Necessity Is the Mother of Invention. The Story of a Simulated Inpatient Medicine Rotation

Abstract

What do you do when a podiatric medicine–friendly teaching hospital abruptly terminates a required monthlong inpatient medicine rotation? You can try to negotiate a new rotation at another facility, but that's difficult in the San Francisco Bay Area with three local medical schools vying for similar positions. Instead, you need to think creatively.

In 2001, the 87-year-old California College of Podiatric Medicine campus was sold and the college legacy was merged into Samuel Merritt University (SMU), with the college being renamed as the California School of Podiatric Medicine (CSPM). Founded in 1909, SMU, an affiliate of Sutter Health, offers undergraduate degrees in nursing and graduate degrees in occupational therapy, physical therapy, nursing, and physician assistant. In addition to the usual university amenities, SMU also has a multimillion-dollar Health Science Simulation Center (HSSC)—one of the West's most advanced health-care simulation facilities.

Net proceeds from the sale of the California College of Podiatric Medicine campus were directed into an educational endowment fund. Overseen and protected by a newly created, podiatric physician–governed advisory committee (the Podiatric Medical Education Advisory Committee), the endowment has funded annual student scholarships and worthy educational projects—with funding further supported by matched funds from SMU.

With the urgent need for a medicine rotation, the CSPM dean, John Venson, DPM, approached the SMU HSSC faculty in 2013 with one question: “Would it be possible to deliver a monthlong inpatient medicine rotation entirely in a simulated environment?”

Faculty of the HSSC said “yes,” and the adventure began. Startup funds were obtained from the Podiatric Medical Education Advisory Committee, rotation goals and objectives were established, and faculty were hired. The goal was not only to replace a third-year medicine rotation but also to substantially improve it. In contrast to the unpredictable availability of pathology found on “in-hospital” clinical rotations, this simulated rotation would provide consistent, reliable delivery of a wide range of pathologic states, ensuring uniform and reproducible delivery of a “clinical” experience. To further the learning experience, the rotation would be limited to small groups of four students.

Objectives included development of the history and physical examination (H&P), creation of a well-organized differential diagnosis, writing reports, and presenting cases during “bedside rounds.” Technical skills were also promoted, including advanced cardiac life support, endotracheal intubation, needle thoracostomy, lumbar puncture, placement of intravenous lines, arterial blood gas draws, ventilator management, and nasogastric tube placement. Nontechnical skills, such as professional rapport, compassion, and empathy, emphasizing the patient/family-centered care model, were also stressed.

Using the 2013 weighted learning objectives from the American Association of Colleges of Podiatric Medicine Curricular Guide for Podiatric Medical Education, William Stiers, MD, and Henry Curtis, MD, both emergency medicine physicians, designed a 4-week medicine rotation with a library of cases in the areas of cardiology, pulmonology, neurology, and perioperative management. Each core case was woven with comorbidities, social circumstances, psychiatric/psychological conditions, addictions, insurance problems, and family dynamics, which the student learners were to recognize and address in the total care of their patients.

Cases were wholly self-contained and were scripted using a template adapted from the Bay Area Simulation Collaborative. Each 30-page template provided a full description of the primary, secondary, and critical learning objectives; details about the patient, the setting, needed equipment, medications, medical history, review of systems, laboratory tests, imaging, and electrocardiography; and a storyboard of the scenario. Templates also included expected learner interventions, subsequent patient responses, and a faculty debriefing guide.

Each patient state or condition incorporated the fundamentals of critical thinking with information gathering (H&P), synthesis/processing (how this all fits together), decision making (correct decisions result in patient improvement), and reevaluation (did my intervention have the anticipated response).

The weekly modules were scheduled 4 days per week. Mondays were reserved for instruction on the essentials of a focused H&P of the designated primary subject area. Using faculty-produced videos, the Harvey cardiopulmonary patient simulator (Laerdal Medical), and Laerdal SimMan 3G manikins (correct spelling—mannequins are in clothing stores), the students practiced the acquisition of fundamental examination skills. Brief didactics on key elements of a focused history guided by the patient complaint were also provided. On Monday afternoons, the students engaged in their first simulated clinical experience, which may occur in a clinic, an emergency department, a medical-surgical floor, or an intensive care unit.

Each clinical encounter has a primary student provider and a student scribe. The scribe allows the primary provider to focus on engagement and inquiry with his or her patient without the interference and distraction of note-taking. Each primary provider works up a unique case/patient, performing a problem-focused H&P while applying a “curious mind” approach to formulate a differential diagnosis. Each encounter is also video recorded for learner self-reflection. The other students not in the patient encounter are in a conference room, observing via closed-circuit television, where they are identifying high-quality performance markers and opportunities for clinical improvement.

The Monday patient is a SimMan 3G manikin, a wireless computerized human model with physical features representative of the human experience. The SimMan 3G can be programmed with normal or pathologic breath sounds, heart tones, murmurs, stridor, arrhythmias, seizures, and even diaphoresis, bloody/frothy sputum, cerebrsospinal fluid rhinorrhea, and bleeding as the case may require. A faculty operator, seated behind a two-way control room mirror, engages in dialogue with the student learner as the voice of the patient. Following scripted information within each template, the faculty operator offers information in response to questioning by the student.

A bedside monitor is present that displays vital sign configurations consistent with the clinical setting, from an intensive care unit with typical five-wave monitoring of central venous pressure, arterial blood gas, pulmonary artery pressure, plethysmography, electrocardiography, partial pressure of end-tidal carbon dioxide (PetCO₂), temperature, cardiac output, etc, to a simple set with blood pressure, heart rate, respiratory rate, and temperature.

All elements of the H&P are there for the learners to identify, collect, process, decide, and act according to their level of investigation and understanding of the disease process. Four representative cases include the following: 1) a 75-year-old man with a history of hypertension, congestive heart failure, tobacco use, and medical noncompliance presenting in congestive heart failure with rapid atrial fibrillation and bilateral lower-extremity edema; 2) community-acquired pneumonia in a 60-year-old woman with breast cancer taking tamoxifen who requires intubation and sepsis resuscitation; 3) altered level of consciousness in a 68-year-old woman with fever, aphasia, and stiff neck; and 4) a 62-year-old man returning to the clinic 3 days postoperatively after a calcaneal fracture open reduction and internal fixation with a deep venous thrombosis.

After a 20- to 30-minute engagement with the patient the students reconvene in a conference room to discuss the case collectively and to work together to develop eight to ten differential diagnoses. For each differential diagnosis, the primary learner must explain why it was included, what speaks for and against the likelihood of this diagnosis, and what further diagnostic studies, physical examinations, and consultations would be most appropriate to rule in/out that diagnosis. The observing students then give feedback on their observations. The primary learner self-identifies two personal knowledge gaps that were revealed through the encounter, and these become that student's student learning objectives (SLOs), which the student will research and prepare a two-page summary to be distributed to all of the members of the group. That student then becomes the resident “expert” on that topic, but all students are expected to read, learn, and ask questions about each other's SLOs. For each SLO the student prepares two discussion questions that cover the key elements of the subject. These questions are shared only with the instructor and are collated into a weekly question-and-answer packet that is distributed to ensure that all learners are reading and learning from each SLO developed by their peers. Each primary provider concludes by writing admission orders for the patient.

At the end of each Monday, each student has been the primary caregiver, scribe, observer, mentor, and coach. Usually there are four students, four cases, four H&Ps, 32 to 40 differential diagnoses, eight SLOs, 16 questions, and four admission notes. This is just day 1.

Tuesday. Day 2. This day begins with “morning rounds,” where each student presents his or her patient, reviewing the H&P, differential diagnoses, and plan. Students also incorporate the SLOs from their case and discuss how the SLOs improved their understanding of their patient's condition and management.

After morning rounds, bedside rounds occur during which the primary providers see their patients and receive the results of their planned interventions. With this new information, students reevaluate their patients and prioritize their plans. They then identify two SLOs and write a SOAP (subjective, objective, assessment, and plan) note for the day's encounter and begin working on a discharge plan.

Wednesday. Day 3. Grand rounds, where students provide slide presentations of topics relevant to their cases. Two more SLOs are then identified by discussion. Afterward, students participate in task trainer instruction on technical skills.

Friday. Day 4. The day begins with review of the SLOs and SOAP notes, followed by a standardized patient (SP) encounter. These SPs are professional actors who have been given patient identifiers and written case instructions. After the SP encounter, group coaching, and mentoring occurs, the SP then shares comments about being under the care of that provider, focusing on empathy, compassion, caring, and attentiveness. Two SLOs per student and two questions per SLO. The SLO questions are then distributed to students to complete over the weekend.

At the end of the week, each student has completed two H&Ps, two SOAPs, eight SLOs, one presentation, and 16 questions. Among the four students, a total of 8 H&Ps, 8 SOAPs, 32 SLOs, 4 presentations, and 64 questions have been completed. At the end of four weeks, those totals increase to 32, 32, 128, 16, and 256, respectively.

So how has the new medicine rotation performed? Student feedback on end-of-course evaluations has been highly positive at 4.7 on a scale of 5, and calls for more of this type of instruction that allows the learner to engage, think, process, decide, act, and reflect in the safety of a simulated environment. The American Podiatric Medical Licensing Examination Part II board scores in the area of medicine for the first two student cohorts have also markedly improved.

In conclusion, the CSPM third-year medicine rotation has been successfully unique in its delivery of a clinical rotation in an entirely simulated environment. The CSPM has been able to replace and improve a critical clinical rotation, and it's expected that ongoing educational studies will further prove the effectiveness of this safe clinical teaching modality.