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The principle of the 8-week clerkship is that if medical students are treated with respect and compassion with clearly defined goals and objectives, and if the faculty is responsive to the total needs of the medical student, the students in turn will be more humanistic as advocates of their patients. Students learn best when they feel good about themselves and have a positive self-image. They respond best when they are treated with respect and are actively involved in the learning process. The objective of the core curriculum in obstetrics and gynecology is that the student learns the basic skills, attitudes and knowledge that are essential in dealing with women patients and learns how to apply the science of medicine in a caring and compassionate manner so as to benefit the patient.
The overall organization, format, and learning experience is divided into the following areas:
1. Clinical Skills Laboratory:
During the first week of the clerkship the students are divided into two groups of 13, and using teaching aids and mannequins they are taught the breast and pelvic examination, interpretation of cervical dilatation and station during labor, the Leopold maneuver, and spontaneous vaginal delivery, episiotomy repair and knot tying. This is accomplished in our clinical skills laboratory.
2. Hospital Clinical Experience & Training:
The students are assigned to the following hospitals for their clinical experience and training: University, Christ, Good Samaritan, St. Luke, and St. Elizabeth Hospitals. They report to the College of Medicine at the University for the lecture series, interactive group learning sessions, and problem-solving case presentation sessions. The mid-clerkship interviews, oral and written examinations also take place at the College of Medicine. The breast and pelvic examination skills and establishment of patient rapport evaluation by the gynecological teaching associates takes place in the Center for Competency Development.
3. Interactive Group Learning: Empowering Students To Be Responsible For Their Own Learning
The goals of the interactive small group learning sessions are to encourage active learning, to generate enthusiasm for content learning, to reinforce the knowledge base, to stimulate problem-solving skills, and to develop interactive communication and listening skills. A 10-question quiz in the first 10-15 minutes of the session, which will be administered by the faculty preceptor who is assigned to the case. (The students’ average score of these quizzes will account for 17.5% of their overall clerkship grade.) These goals are accomplished by assigning cases at the beginning of the clerkship with specific dates that the cases will be presented for discussion. Each session is 2 hours in length with a brief 10-minute
break after the first 50 minutes. After the first break the group critiques the process. For each case there is a group leader and 3 or 4 consultants who become experts in the subject to which they are assigned, and a recorder records important data as it is brought up by the group. The group leader serves as a facilitator with each consultant leading a format of learning based on questioning the other members of the group in regard to data and clinical problem-solving decisions. The participants in the group adequately prepare for each session. The role of the faculty tutor is to serve as a back up to the group leader in terms of the group leader's role as a facilitator and to monitor the discussion to insure that the session objectives are met. The faculty tutor encourages the students to become self-directed learners.
4. Small Group Learning Sessions
The small group learning sessions are based on 34 of the 64 learning objectives from The Association of Professors in Gynecology & Obstetrics (APGO). There will be 12 sessions, each containing half of the class (12 – 14 students). Although all of the learning objectives are important and deserving of instruction, 34 were chosen as they are most common and not covered elsewhere in the clerkship. Each session will cover 1 – 4 learning objectives and is expected to last about 2 hours, although some sessions are shorter. The participants will prepare by reading assigned chapters in the text. During the session, no books will be permitted, but notes taken of assigned reading are permissible and encouraged. A 10-question quiz covering one of the topics will be taken in the first 10-15 minutes of the session, which will be administered by the faculty preceptor who is assigned to the case. (The students’ average score of these quizzes will account for 17.5% of their overall clerkship grade.) Each objective will have a student assigned as the discussion leader. The leaders will lead the discussion covering the assigned reading and the learning objectives. The leaders will involve the group by encouraging individuals to answer questions regarding the objective. At the end of the discussion the group will answer the questions in the clinical vignette. The role of the faculty preceptor is to evaluate the students on their preparation, knowledge and participation, and to redirect, clarify or emphasize important learning points.
5. Clinical Problem-Solving & Case Presentations:
These are small group case presentations, which require problem-based learning and the student knowing the total patient. This includes the patient's environment, education, work, home and family structure. The student presenting the case assumes the role of the patient and provides only the chief complaint initially. The other participating students extract the information from the history, physical examination, select appropriate diagnostic studies, and apply the knowledge to problem solving and patient management. The format for these presentations is as follows:
1. The case presenter has all of the information necessary for clinical problem solving of the given patient.
2. The presenter states the chief complaint as the patient comes to the hospital emergency room, labor and delivery unit, or office. Another student serves as the recorder of the information on the blackboard.
3. The participants formulate questions to the presenter in order to develop a present illness.
4. When the present illness has been formulated by the participants and presenter, a differential diagnosis or problem list is recorded on the board.
5. Questions are developed by the participants in regard to the past history, family history, social history, and review of systems. The differential diagnosis is modified based on information obtained and finalized prior to the physical examination.
6. Following the physical examination the problem list and differential diagnosis is upgraded and a list of procedures and laboratory studies are developed in order to make an accurate diagnosis.
7. When a participant formulates a question or suggests a procedure or laboratory test, he/she should state the reason for asking the question.
8. A plan of management is formulated and follow-up is necessary to ascertain if the desired outcome has been achieved.
6. Two-week Ambulatory Preceptorship:
The student receives a one-on-one teaching experience by a preceptor in the private patient office for 2 weeks out of the 8-week clerkship. The syllabus and learning objectives are used as a guide and reference during the 2-week ambulatory experience. One of the most important learning experiences is the role model that the preceptor plays in the caring doctor-patient relationship. At the end of the two weeks the student will accomplish the following:
A. Develop the skills necessary for establishing rapport with patients by demonstrating good communication skills in obtaining the history and performing the physical examination with proper documentation in the office medical record. The student will demonstrate the ability to perform a quality breast and pelvic examination, Pap smear, and cultures, as indicated.
B. Understand the gynecological screening procedures and recommended time intervals for the performance of the Pap smear, breast and pelvic examination, and mammography.
C. Participate in patient education and develop skills in behavioral modification to improve health, for example, use of contraceptives, preconception counseling, prevention of STD's, exercise and nutrition, drugs, alcohol, smoking, domestic abuse, and sexual assaults.
D. Focus learning and management of common gynecological problems.
7. General Lecture Series:
On Monday and Thursday afternoons during the clerkship a total of 7 lectures are given by various faculty members, 8 interactive group learning sessions, 24 small group learning sessions and 6 clinical problem-solving case presentation sessions are conducted.
8. The Practice of Medicine in the New Millennium: The Challenge – Lecture Series
Topics included under this heading are:
1. The Physician-Patient Relationship & the Impact of Managed Care on that Relationship
2. Physician Responsibility & Accountability
3. Quality Assessment & Improvement of Clinical Practice (Criteria Sets)
4. Stress in Medicine - What Can We Do About It?
5. Transforming Stress into Positive Energy
9. Open Forum at the Clerkship Director's Home:
The title of the open forum is, "What Is Our Future In Medicine?" and covers the subjects that are presented in the lecture series under The Practice of Medicine in the New Millennium: The Challenge. The preceptors and faculty are invited to attend these Saturday morning sessions. The environment is relaxed and pleasant.
10. Art of Medicine Essay:
Near the end of the clerkship the students write an essay entitled, "Personal Attributes I Would Like To Have To Practice The Art Of Medicine", which are read by each student to the class and discussed.
11. Mid-clerkship Interviews:
At the mid-point of the clerkship, approximately after the first 4 weeks, the course director and other faculty meet with each individual student for a 20-minute mid-clerkship interview. This interview is used as a means of identifying the strengths and weaknesses of the student using the feedback received from faculty and residents who worked with the student during the first month. Feedback regarding self-evaluation and experiences is also part of the process. It gives the student the opportunity to express concerns and share their experiences regarding the clerkship.
12. Oral Examination:
The oral examination is given during the last week of the clerkship by one of five faculty members who are specially trained for the oral examination. It covers specifically the material in the learning objectives and the syllabus that is used for the 2-week ambulatory preceptorship. This exam accounts for 10% of the student’s overall clerkship grade.
13. Departmental Examination:
The examination consists of 100 multiple choice questions that are taken from the students’ textbook, Obstetrics & Gynecology, 3rd Edition, by Charles R. Beckmann, et al, in addition to the contents of the interactive group learning sessions. This exam accounts for 12.25% of the student’s overall clerkship grade.
14. SHELF Examination:
The SHELF examination, which is a National Board of Medical Examiners Clinical Science Exam, is administered at the end of the clerkship and consists of 100 multiple-choice questions. This exam accounts for 5.25% of the student’s overall clerkship grade
15. Gynecological Teaching Associates - Evaluation of Breast & Pelvic Examination Skills:
The second-year students meet with the gynecological teaching associates for the instruction of skills in performing the breast and pelvic examination. The third-year students meet with them during the last week of the clerkship as part of a final evaluation, which is incorporated as part of their final clerkship grade. They are evaluated on their ability to establish rapport with patients and in performing the breast and pelvic examination. The student must pass this skills test in order to pass the clerkship.
16. Evaluation of the Medical Student and by the Medical Student:
At the end of the clerkship students complete an OB/GYN Clerkship Evaluation that evaluates each component of the clerkship. The final evaluation of the medical student by the faculty and resident staff consists of the student's performance on the written and oral examinations, clinical performance, two-week ambulatory preceptorship, interactive group learning, GTA breast and pelvic exams, and case presentations. The clinical performance and ambulatory preceptorship evaluations are completed by the residents and attending staff who work with the students. The interactive group learning and small group learning sessions have an evaluation form that is completed by the faculty member who monitors the session. The skills in establishing rapport with patients and in performing the breast and pelvic examination are evaluated by the gynecological teaching associates. There is a narrative description of the student's performance that is sent to the Dean's office. This also includes two areas that identify the student's strengths, as well as areas needing improvement. The medical student evaluations of the eight-week clerkship are on a rating scale of 1 to 5, with 5 being an excellent rating. Recent evaluations for the year are as follows:
Mid-clerkship Interviews = 4.53
Two-week Preceptorship = 4.42
Interactive Group Learning = 4.33
Open Forum = 4.33
Overall Evlauation = 4.4
SUMMARY:
All of these activities and new methods of teaching require individual, one-on-one mentoring and creates much enthusiasm and interpersonal interactions between the faculty and students. The purpose is to empower the students to be responsible for their own learning. It encourages compassion and empathy in the delivery of care for patients, and it encourages the students to work as a group in achieving common goals. The clerkship director works with the resident staff in stressing successful teaching of medical students, and emphasizes why these teaching skills are important to residents. The final message to the student is: "May the humanistic qualities of honor, trust, integrity, respect, and compassion prevail as you become the advocates of your patients. Listen to your patients for they will become your best teachers. Take care of yourselves so that you may care for others."
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