1. New challenge for students and staff!
Marijke van Santen-Hoeufft
ass. prof. internal medicine/rheumatology,
consultant in clinical education, curriculum development and assessment
Maastricht, the Netherlands
My name is… I was asked to tell you about…
Clinical phase

2. The ambulatory and clinical environment in a modern medical curriculum
My name is… I was asked to tell you about…
Clinical phase

3. The Maastricht Curriculum Educational buildings and laboratories
Hospital
Educational buildings and laboratories
Good afternoon everyody
You are sitting here…in the cellar. My workingplace is there on the 5th level of the hospital, internal medicine. About 3 minutes walking to give you an impression
Clinical phase

4. How do we prepare our future doctors best for the challenges of the 21st century?
‘The Maastricht experience’
My name is… I was asked to tell you about…
Clinical phase

5. Outline of presentation
Motivation for curriculum change
Year 3
Strenghts and weaknesses of clinical rotations
Conclusion
Motivation… the old curr. Wasn’t that bad…why change? Cost a lot of money
Clinical phase

6. A tremendous ‘shock of practice’!
Many motivations for curriculum change
in Maastricht 2001…
The most important overall:
The transition of preclinical to clinical phase is experienced as quite a shock of practice
and…
The transition of graduate to post-graduate training is experienced as…
As an academic clinician I work with starting postgraduates, hardly celebrated their graduation to physician orhaving to deal
With the burden of stressy routine care
A tremendous ‘shock of practice’!
Clinical phase

7. Why shock of practice? Post-graduate training requires:
Working under time pressure
Facing larger responsibility
Dealing with more complex problems
Having insufficient competencies
There is so much more timepressure compared to being a clerk, so much more…
Clinical phase

8. How to prevent shock of practices?
Critical appraisal of current content year 4 - 6
Better preparation for the ‘real work’ in year 3
HOW TO DO THIS?
Start with real patient encounters in year 3
Broadening of competencies other than medical expert
I don’t know whether you recognize these shortcomings in the clerkships and if you have ever wondered wether the preparation for the clerkships
in the preclinical years was adequate in your faculty. Anyway we thought to…
Clinical phase

9. Structure of the 2001 curriculum
Year
C o n t e n t 1
Emergency care and regulatory systems 2
Stages of life and diagnostics 3
Chronic disorders, ambulatory patient contacts 4
Internships, focus basic sciences 5
Internships 6
Participation in research and patient care
All this made us to develop a curriculum with early practice contacts and with structured time for theory till the last days
Practice
Theory
Clinical phase

10. Why early patient contacts?
There is so much more timepressure compared to being a clerk, so much more…
Clinical phase

11. How do we learn best ? Teach 80% Practice by doing 75%
Average
Retention Rate1
Teach
others
80%
Practice by doing
75%
Discussion group
50%
Demonstration
30%
An intermezzo…you undoubtedly recognize this slide where different educational tools have been compared according to the amount of knowledge
students remembered later on… you can see that practicing by doing and teaching/telling others score best
Audiovisual
20%
Reading
10%
Lecture 5%
1 National Training Laboratories, Bethel, Maine, USA
Clinical phase

12. Educational objectives
Integration theory
& practice
Patients are starting point
for learning
Instructional
methods
Variability in instructional
methods in which students
are required to be active
Learner control
Active learning
Collaborative learning
Self-directed learning
Teachers
Teachers as coach
Clinical phase

13. Activities around patient encounter Formulation learning objectives
The learning cycle
Patient
vignette/case
Preparation in
tutorial group
Self study
Report to
Tutorial group
Activities around patient encounter
Preparation with
clinical supervisor
Self study
Patient
encounter
Evaluation &
Formulation learning objectives
Clinical phase

14. Tutorial group 10 weak cycle n = 10 1x per week 4 hours
presentation and discussion of patient problems (3 hours).
Preparing next patient encounter (1 hour)
staff member is coach
Clinical phase

16. ‘SOEPEL’: Structured Consultation Report
Subjective
Objective
Evaluation
Planning
Elaboration: discussing learning goals with clinical supervisor,
after patient encounter. Student formulates new learning goals
Learning goals: the new learning goals are the guide for further
self study and for report in the base group
The basis is a the format of a medical record extended with E and L explicitly. The E from…
Clinical phase

20. Activities around patient encounter Formulation learning objectives
The learning cycle
Patient
vignette/case
Preparation in
tutorial group
Self study
Report to
Tutorial group
Activities around patient encounter
Preparation with
clinical supervisor
Self study
Patient
encounter
Evaluation &
Formulation learning objectives
Clinical phase

21. Formulating learning goals…….
Eindtermen basisarts
Formulating learning goals…….
Clinical phase

22. Year 3 A students’ week Participating disciplines Gastro-enterology
Gynecology / Obstetrics
Surgery
heart / lungs / vessels abdomen locomotion brain and behaviour
Family medicine
Urology
Eindtermen basisarts
Pediatrics
Participating disciplines
Clinical phase

23. Back to Brazil, back to the transition of students from the safe escola Pernambucana to the challenging IMIP environments… How to use PBL in a ambulatory and clinical context?
Clinical phase

24. All medical faculties want to prepare
their students the best they can for the
6th year and post graduate education
But what is the best way?
Evidence for ‘best practice’?
A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group
They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation
Clinical phase

25. “It may not be a perfect wheel, but it’s a state-of-the-art wheel.”

26. Effectiveness of clinical rotations??
A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group
They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation
Clinical phase

27. Strenghts of internships
Learning in real, relevant context
Integration of theory and workplace learning
Active participation in practice
Coping with increasing complex and diverse patient problems
Increasing self-reliance
success depends on length of internship!
A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group
They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation
Clinical phase

28. Why are internships generally less effective than ideally possible?
Unfortunately all internships have their
weaknesses too…
Why are internships generally less effective
than ideally possible?
A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group
They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation
Clinical phase

29. The effectiveness of internships is hampered by problems regarding:
the teacher
the workplace
the students
the elements of good clinical teaching
A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group
They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation
Clinical phase

30. Common problems in clinical phase regarding the teacher(1):
Time pressures
Competing demands (clinical with parttime availability; administrative; research)
Teaching often opportunistic, making planning more difficult
Often under-resourced
Rewards and recognition for teachers poor
Good teaching needs intrinsic motivation of teacher
A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group
They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation
Clinical phase

31. Common problems in clinical phase regarding the teacher(2):
Lack of knowledge about:
the effects of being a role model
motivating students
assessing competence
giving constructive feedback
the curriculum content, end-objectives…
etc.
Lack of training in:
educational skills
evaluating his own teaching and
asking feedback (self reflection)
A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group
They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation
Clinical phase

32. Common problems in clinical phase regarding the workplace:
Increasing numbers and types of students
Fewer patients (shorter hospital stays; patients too ill or complex)
Competing demands (patient-care related actions come first)
Clinical environment not ‘teaching friendly’
(busy hospital ward; no suitable meetingplace with students; no learning climat)
Ambulatory care insufficiently involved in education
A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group
They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation
Clinical phase

33. Common problems in clinical phase regarding the teacher(1):
Time pressures
Competing demands (clinical with parttime availability; administrative; research)
Teaching often opportunistic, making planning more difficult
Often under-resourced
Rewards and recognition for teachers poor
Good teaching needs intrinsic motivation of teacher
A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group
They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation
Clinical phase

34. Common problems in clinical phase regarding the teacher(2):
Lack of knowledge about:
the effects of being a role model
motivating students
assessing competence
giving constructive feedback
the curriculum content, end-objectives…
etc.
Lack of training in:
educational skills
evaluating his own teaching and
asking feedback (self reflection)
A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group
They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation
Clinical phase

35. Common problems in clinical phase regarding the workplace:
Increasing numbers and types of students
Fewer patients (shorter hospital stays; patients too ill or complex)
Competing demands (patient-care related actions come first)
Clinical environment not ‘teaching friendly’
(busy hospital ward; no suitable meetingplace with students; no learning climat)
Ambulatory care insufficiently involved in education
A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group
They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation
Clinical phase

36. Common problems in clinical phase regarding the students:
Insufficiently prepared (knowledge, skills)
Don’t take the opportunities for examining patients independently
Stay passive observers in stead of active participants due to too short clerkships (no time for professional socialisation)
A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group
They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation
Clinical phase

37. Common problems with clinical teaching(1):
Lack of clear objectives and expectations
Focus on factual recall rather than on development of problem solving skills and attitutes
Teaching pitched at the wrong level (too high or too specialistic)
Inadequate supervision and provision of feedback (due to lack of time, lack of skills or motivation, no continuity)
A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group
They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation
Clinical phase

38. Isn’t it a wonder there are competent physicians anyway
Isn’t it a wonder there are competent physicians anyway?! At least we think we are….
A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group
They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation
Clinical phase

39. Important determinants of the effectiveness of student learning in a clinical environment:
Patient mix
Opportunities for examining patients independently
Received supervision and feedback
Organisational quality
Student being part of a team
Number of students at one time
Educational sessions
Positive attitude of staff towards students
A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group
They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation
Clinical phase

40. Most important determinants of the effectiveness of student learning in a clinical environment:
1- received supervision and feedback
2- opportunities for examining patients
independently
3- patient mix
A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group
They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation
Clinical phase

41. Measures to improve effectiveness of clerkships:
Clerkship study guides
Teach the teachers trainings
Create a positive learning environment
More direct observation and feedback
Include protected time for selfstudy
Integration of learning and assessing on the workplace by using miniCEX, logbooks etc.
A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group
They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation
Clinical phase

42. Integration of learning and assessing by:
Observing multiple events during clerkship involving multiple people
Using mini CEX (Clinical Evaluation eXercise) or other ‘on the job assessment tools’
Using the logbook in which structured clinical records are gathered of all patients seen by the student
Coaching
Critical incident analysis
Portfolio etc.
A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group
They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation
Clinical phase

43. Integration in medical curricula
Faculty of Medicine Universiteit Maastricht
Clinical phase

44. Clinical phase

45. In summary, improvement of the effectiveness of the ambulatory and clinical phase can be achieved, but not without effort and lots of motivation of organisation, staff and students!
A basegroup is more than a tutrioal because the student group share more things together like practices skilltrainings etc. They really function as a group
They meet for 4 hours weeekly of which 3 hours… The soepel is the central structure of each patientcontact and presentation
Clinical phase

46. Thank you for your attention!

47. Traineeship year 6 Participation in health care:
20 weeks junior doctor in general practice or
hospital setting
Focus on doctor’s role of medical expert,
scientist, health care worker, person
Further development of competencies in:
medical acting
communication
cooperation
knowledge/science
social acting
organisation
professionalism
And meet the more extended competencies our postgraduates have to meet
Clinical phase