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Yankton Ambulatory Program

An Integrated Model

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50 students per year 4 MD/PhD

Year 1 and 2: Basic Sciences Year 3: Required clerkships

Sioux Falls Rapid City Yankton Ambulatory Program

Year 4: Electives and required clerkship

Sanford School of Medicine of the University of South Dakota

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Yankton County - 20,000 population Avera Sacred Heart Hospital

- 144 acute care beds- 75 physicians in community

Yankton Medical Clinic – private multispecialty clinic

- 42 physicians - 150,000 patient visits per year

No resident physicians

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1989 Planning began YMP Climate of Medicine/Education

Changes in Medical Practice GPEP Recommendations

Students

10-14 per year Students self-select during year 2 200 graduates

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Core Faculty

Family Medicine – 8 Internal Medicine – 10 Surgery – 7 Pediatrics – 5 Obstetrics/Gynecology – 4 Psychiatry - 6

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Yankton Ambulatory Program

Ambulatory-based Integrated Student-centered Continuity care

experience Problem-based

learning

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Ambulatory - Based

Yankton Medical Clinic Affiliated clinics Assigned to Family Medicine, Internal Medicine, Pediatrics, OB/Gyn, Surgeryo Psychiatry – Human Services Center

Goals

Provide broad based education Teach life-long learning skills Provide real-life experiences

“doctoring” Promote primary care

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Mission StatementThe mission of Sanford School of Medicine of the University of South Dakota is to provide the opportunity for South Dakota residents to receive a quality, broad-based medical education with an emphasis on family practice. The curriculum is to be established to encourage graduates to serve people living in the medically under served areas of South Dakota, and is to require excellence in the basic sciences and in all clinical disciplines.

 Sanford School of Medicine of the University of South Dakota is to provide to its students and to the people of South Dakota excellence in education, research and service. To these ends, the School is to provide educational pathways to both the Doctor of Medicine and the Doctor of Philosophy Degrees; and

 Quality health care for the people of South Dakota is addressed by undergraduate, graduate and continuing educational programs as well as by basic and applied medical research. Sanford School of Medicine should serve as a technical resource in the development of health care policy in the state and provide extension and research initiatives to improve the health care of the citizens of the state.

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Integrated

Students not “on” a specialty Primary care 12 months

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Student Centered

Faculty outlines objectives Student responsible for obtaining

knowledge Faculty provides resources and

opportunities

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Continuity Care

Patients followed in: Clinic Subspecialty clinic Hospital Surgery ER

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Week 1 Monday Tuesday Wednesday Thursday Friday

am Rounds FMF. M.

RoundsPsych

Rounds IMInt. Med.

ORSurg/OB/Gyn

Rounds Peds

noon

* *** * Chart Audit,J. Club, Pediatric Presentation, Psychiatric Presentation

pm ** Surgery Bedside Teaching1:30 –3:30

Week 2 Monday Tuesday Wednesday Thursday Friday

am Rounds F.M.

RoundsSurg/OR

Rounds IM

OROB/Gyn

Rounds Peds

noon * *** *Chart Audit,J. Club, Pediatric Presentation, Psychiatric Presentation

pm OB/Gyn**

Peds Psych Bedside Teaching1:30 –3:30

* Small Group – 11:30 – 1:00 ** Call – ER, OB/Surgery *** Requested lectures

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Problem-Based Learning

Six students per group two 1 ½ hour sessions/week Actual patient hx presented by student Serves as stimulus for learning issues Facilitators from Basic and Clinical Sciences

Friday afternoon

Bedside teaching Chart audit Journal Club Pediatric case presentation Psychiatry case presentation

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Other opportunities

Grand rounds Local Videoconference

Requested lectures

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Coordinating Committee

Physician from each discipline Deans Student coordinators Meet 1-2x/month

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Student Evaluation

Triple Jump – 3x/year Departmental exams – 1x/year NBME Shelf Exams - 3x/year Database - monthly OSCE- end of year Observed H&P Pediatric & Psychiatry Case

Presentation

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Student Evaluation (cont.)

Continuity experience Oral Exams – Psychiatry Clinical skills – Attending Eval

3x/year Interpersonal skills Physician-related characteristics Peer Evaluation

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DatabaseComparison for July 2007-finalCUMULATIVE REPORT

Range Average

Total Encounters 1189-1478 1330

Clinic Visits 655-911 748

Patient seen 2 times 45-219 129

Patient seen 3-6 times 40-176 92

Patient seen > 7 times 4-59 26

ER visits 178-274 213

History and Physical (Audits) 30-41 32

Psychiatric Examination (Audits) 12-13 12

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Database

Range Average

Pap Smear/Pelvic 27-154 82

Vaginal Delivery 20-24 21

“Other” Delivery 5-14 8

Newborn Examination 14-34 24

Well Baby/Child Examination 5-160 38

Circumcision 1-8 3

Comparison for July 2007-finalCUMULATIVE REPORT

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DatabaseComparison for July 2007-finalCUMULATIVE REPORT

Range Average

Skin Surgery/Laceration repair 34-152 78

Abdominal Surgery 25-76 43

Hernia Repair 1-14 5

Laparoscopic Surgery 10-28 17

Chest Surgery 1-9 3

Breast Surgery 1-9 3

Orthopedic Surgery 2-46 12

OB/Gyn Surgery 20-56 43

Head/Neck Surgery 2-104 15

Endoscopy 2-34 15

Vascular, Carotid endart. 1-2 1

Vascular, venous access 3-12 6

Vascular 1-11 4

Total Surgeries 99-268 155

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Evaluation 50 Credit Hours

9 Clinical skills (H&P) 9 Clinical skills (Dx & Tx) 9 Problem solving skills 10 Knowledge base 10 Physician-related characteristics 1 Radiology 2 Clinical Colloquium

Colloquium

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o Three times a yearo All studentso Professionalism, Ethics, Diversity, ACLS, Radiology, Nutrition, Residency Day

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Feedback

Coordinator for each student 3x/year minimum Database, attending evaluation, small group, and peer evaluation

Program Evaluation

Students twice per year Medical Education Committee

Comparison of board scores OSCE

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Benefits to YMC

Recruiting Payment for teaching Education part of mission statement Students knowledgeable and skilled

at end of year

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Summary

Yankton Ambulatory Program - 16th year

Ambulatory based Integrated program Longitudinal – 1 year Continuity of care

Yankton Ambulatory Program

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Obs NAME LOCATION LS MEAN STDERR 1. FIRST IM Rapid City 69 2.8042 2. LAST IM Rapid City 74.4444

2.29923 3. FIRST IM Sioux Falls 71.375

2.97431 4. LAST IM Sioux Falls 72.625

2.43871 5. FIRST IM Yankton 66.5714

1.83578 6. LAST IM Yankton 78.4286 1.5052

Shelf Board Score Comparison

• IM, Surgery, OB/GYN

• 3x year

• No statistical difference

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Evaluation Criteria

a. Clinical skills (H&P): Ability to perform a directed history and physical examination

Attending’s evaluation 80% Coordinator evaluation 10% Observed H&P none Final Psych oral 10%

b. Clinical skills (Dx & Tx): Ability to develop efficient diagnostic and educational plans and execute the plans

Attending’s evaluation 80% Coordinator evaluation 10% Psych oral 10%

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Evaluation Criteria (cont.)c. Problem solving skills

Small group facilitator evaluation 20% Triple Jump evaluation 40% Attending evaluation 40%

d. Objective Knowledge Base Performance on national board shelf exams

100%

e. Interpersonal skills and Physician-related Characteristics Clinic and Program Staff evaluation 10% Attending evaluation 50% Coordinator evaluation 30% Small group facilitator evaluation 10%

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Evaluation Criteria (cont.)

f. Radiology Evaluated on radiology material, lectures, and examcovered during clinical colloquium

g. Colloquium Meaningful participation 10% Professionalism paper 15% Cultural diversity experience 25% ACLS 25% Ethics 25%

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Outcomes

Student satisfaction Board scores (+ 12 vs 10 Step 1 → 2) 2005

(+ 11 vs 10 Step 1 → 2) 2006

OSCE Residency choice Shelf Board Exams

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Positive Student Commentso “I thought the clinical experience was excellent.”o “I enjoyed working with and learning from all the physicians I interacted with.”o “Small Group continues to be one of the strengths of the program. It allowed us to learn more effectively from each other.”o “Emergency Department duty was an important learning tool and provided excellent experience in physical exam, history taking, and diagnosing common problems.”o “The NBME Board Shelf exams are an exceptional way to monitor progress.”o “I enjoyed working with and learning from all the physicians I interacted with.”o “My experience with each of my attendings was very positive”

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Positive Student Commentso “I think our community project experience was one of the most important aspects contributing to our professional and personal development.”o “The immersion project was a wonderful and meaningful experience.”o “Bedside teaching was excellent and a very good learning tool.”o “I think Triple Jumps are a valuable component of the YMP. It is clear the process is about assessing the students approach to a case and their ability to reason and think things through than it is about coming up with the correct diagnosis.o “If I had to do it over again, I would enthusiastically choose the Yankton campus again.”

Negative Student Comments

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Comparability of 3 clinical campuses Objectives the same Database Evaluations

Same requirements Oral Exams Department exams Shelf Board

Different evaluation

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YAP ExperienceLocal Barriers to Change

Department Chairs (loss of control)

Recruiting faculty Change in teaching style Comparability