From the 4/17/2020 newsletter
Preparing our students for Internship during the pandemic. The Virtual “Night onCall” (NOC)
Adina Kalet, MD MPH
Ring! Ring!
The medical student clicks the mouse and looks at the face on her computer screen.
“This is Dr. M. You paged me?”
“Yes Doctor, you’re covering Mr. Jackson, right? He was ready to go home in the morning, but… ”
So begins a 3-1/2-hour immersive, simulated “Night onCall” (NOC) we designed six years ago to assess each senior medical student’s readiness for transition to internship – the final medical school clinical exam just before graduation. This year, for obvious reasons, NOCs are being conducted virtually and are much “higher stakes,” since students have been on a clinical pause and are unable to complete their graduation requirements in any other way.
On the computer screen are two colorfully outlined squares. In one, “Dr. M,” a soon-to-be graduate of MCW – Central Wisconsin, wears her white coat and is playing herself as a brand-new intern. In the other square is a nurse, “Mr. D,” who tells Dr. M he arrived for his hospital shift to discover that Mr. Jackson in room 212 is having an unexpected, worrisome new problem. Dr. M and Mr. D discuss the case and agree to meet in Mr. Jackson’s room to explore the clinical issues and make a plan.
A third square appears on the screen. It contains a middle-aged man wearing a hospital gown. Dr. M introduces herself. “Hi, Mr. Jackson, I am covering for Dr. Green, I hear you have a new problem.”
“No problem here! I’m just eager to go home tomorrow,” answers Mr. Jackson.
And so it goes. Dr. M cajoles Mr. Jackson to tell his story. She asks Mr. D to share Mr. Jackson’s lab results, EKG, and fluid intake and output (all done on the screen). Dr. M lists the physical exam maneuvers she will conduct and why. Dr. M, Mr. D, and Mr. Jackson – who still insists on going home – agree on a plan. Dr. M says goodbye, promises to return, switches screens, and writes a “cross-coverage note.” She contacts the surgery attending on-call (whose role is played by her favorite clinical teacher and family physician) to present her findings and discuss the plan.
Dr. M is called to see two more patients. Before the “simulated night” is over, she manages three patients and interacts on-screen with two more nurses, another attending physician, and a family member. She searches the internet for resources, interprets laboratory results and an EKG, writes clinical notes, and finally, once “morning” arrives, hands off the three patients to another clinician (played by another favorite clinical teacher).
She and two other students take deep breaths and undergo an online debriefing by a seasoned clinician. She thinks things went well, but she also realizes that there were gaps. She forgot to aske a couple of critical questions. She realizes that the other students were as anxious as she was. In a few days she will receive an individualized, detailed report on her performance with prompts for self-assessment of her strengths and weaknesses and a set of learning goals. She is one step closer – and a bit more confident – as she prepares herself for internship.
Colleagues at the NYU Grossman School of Medicine, The Texas Tech University Health Sciences Center School of Medicine, and MCW – Central Wisconsin have worked together over three time zones to develop and implement in-person Night onCall opportunities that assess the thirteen core Entrustable Professional Activities (EPAs) that the Association of American Medical Colleges (AAMC) has determined all graduates – regardless of future specialty – should be able to perform before entering residency. Night onCall is a feasible, reliable, and exciting way to assess whether near-medical school graduates are ready to assume their roles.
Therefore, when the AAMC recommended a pause in clinical rotations in mid-March 2020, the medical school Deans approached the Liaison Committee on Medical Education (LCME) for permission to employ simulations and other virtual strategies to demonstrate students have achieved the core objectives and requirements for graduation. Our group sprang into action organizing, testing technology, and recruiting experienced Night onCall actors from around the country.
This week twenty-five MCW – Central Wisconsin students participated in Night onCall. In mid-May, seventeen MCW – Green Bay students will go through the same experience.
Students have appreciated the opportunity to practice and get feedback. They tell us that the virtual structure, although artificial, feels authentic. Faculty members enjoy observing their students in action and are proud of how the students perform. One MCW – Central Wisconsin faculty member said that the day was a “moon shot.” The Night onCall program required skilled and committed staff support, and special mention goes to Kelly Mulder, Tavinder Ark, and Kinga Eliasz.
Our students are being launched into a rapidly changing healthcare landscape and we must adapt as we prepare them. Telehealth will be front and center in their careers. Over the coming months, our graduates might find themselves trying out their history and physical skills while working in full personal protective equipment while they balance their fears with their compassion for the suffering of others. The decisions and challenges they face will be unprecedented. Even after the COVID-19 danger passes, nothing will be the same.
No one knows exactly what they will encounter. At the very least, by providing experiences like Night onCall, we help assure our near-graduates that they are ready to face the challenges offered by the the next phase of their careers in medicine.
References:
Kalet, A., Zabar, S., Szyld, D., Yavner, S., Song, H., Nick, M., Ng, G., Pusic, MV, Denicola, C., Blum, C., Eliasz., K., Nicholson, J., Riles, T., A Simulated “Night-onCall” to Assess and Address the Readiness for Internship of Transitioning Medical Students, Advances in Simulation (2017) 2:13. DOI 10.1186/s41077-017-0046-1
Eliasz KL, Ark TK, Nick MW, Ng GM, Zabar S, Kalet AL, Capturing Entrustment: Using an End-of-Training Simulated Workplace to Assess the Entrustment of Near-graduating Medical Students from Multiple Perspectives, Medical Science Educator (2018) 28:739-747. DOI: https://doi.org/10.1007/s40670-018-0628-0
Adina Kalet, MD MPH is the Director of the Robert D. and Patrica E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin
“Yes Doctor, you’re covering Mr. Jackson, right? He was ready to go home in the morning, but… ”
So begins a 3-1/2-hour immersive, simulated “Night onCall” (NOC) we designed six years ago to assess each senior medical student’s readiness for transition to internship – the final medical school clinical exam just before graduation. This year, for obvious reasons, NOCs are being conducted virtually and are much “higher stakes,” since students have been on a clinical pause and are unable to complete their graduation requirements in any other way.
On the computer screen are two colorfully outlined squares. In one, “Dr. M,” a soon-to-be graduate of MCW – Central Wisconsin, wears her white coat and is playing herself as a brand-new intern. In the other square is a nurse, “Mr. D,” who tells Dr. M he arrived for his hospital shift to discover that Mr. Jackson in room 212 is having an unexpected, worrisome new problem. Dr. M and Mr. D discuss the case and agree to meet in Mr. Jackson’s room to explore the clinical issues and make a plan.
A third square appears on the screen. It contains a middle-aged man wearing a hospital gown. Dr. M introduces herself. “Hi, Mr. Jackson, I am covering for Dr. Green, I hear you have a new problem.”
“No problem here! I’m just eager to go home tomorrow,” answers Mr. Jackson.
And so it goes. Dr. M cajoles Mr. Jackson to tell his story. She asks Mr. D to share Mr. Jackson’s lab results, EKG, and fluid intake and output (all done on the screen). Dr. M lists the physical exam maneuvers she will conduct and why. Dr. M, Mr. D, and Mr. Jackson – who still insists on going home – agree on a plan. Dr. M says goodbye, promises to return, switches screens, and writes a “cross-coverage note.” She contacts the surgery attending on-call (whose role is played by her favorite clinical teacher and family physician) to present her findings and discuss the plan.
Dr. M is called to see two more patients. Before the “simulated night” is over, she manages three patients and interacts on-screen with two more nurses, another attending physician, and a family member. She searches the internet for resources, interprets laboratory results and an EKG, writes clinical notes, and finally, once “morning” arrives, hands off the three patients to another clinician (played by another favorite clinical teacher).
She and two other students take deep breaths and undergo an online debriefing by a seasoned clinician. She thinks things went well, but she also realizes that there were gaps. She forgot to aske a couple of critical questions. She realizes that the other students were as anxious as she was. In a few days she will receive an individualized, detailed report on her performance with prompts for self-assessment of her strengths and weaknesses and a set of learning goals. She is one step closer – and a bit more confident – as she prepares herself for internship.
Colleagues at the NYU Grossman School of Medicine, The Texas Tech University Health Sciences Center School of Medicine, and MCW – Central Wisconsin have worked together over three time zones to develop and implement in-person Night onCall opportunities that assess the thirteen core Entrustable Professional Activities (EPAs) that the Association of American Medical Colleges (AAMC) has determined all graduates – regardless of future specialty – should be able to perform before entering residency. Night onCall is a feasible, reliable, and exciting way to assess whether near-medical school graduates are ready to assume their roles.
Therefore, when the AAMC recommended a pause in clinical rotations in mid-March 2020, the medical school Deans approached the Liaison Committee on Medical Education (LCME) for permission to employ simulations and other virtual strategies to demonstrate students have achieved the core objectives and requirements for graduation. Our group sprang into action organizing, testing technology, and recruiting experienced Night onCall actors from around the country.
This week twenty-five MCW – Central Wisconsin students participated in Night onCall. In mid-May, seventeen MCW – Green Bay students will go through the same experience.
Students have appreciated the opportunity to practice and get feedback. They tell us that the virtual structure, although artificial, feels authentic. Faculty members enjoy observing their students in action and are proud of how the students perform. One MCW – Central Wisconsin faculty member said that the day was a “moon shot.” The Night onCall program required skilled and committed staff support, and special mention goes to Kelly Mulder, Tavinder Ark, and Kinga Eliasz.
Our students are being launched into a rapidly changing healthcare landscape and we must adapt as we prepare them. Telehealth will be front and center in their careers. Over the coming months, our graduates might find themselves trying out their history and physical skills while working in full personal protective equipment while they balance their fears with their compassion for the suffering of others. The decisions and challenges they face will be unprecedented. Even after the COVID-19 danger passes, nothing will be the same.
No one knows exactly what they will encounter. At the very least, by providing experiences like Night onCall, we help assure our near-graduates that they are ready to face the challenges offered by the the next phase of their careers in medicine.
References:
Kalet, A., Zabar, S., Szyld, D., Yavner, S., Song, H., Nick, M., Ng, G., Pusic, MV, Denicola, C., Blum, C., Eliasz., K., Nicholson, J., Riles, T., A Simulated “Night-onCall” to Assess and Address the Readiness for Internship of Transitioning Medical Students, Advances in Simulation (2017) 2:13. DOI 10.1186/s41077-017-0046-1
Eliasz KL, Ark TK, Nick MW, Ng GM, Zabar S, Kalet AL, Capturing Entrustment: Using an End-of-Training Simulated Workplace to Assess the Entrustment of Near-graduating Medical Students from Multiple Perspectives, Medical Science Educator (2018) 28:739-747. DOI: https://doi.org/10.1007/s40670-018-0628-0
Adina Kalet, MD MPH is the Director of the Robert D. and Patrica E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin
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