Friday, May 13, 2011

What is student autonomy?

I just went through a review of our neurology clerkship by the curriculum committee at the school of medicine level. One of the things our particular clerkship has struggled with is that the students have a perception that there is not enough autonomy while they are working on the neurology service. I think we have some obvious barriers to overcome as there are times the residents will see new admissions and consults with the student just along for the ride on the wards, and in the clinic the experience is variable with some faculty having the students shadow (hence why I did my grand rounds last week on teaching techniques to use in the clinic). So, we have some work to do as fourth year students are not used to being put into a shadowing role, and really they shouldn't be at an academic institution.

My pondering since the review is not so much on the specifics of what I can do to improve the student experience, but more a puzzling at what autonomy for a student truly looks like in 2011. My medical school professors related stories of working in public hospitals during their training where they were relatively unsupervised as fourth-year medical students, and truly were first call and had a great amount of responsibility for the patient. This has obviously changed, and I don't think this was the best way to teach the next generation of physicians. In reality, the ultimate autonomy in terms of what happens to the patient and what testing and treatment modalities should be chosen rests on the shoulders of the attending physician. From an ethical and legal perspective, the attending is the one responsible for the outcomes be them good or poor. The dance and the nuance comes with how the responsibility then trickles down through a resident team sometimes overfilled with fellows, senior residents, junior residents, and medical students. Added to this dynamic struggle for decision making power are the constraints of time, billing, and EMR implementation to name just a few.

In the light of all of this, I would like to look at a specific case of student autonomy as an example. In our ward, patients are admitted overnight by a resident (and sometimes a student) covering multiple neurology services at our university hospital and the VA. Thus, it is likely the resident team and students have not seen the patient when they were admitted, and are picking them up fresh in the morning. What does autonomy look like in this situation for the student? I would posit that a fourth year student should at a minimum see the patient independently or directly observed by the resident, and should be allowed to formulate their own interpretation of the history and physical and outline an initial plan of care. This can then be honed and refined by the resident and fellow team, and ultimately approved or modified by the attending. The reality is that (at least on our service), the student is often reading from a printed copy of the note written by the on-call resident the night before as they have been trained not to write notes in the chart. The assessment and plan has likewise also been laid out by the on-call resident. Thus, just by looking over the notes to prepare themselves to see the patient, all the work has essentially been done for the student, and they are essentially verifying findings on examination, and deciding if the plan overnight is reasonable. They are also serving to update the condition of the patient from the previous night through to the morning.

So, how do we improve this paradigm? Should we send the student in without looking at the notes? This seems a bit artificial to me, and if time is a factor, is not very efficient either. Should we print out the note up to the physical examination and assessment and plan? Again it is a bit artificial, but at least now the student has a chance to try to formulate a plan independently. Or is it enough to have the student and resident work together to refine the plan as laid out by the on-call resident? Or is it just as valuable to learn from seeing what others have done, and then seeing how that plan works over the course of the patient's hospitalization. When I'm attending, I try to get around this a little by asking the students who haven't seen this particular patient to formulate their own localization of the lesion, differential diagnosis, and plan. But that doesn't get to the student that is following the patient. What do they gain through this experience? Maybe it is enough to have seen the physical findings and think through the differential diagnosis albeit in retrospect and with some heavy prompting from the already completed note.

Not sure I have a great answer yet, and I was hoping to gain from your experience. How also does this model change from third to fourth year, and then into residency? I look forward to your comments.

Friday, May 6, 2011

Strategies to more effectively teach in the ambulatory clinic

Here's a grand rounds I gave this week for the OHSU Department of Neurology on some tips I've found useful for teaching in clinic. We go over barriers to teaching in clinic, and some strategies to overcome those barriers. Our clinics are set up so that students spend roughly a half-day with each provider over the course of a week which gives some background to our unique issues. I do feel many of these points are useful in many settings. I do briefly discuss the 'One Minute Preceptor' toward the end, and I realized I didn't reference the paper in this talk. That original paper is - Naher, et. al. J Am Board Fam Pract. 1992 Jul-Aug;5(4):419-24.

Feel free to leave comments below on idea you have used to improve your effectiveness while teaching in ambulatory clinic setting.