- Participants given 1 week to submit survey  Statistical analyses- One-way ANOVAs and correlations using SPSS

III. RESULTS

 Participants: 145 medical students  66 Men, 79 Women  117 third-year, 28 fourth-year students

III. RESULTS (continued)

 Comparison of sites for individual clerkships  Quality  Lecture time  Attending interaction  Resident teaching  One-way ANOVA  Correlations

Quality of Individual Clerkship Experiences

2.5

2 1.5

1 0.5

0 5 4.5

4 3.5

3 3.14

RESULTS

3.62

3.45

3.16

3.35

3.51

3.44

3.36

Surgery Medicine Pediatrics Ob/Gyn Neurology Psychiatry Ambulatory Medicine

Clerkship

Family Medicine

Individual Clerkship Results

PEDIATRICS

Quality of Pediatric Clerkship Experience by Site

6 5 4 3.88

3 2 3.15

1 0 UCLA/Oliveview 3.12

Harbor

Site

Cedars 3.3

Kaiser Sunset

PEDIATRICS

Amount of Lecture Time for Pediatrics Clerkship by Site

6 5 4 3 2 1 3.41

3.35

4.36

3.4

0 UCLA/Oliveview Harbor

Site

Cedars Kaiser Sunset

PEDIATRICS

Amount of Attending Interaction for Pediatrics Clerkship by Site

5 4.5

4 3.5

3 2.5

2 1.5

1 0.5

0 2.58

UCLA/Oliveview 2.41

3.08

3 Harbor

Site

Cedars Kaiser Sunset

Pediatrics

 Cedars  Excellent and enthusiastic teaching by site directors and residents   Outpt clinics less helpful “the best rotation of the year”  Excellent (albeit very long) lectures  Kaiser students attended these as well  Good variety of experiences (clinic, inpt, nursery, specialty clinics, etc.)  Extremely well-organized

SURGERY

Quality of Surgery Clerkship Experience by Site

5 4.5

4 3.5

3 2.5

2 1.5

1 0.5

0 3.12

CHS 3.12

3.33

3.11

2.58

3.36

Harbor Oliveview

Site

WVA Cedars Santa Monica

SURGERY

Amount of Lecture Time for Surgery by Site

2 1.5

1 0.5

0 5 4.5

4 3.5

3 2.5

2.83

CHS 3.41

2.86

3.07

2.37

2.54

Harbor Oliveview WVA

Site

Cedars Santa Monica

Inpatient Surgery

 Cedars  General surgery  Minimal teaching by housestaff/attendings, no guidance  Students not allowed to write notes/orders  Good exposure to variety of surgeries  Trauma Surgery  No hands on experience, very little “true trauma”  Some students were not allowed to write notes/orders, some were “scutted out” all day  “this should not have been a surgery rotation”

Inpatient Surgery (continued)

 Harbor  Great teaching by housestaff and attendings  Excellent lectures and conferences (particularly the student-directed ones)  Good learning on call nights  Excellent variety of cases  Significant amount of 1:1 time with attendings  Good continuity of care via clinic activities

Outpatient Surgery

 General comments    Great introduction to subspecialty surgeries “I now want to go into _________” Excellent opportunity to “create your own rotation”   Very good way to find out when to refer to different subspecialists Good teaching “as long as you showed interest”  Not enough time spent with any given subspecialty

NEUROLOGY

Quality of Neurology Clerkship Experience by Site

5 4.5

4 3.5

3 2.5

2 1.5

1 0.5

0 3 2.9

3.36

3.39

UCLA Oliveview

Site

Harbor WVA

NEUROLOGY

Amount of Resident Teaching for Neurology Clerkship by Site

6 1 0 3 2 5 4 2.85

2.96

3.45

3.48

UCLA Oliveview

Site

Harbor WVA

Neurology

     General comments  3 weeks is too short  Excellent Monday lectures Harbor  Good teaching faculty OVH  Too many students per team, leading to limited pt interaction  Good teaching by residents/housestaff CHS  Stroke team sees very little other than strokes WVA  Good teaching by residents, but little to no interaction with and teaching from attendings

PSYCHIATRY

Amount of Attending Teaching Time or Psychiatry Clerkship by Site

6 5 1 0 4 3 2 2.19

3.86

3.09

3 2.5

UCLA Oliveview Harbor

Site

WVA Cedars

Psychiatry

 General comments    Little to no benefit of PBLs Organized didactics would be helpful “5 weeks is too long”

INTERNAL MEDICINE

Amount of Attending Interaction for Internal M edicine Clerkship by Site

6 5 4 3.49

3.22

3 2 1 2.92

3.06

2.74

2.38

0 CHS Harbor Oliveview WVA

Site

Cedars Kaiser Sunset

Internal medicine

 Cedars    Excellent residents and resident teaching Less interaction with attendings Slower service allows more teaching; good lectures  Harbor  Good 1:1 interaction w/ attendings, but residents overworked leading to minimal resident teaching  Excellent breadth of exposure  Kaiser Sunset   Excellent organized didactics and conferences Good teaching by “friendly residents,” though some residents less interested in teaching than others

Internal medicine (continued)

   OVH     Fantastic teaching by housestaff and attendings Significant 1:1 time with attendings Good patient exposure and variety Great pt continuity 2/2 f/u clinic responsibilities CHS  Excellent teaching by attendings, less by housestaff 2/2 time constraints  Many complicated patients, can take away from learning WVA    Great interaction w/ attendings Mixed response to computer system, could use “orientation” “great patient population”

OB/GYN

Amount of Attending Interaction for Ob/Gyn Clerkship by Site

4.5

4 3.5

3 2.5

2 1.5

1 0.5

0 2.21

2.46

3.06

2.04

UCLA Oliveview

Site

Harbor Cedars

OB/GYN

 Cedars   Typically good exposure, but many private pts can hinder this Poor organization, poor/minimal teaching by many “catty residents,” attendings, and “temperamental” site director  Good prep for exam by site director but lectures prep for exam much more than general OB/GYN knowledge  CHS   Good exposure to a variety of cases Some residents unfairly abusive of students

OB/GYN (continued)

 Harbor  Good, friendly residents and attendings; good teaching   Need for more organized didactics Long hours, but good amount of hands-on experience  OVH   Long hrs, frequent resident-on-resident abuse, which often filtered down to students Good didactics but often late/poorly organized

AMBULATORY MEDICINE

Quality of Ambulatory Medicine Clerkship Experience by Site

5 4.5

4 3.5

3 2.5

2 1.5

1 0.5

0 3 3.77

3.33

2.67

3.29

3.64

3.53

CHS Oliveview Harbor WVA

Site

Cedars Kaiser Sepulveda VA

AMBULATORY MEDICINE

Amount of Attending Interaction for Ambulatory Medicine Clerkship by Site

3 2 1 0 6 5 4 3.57

3.54

4.11

2.47

4.14

3.86

CHS Oliveview Harbor 3.6

WVA

Site

Cedars Kaiser Sepulveda VA

Ambulatory Medicine

 Cedars  Great experience at LA Free Clinic w/ good breadth  Harbor  Excellent attendings; significant autonomy  Kaiser-Sunset  Great pt exposure in urgent care clinic  King-Drew  Great variety but very busy, allowing for minimal teaching

Ambulatory Medicine (cont’d)

 OVH  Good 1:1 interaction with attendings, good teaching  Sepulveda VA  Excellent autonomy (sometimes TOO much), continuity of care, 1:1 interaction with attendings  CHS  Good interaction w/ GIM attendings, good variety  Poorly organized, specialty clinics mostly shadowing  WVA  Very mixed responses

RADIOLOGY

Quality of Radiology Clerkship Experience

5 4.5

4 3.5

3 2.5

2 1.5

1 0.5

0 2.72

2.25

2.33

2 Lecture Angel 1.81

Exposure on the Wards Teaching on the Wards Preparedness of Radiology Exam

Feature

Radiology

 Structured radiology clerkship necessary  Lecturers often do not show up  Slides should be labeled to allow for reviewing after lecture  Poor correlation between material covered by radiology lectures and radiology exam questions  “the worst part of third year”

IV. RESULTS SUMMARY

 Educational experience varies by clinical training site  Quality of the clerkship is strongly associated with:  Amount of lecture time  Amount of attending interaction  Amount of resident teaching

V. RESULTS AND THE CETF

 Lack of clinical teaching  Lack of exposure to health care systems  Lack of ownership

V. RESULTS AND THE CETF

 Lack of clinical teaching  Some sites with excellent teaching and/or didactics (ie, med @ OVH, peds @ Cedars, surg @ Harbor, neuro @ CHS)  Lack of exposure to health care systems   Best experiences are at various different sites Across the board, students enjoyed variety  Lack of ownership   Methods in place in some rotations to promote continuity of care (ie, f/u med clinic @ OVH, surg clinic @ Harbor) Some rotations severely lacking in ownership/autonomy (ie, surg @ cedars, amb med @ CHS

ACKNOWLEDGEMENTS

 Survey author: Liz Volkmann  Web manager: Vivian Ng  Survey contributors: Jon Marron, Wendy Liu, Kevin Koo  Statistical analysis: Liz Volkmann  Staff Collaborator: Sebastian Uijtdehaage