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Medical Student Education
Medical Student Education
Junior year Core Clerkship
in Obstetrics and Gynecology: A Humanistic Approach
Thomas A. deHoop, M.D.,
Clerkship Director
Contact: Rose M. Wolterman,
Medical Student Education Coordinator
Department of Obstetrics and Gynecology
Medical Sciences Building, Room 4507
231 Albert B. Sabin Way
PO Box 670526
Cincinnati, Ohio 45267-0526
Telephone (513) 558-7651
Fax (513) 558-6138
Email rose.wolterman@uc.edu
Hours Monday, Tuesday, Thursday, 8 am - 4:30 pm, Eastern Time
Overview/Goals
The third year clerkship
is a comprehensive eight-week exposure to in-patient and outpatient obstetrics
and gynecology. Six of the eight week rotation are in an in-patient setting
at one or more affiliated hospitals: The Christ Hospital, Good Samaritan Hospital,
University Hospital, St. Elizabeth South or St. Luke Hospital. While there,
the rotation is split between labor and delivery, high-risk obstetrics, benign
gynecology and for some, gynecologic oncology. The remaining two weeks are dedicated
to outpatient ob/gyn with one-on-one teaching by a physician in private practice
to expose the student to the realities of office ob/gyn. In addition to viewing
the day-to-day practice of an ob/gyn, the student may take call and operate
with the physician they are following. Two half-days a week are dedicated to
formal teaching. This takes place in traditional didactic lectures, student
lead interactive group learning sessions and problem-solving case presentations.
At the beginning of the rotation, a session in the clinical skills lab orients
the student to the more common skills required on the clerkship. In addition
to the traditional subject matter, students will participate in discussions
on "The Practice of Medicine in the New Millennium" which includes such subjects
as: The Art of Medicine, The Physician-Patient Relationship, Stress in Medicine,
Quality Assessment and Managed Care Reform. The mid-clerkship interviews take
place at the end of the first 4weeks of the clerkship and provide an opportunity
for an in depth understanding of the student. Their abilities are assessed using
feedback from residents and faculty. Feedback regarding self-evaluation is part
of the process and steps are taken to remedy shortcomings and build on strengths.
At the end of the rotation, students are evaluated by both written and oral
exams. In addition to clinical knowledge, clinical skills in performing the
breast and pelvic exam as well as establishing rapport with patients are evaluated
by gynecologic teaching associates.
The principle of the 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.
Organization
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 take place in the Clinical Skills Laboratory of the College
of Medicine.
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. 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.
They are attentive listeners, they maintain congenial interpersonal relationships,
are non-critical of others, and allow others to make a contribution to the group.
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.
The following are student
comments about the interactive group-learning format:
"I really enjoyed interacting
with my classmates in this thought-provoking decision format."
"I was able to be more enthusiastic
about leaning and sharing information with my peers, which helps me remember
the material."
"Keep it up and add more sessions.
This was very valuable to me as an exercise in finally becoming comfortable
speaking in a group and getting to know my classmates."
4. 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:
- The case presenter should have
all information necessary for clinical problem solving of the given patient.
Another student serves as the recorder of the information on the blackboard.
- The presenter starts with stating
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.
- The participants formulate questions
to the presenter in order to develop a present illness.
- When the present illness has been
formulated by the participants and presenter, a differential diagnosis or
problem list is recorded on the board.
- 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. The recorder writes
on the blackboard the information of special importance regarding the physical
examination.
- 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.
- When a participant formulates
a question, he/she should state the reason for asking the question. When a
participant suggests a procedure or laboratory test, the participant should
give the reasons for requesting the procedure or laboratory test.
- A plan of management is formulated.
- Follow-up is necessary to ascertain
if the desired outcome has been achieved.
5. 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 for training the preceptors, and they are used
by the student and preceptor 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. The opportunity of a third-year
medical student to work with an experienced obstetrician/gynecologist in his/her
office is an excellent learning experience. The preceptor's instruction on the
needs of the patient at hand is essential for the medical student to become
a good physician. At the end of the two weeks the student will accomplish the
following:
- 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.
- Understand the gynecological screening
procedures and recommended time intervals for the performance of the Pap smear,
breast and pelvic examination, and mammography.
- 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.
- Focus learning and management
of common gynecological problems:
- vaginitis & vulvitis
- abnormal uterine bleeding
- hormonal replacement therapy
- work-up & management of
the abnormal Pap smear
- amenorrhea & dysmenorrhea
- evaluation of the infertile
couple
- chronic pelvic pain
- operative management for common
gynecologic problems
- sexually transmitted diseases
The preceptor serves as a role model
and mentor in the caring and compassionate doctor-patient-student relationship.
Personal attributes that we expect our preceptors to have are integrity, sincere
concern, patience, compassion, humility and wisdom. We have meetings in the
clerkship Director's home to honor the preceptors and to improve the teaching
and learning process. The following is an example of comments made by a student
regarding his preceptor:
"He taught the fine art of listening.
This was linked even to the finer art of matching the science of medicine with
what is practical and ultimately acceptable to the patient. It is hard to explain
exactly how he did this, but what it really boiled down to is that he truly
cared for both the patient and the student."
6. General Lecture Series:
On Monday and Thursday afternoons during the 8-week clerkship a total of 26
lectures are given by various faculty members, 14 interactive group learning
sessions, and 8 problem-solving case presentation sessions are conducted.
7. Lecture Series on The Practice
of Medicine in the New Millennium: The Challenge
Topics included under this heading are:
- The Physician-Patient Relationship
& the Impact of Managed Care on that Relationship
- Physician Responsibility &
Accountability
- Quality Assessment & Improvement
of Clinical Practice (Measuring What You Do So You Can Manage What You Do)
- Honest Peer Review
- Stress in Medicine - What Can
We Do About It?
- Transforming Stress into Positive
Energy
8. 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.
9. 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." Two sessions
are set aside for each student to read his or her essay to the group for discussion.
10. 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 30-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. Steps are made to either improve the student's function or to modify
behavior and function.
11. 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.
12. Written Examination:
The written examination is a 5-question essay examination that covers the textbook
entitled, Obstetrics & Gynecology, 3rd Edition, by Charles R. Beckmann,
et al, in addition to the contents of the interactive group learning sessions
and lecture series.
13. 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.
14. 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 on a scale of Excellent, Good,
Satisfactory, Fair, and Poor. There is room for comments for each component.
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 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 teaching of the Art of Medicine
would not be complete without strong consideration to the stresses that are
involved in medical school and in the practice of medicine. We emphasize that
the foundation for managing stress is in balancing your life. Good health, happiness,
and performance are all part of the same mosaic of life.
Summary
All of these activities and new
methods of teaching require individual, one-on-one mentoring and create 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 generates respect between the students and faculty and encourages students
to experience positive role models. Above all, it encourages compassion and
empathy in the delivery of care for patients. An important aspect of this is
that it encourages the students to work as a group in achieving common goals.
The philosophy is that the students learn best when they feel good about themselves
and they respond to the way in which they are treated. The clerkship director
formally works with the resident staff in stressing successful teaching of medical
students, and emphasizes why these teaching skills are important to residents.
He has defined the successful teaching of medical students and shares this with
the faculty, residents and students.
"Becoming an excellent teacher
requires continual learning and improvement, and each of us has yet to do our
best teaching."
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."
Continuous Training of Residents, Faculty & Preceptors
for Successful Teaching of Medical Students
1. Why are the skills
of teaching important for residents?
First, it is important because you do a lot of teaching. Other residents, as
well as medical students depend upon you for this. Overall, most teaching by
residents is probably informal teaching, which occurs within the constant exposure
on the clinical services. Teaching is the best way for you to learn. There is
a saying in education: "To teach is to learn twice." Finally, a good physician
is a good teacher. Patient education really depends on the teaching skills of
the clinician.
2. The Successful Teacher
The key to being a successful teacher is to learn behaviors that make you both
novel and useful. Several studies have determined which teacher behaviors contribute
most to successful learning. These can all be listed according to whether the
teacher is novel or useful. The teacher who is novel is enthusiastic, stimulating,
compassionate, and assessable to students. The teacher who is useful is well
organized, competent, practical, answers questions, and emphasizes comprehension
over recall.
3. Learning Objectives
of the Core for Evaluation
- Overall objectives for
the third-year clerkship as a learning experience
- Objectives for the following
components of the clerkship
- Two-week preceptorship
- Techniques and Procedures
- Breast and Pelvic
Examination
- Interactive Group
Learning Sessions
- Clinical Problem
Solving Case Presentations
- Personal attributes
such as attitudes/values, honesty, trust, integrity, respect, sincere
concern, patience, compassion, empathy, human understanding, humility,
wisdom & willingness to be non-judgmental communication & listening
skills learning patient expectations management of stress physician responsibility
& accountability
- The Practice of Medicine
in the New Millennium: The Challenge.
Topics included under this heading:
- What Patients
Expect From the Doctor-Patient Relationship
- the Impact of
Managed Care on that Relationship
- Physician Responsibility
& Accountability
- Quality Assessment
& Improvement - Honest Peer Review
- Managed Care
Reform and the Problems of our Current Health Care System
- Stress in Medicine
- What Can We Do About It?
- Transforming
Stress Into Positive Energy
- Open Forum at the
Clerkship Director's Home
- Resident and Attending
Faculty Teaching on the Outpatient & Inpatient Clinical Services
- Lecture Series and
Mid-clerkship interviews
- Evaluation
4. Characteristics of
Learning
- Learning is promoted
or enhanced when:
- The information is
perceived as having immediacy or relevance
- Problem-solving opportunities
are provided rather than learning facts
- Learning is self-paced
- The learner plays
an active role in setting objectives
- Appropriate feedback
is given to the learner
- The effective teacher
can stimulate and facilitate learning by:
- Identifying what
is already known by the student
- Identifying what
is not known by the student
- Investigating the
learning issues to arrive at a new level of understanding
- Emotional Factors
- Students learn best
when they have a positive self-image
- They respond to the
way in which they are treated
5. Role of Evaluation
- When effectively done,
evaluation achieves the following:
- Provides an awareness
for the student's personal and intellectual growth.
- Helps the student
develop realistic and balanced insights into both his/her strengths and
weaknesses.
- Offers the student
specific opportunities to learn and make positive changes.
- Motivates the student
to achieve new heights.
- Types of Evaluations:
- Formative evaluations:
i.e. mid-clerkship interviews, on-going evaluations and feedback
- Summative evaluation:
i.e. final clerkship evaluation
- Providing feedback
- All feedback
should be relevant to the established goals and objectives of the
team
- Listen to the
other person's side
- Jointly agree
upon action to be taken
- Summarize the
discussion and express appreciation
- Give prior thought
to feedback you wish to provide. Do not "wing it".
- Provide feedback
as soon as possible so corrective action can be accomplished in a
timely fashion.
- Have accurate
data to support the feedback
- Be careful of
personality factors
- Do not concentrate
on trivia
- Steps in receiving
feedback
- Listen with intent
to learn from the feedback
- Approach the
situation with a positive attitude rather than a defensive one
- Ask clarifying
questions - try to understand the situation as completely as possible.
- Share your views
about the situation. Although you do not want to make excuses for
a situation, it is appropriate to provide information that may explain
the situation. Try to remain objective.
- Jointly develop
an action plan to address the problem. The purpose of feedback is
to continue to grow and improve. Without an action plan, there is
little point in providing feedback.
- Express appreciation.
Giving feedback is not easy and takes a certain amount of courage
and willingness to take risks. Recognize that you appreciate the person's
interest in you
Conclusion
Becoming an excellent teacher
requires continual learning and improvement, and each of us has yet to do our
best teaching.
Senior Year Electives in
Obstetrics and Gynecology
Maternal-Fetal Medicine
at The University Hospital
http://www.med.uc.edu/meded/academics/electivesonline/PDF/110101sf.pdf
Advanced Obstetrics at Good Samaritan Hospital
http://www.med.uc.edu/meded/academics/electivesonline/PDF/110106sf.pdf
Advanced Clerkship in Obstetrical Care at The University Hospital
http://www.med.uc.edu/meded/academics/electivesonline/PDF/110107sf.pdf
Advanced Clerkship in Outpatient Obstetrics and Gynecology (AHEC)
http://www.med.uc.edu/meded/academics/electivesonline/PDF/110108sf.pdf
Reproductive Endocrinology and Infertility at The Christ Hospital
http://www.med.uc.edu/meded/academics/electivesonline/PDF/110116sf.pdf
Preceptorship in Obstetrics and Gynecology (AHEC)
http://www.med.uc.edu/meded/academics/electivesonline/pdfsf/110126sf.pdf
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