Objectives Describe how a clinical track based on ACGME competencies could bridge the chasm between UGME and GME. Demonstrate how Clinical Tracks are improving the 4th year at our institution.

1. Transition to Residency: Who's
Responsible?
Using Clinical Tracks to Assess
Preparedness for Internship
Nicholas E. Kman, MD FACEP
Associate Professor-Clinical Emergency Medicine
Director, Part 3/Med 4 Academic Program

2. Objectives
 Describe how a clinical track based on ACGME
competencies could bridge the chasm between
UGME and GME.
 Demonstrate how Clinical Tracks are improving the
4th year at our institution.

3. 3
Medical
Knowledge and
Skills
Practice and
Lifelong Learning
Interpersonal
Communications
Systems Based
Practice
Professionalism
Patient Care
Medical Knowledge
and Skills
Curricular Reform at OSU
Old Curriculum
2 + 2 Approach

4. 4
Advanced
Clinical
Management
4 Years
18 months 12 months 13 months
Longitudinal Projects
Life-Long
Learning/
Reflection
Longitudinal
Health Coach
Community
Health
Education
Patient
Safety

5. Hallmarks
of L.S.I. Curriculum
 Reinforce foundational science throughout curriculum
 Early clinical service-learning experiences
 Faculty coaching
 Mastery based evaluations
 Building Entrustment on all 13 EPA’s
 Preparing for residency through increased patient care and
working toward Milestones with Clinical Tracks
5

6. Lyss-Lerman P, et al. What training is needed in the fourth
year of medical school? Views of residency program
directors. Acad Med. 2009 Jul;84(7):823-9.
 “Organizing the curriculum with specialty-specific
tracks could be explored by looking at specialty-
specific data and expanding the interviews to
include more PDs.”
6

7. Walling A, Merando A. The fourth year of medical
education: a literature review. Acad Med. 2010
Nov;85(11):1698-704.
 ACGME policies and practices will increasingly
influence medical student education
 4th year as capstone for medical school versus
preparation year for residency
 Turned in favor of the pre-residency viewpoint
 Other factors that increase pressure towards
using 4th year to prepare for residency are
student debt and growing specter
of unmatched US graduates
7

8. Reddy ST, et al. ACE perspective paper: recommendations for
redesigning the "final year" of medical school. Teach Learn Med.
2014;26(4):420-7.
 Demonstrate that they have mastered objectives
(based on 6 ACGME Core Clinical Competencies)
 Complete a required capstone course prepares
students for residency.
 Structure their 4th year schedules to accomplish
specialty-specific objectives that prepare them for
their intended specialty.
 Engage in thoughtful inventory of training. Identified
gaps should be addressed through deliberate
participation in rotations that address identified
areas.
8

9. Reddy ST, et al. ACE perspective paper: recommendations for
redesigning the "final year" of medical school. Teach Learn Med.
2014;26(4):420-7.
 Demonstrate that they have mastered objectives
(based on 6 ACGME Core Clinical Competencies)
 Complete a required capstone course prepares
students for residency.
 Structure their 4th year schedules to accomplish
specialty-specific objectives that prepare them
for their intended specialty.
 Engage in thoughtful inventory of their medical
school training. Identified gaps should be addressed
through the deliberate participation in rotations that
address the identified areas.
9

10. Reddy ST, et al. ACE perspective paper: recommendations for
redesigning the "final year" of medical school. Teach Learn Med.
2014;26(4):420-7.
 4th year is a bridge between medical school and
Residency:
 ACGME Competencies and AAMC Core Entrustable
Professional Activities (EPAs) should be used to guide
curriculum development.
 These competencies and specialty-specific
milestones and EPAs provide guidance to medical
schools for the minimum level of competency for
starting intern and can be used to design 4th-year
curricula.
10

11. Chen HC, van den Broek WE, ten Cate O. The case
for use of entrustable professional activities in
undergraduate medical education. Acad Med. 2015
Apr;90(4):431-6
 Specialty-specific EPAs could guide student
selection of senior year electives as well as help
program directors ensure a baseline competency
level of their entering residents.
 If operationalized properly, these specialty-specific
EPAs could ease advising during the fourth year,
ensure more adequately prepared entering
residents, and obviate the need for extracurricular
“boot camps”
11

12. Solution: Clinical Tracks!
12

13. 13
College structure – 6 UCLA colleges
Acute Care: time-based decision-making specialties
(Anesthesia, critical care EM)
Applied Anatomy: structure-oriented fields (Surgery, radiology,
pathology)
Medical Leadership: dual-degree programs in public health or
business administration
Medical Subspecialties: subspecialties focused on clinical reasoning
and advance fellowship training
Primary Care: longitudinal care specialties (FM, IM, pediatrics)
Urban Underserved: focuses on care of underserved communities

14. Advanced Management in
Hospital Based Care
Advanced Management in
Relationship Centered Care
Advanced Competency Elective
Clinical Tracks:
Alongitudinal
experience in a
specialty or
subspecialty designed
to prepare students to
be an intern/incoming
resident by meeting
entry level milestones
in that field.
Other Electives (4 total required
including Advanced Competency)
Flex
Gateway Activities
Advanced
Clinical
Management
HSIQ Project

15. Clinical Track
 Framework for 4th year medical school
“curriculum” that aligns UGME and GME such
that student is working toward entry level
milestones (ACGME milestones) to prepare
them for their intern year in specialty of choice.
 Conglomeration of experiences (required
courses, electives, advanced competencies,
bootcamps) during 4th year to prepare them for
internship.

16. List of current tracks
 Anesthesia
 Emergency Medicine
 Family Medicine
 Internal Medicine
 (Preliminary medicine, IM-Peds included)
 Obstetrics/Gynecology
 Pediatrics
 Psychiatry
 Neurology
 Radiology
 Surgery/Surgical Subspecialties
 (Preliminary Surgery included)

17. How long should a track be?
 A clinical track is not a set number of rotations
but a combination of different
rotations/experiences that will allow the student
to develop skills to become a proficient intern in
that field
 Recommendations for rotations for the
required components of part 3
 Recommendations for electives
 Required rotations
 Advanced topics courses

18. What is required?
 Each department/division decided what is
required in order for students to complete the
track
 Specialty specific scheduling guide (SSSG)-
recommendations for required and elective
rotations put together by
departments/divisions to guide students on
what to take during fourth year to prepare
them for a particular field

19. Specialty Specific Scheduling Guide (SSSG)
2. Emergency Medicine Clinical Track (Revised 2/9/2015)
AMHBC: EMERGENCY MEDICINE: Emergency Med at OSU.
AMRCC: CHRONIC CARE COMPONENT Geriatrics, HIV Patient Care, Congestive Heart Failure, Adult Kidney Disease, Child
Abuse/Child Advocacy, Alcohol and other Drug Abuse.
AMHBC: MINI INTERNSHIP: MICU, Cardiology, Pulmonary.
Electives: Advanced Topics in Emergency Medicine (ATEM: Honors Longitudinal EM Elective), Advanced Competency in Ultrasound,
Advanced Competency in Emergency Preparedness, Radiology, Anesthesia, Sports Medicine, Dermatology, Surgical specialties in
general, including Plastics, ENT/Ophtho (two 2-week electives if possible), Hand Surgery, Orthopedics.
Special Requirements: Away Electives in EM only at places where you may want to match. Students interested in Emergency
Medicine should schedule their AMHBC: EMERGENCY MEDICINE at OSU in July, August or September.
Busiest interview months to consider for flex months are November through January
Residency Directors: Sorabh Khandelwal (Director), Jillian McGrath, Sarah Greenberger, Laura Thompson, Andy King.
Faculty Advisors: Dan Martin, David Bahner, Nick Kman, Mark DeBard, Ash Panchal, Creagh Boulger, Cynthia Leung.

20. How are students evaluated?
 Competency based assessments
 Ideally- the departments/divisions who
created the tracks would select a subset of
the ACGME milestones for that field that
students would be evaluated on
 Students would have “completed” the track if
they achieve the selected milestones
 This could be determined by one person or
Clinical Competence Committee (CCC)

21. Description of the EM Clinical Track
21

22. 1. Patient Care
1. Emergency Stabilization (PC1) Prioritizes critical initial stabilization action and mobilizes hospital support
services in the resuscitation of a critically ill or injured patient and reassesses after stabilizing intervention.
Level 1
Feedback/Assessment
1.1
Part 3 Curricular
Component
1.1 Recognizes abnormal vital signs
Assessment week
simulation
AMHBC1, ATEM
Level 2 1.2 1.2
1.2
Recognizes when a patient is unstable requiring
immediate intervention
Performs a primary assessment on a critically ill or
injured patient
Discerns relevant data to formulate a diagnostic
impression and plan
Assessment week
simulation
2. Performance of Focused History and Physical Exam(PC2) Abstracts current findings in a patient with multiple
chronic medical problems and, when appropriate, compares with a prior medical record and identifies significant
differences between the current presentation and past presentations.
Level 1
Feedback/Assessment
2.1
Part 3 Curricular
Component
2.1
Performs and communicates a reliable, comprehensive
history and physical exam
.
Clinical Performance
Evaluation (CPE), DOC,
Assessment week
simulation
AMHBC1, AMRCC,
ATEM
Level 2 2.2 2.2
2.2
Performs and communicates a focused history and
physical exam which effectively addresses the chief
complaint and urgent patient issues
CPE, DOC, Assessment
week simulation
3. Diagnostic Studies (PC3) Applies the results of diagnostic testing based on the probability of disease and the
likelihood of test results altering management.
Level 1
Feedback/Assessment
3.1
Part 3 Curricular
Component
3.1 Determines the necessity of diagnostic studies
CPE, DOC, Assessment
week simulation
AMHBC1, AMRCC,
ATEM
Level 2 3.2 3.2
Orders appropriate diagnostic studies
Performs appropriate bedside diagnostic studies and
procedures
CPE, DOC, Assessment
week simulation
4. Diagnosis (PC4) Based on all of the available data, narrows and prioritizes the list of weighted differential
diagnoses to determine appropriate management.

23. Assessments
 Required to complete 3 assessment shifts.
 Faculty member will perform a Direct Observation of Competence
(DOC) on each shift. A formal standardized assessment will be
performed and feedback provided.
 Perform common ED procedures under supervision and faculty will
perform a checklist assessment.
 Procedure workshops scheduled throughout the year. Students who
are not able to perform procedures on real patients will perform
required procedures on a simulator or task trainer under
supervision.
 Complete a comprehensive assessment with simulated patient
during the Assessment week to be scheduled March 2016. Students
will be scored on a standardized checklist.

24. List of medical student milestones assessed during
Professor Rounds
24
Milestone Description
Recognizes abnormal vital signs.
Recognizes when a patient is unstable requiring immediate intervention.
Performs and communicates a reliable, comprehensive history and physical exam.
Performs and communicates a focused H&P which effectively addresses the chief complaint
and urgent patient issues.
Constructs a list of potential diagnoses based on chief complaint and initial assessment.
Formulates basic diagnostic and therapeutic plans based on a differential diagnosis.
Establishes rapport with and demonstrates empathy toward patients and their families.
Demonstrates behavior that conveys caring, honesty, patient confidentiality, genuine interest
and tolerance when interacting with a diverse population of patients and families.
Demonstrates basic professional responsibilities such as timely reporting for duty,
appropriate dress, conference attendance, and timely completion of clerkship documents.
Effectively listens and communicates with patients and their families.

25. Simulation
25

26. Simulation
26

27. Questions and Comments
27

28. References
 Wolf, S J (02/19/2014). "Students' Perspectives on the Fourth Year of
Medical School: A Mixed-Methods Analysis". Academic medicine (1040-
2446), p. 1.
 Cosgrove, E M (02/19/2014). "Empowering Fourth-Year Medical Students:
The Value of the Senior Year". Academic medicine (1040-2446), p. 1.
 Reddy ST, Chao J, Carter JL, Drucker R, Katz NT, Nesbit R, Roman B,
Wallenstein J, Beck GL. Alliance for clinical education perspective paper:
recommendations for redesigning the "final year" of medical school. Teach
Learn Med. 2014;26(4):420-7. doi: 10.1080/10401334.2014.945027.
PubMed PMID: 25318040.
 Chen HC, van den Broek WE, ten Cate O. The case for use of entrustable
professional activities in undergraduate medical education. Acad Med. 2015
Apr;90(4):431-6. doi: 10.1097/ACM.0000000000000586. PubMed PMID:
25470310.
 Elnicki, et al for the CDIM/Association of Program Directors in Internal
Medicine Committee on Transition to Internship. Course Offerings in the
Fourth Year of Medical School: How U.S. Medical Schools Are Preparing
Students for Internship. Academic Medicine 2015.
 Lyss-Lerman P, Teherani A, Aagaard E, Loeser H, Cooke M, Harper GM.
What training is needed in the fourth year of medical school? Views of
residency program directors. Acad Med. 2009 Jul;84(7):823-9. doi:
10.1097/ACM.0b013e3181a82426. PubMed PMID: 19550170.

29. References
 Chen HC, van den Broek WE, ten Cate O. The case
for use of entrustable professional activities in
undergraduate medical education. Acad Med. 2015
Apr;90(4):431-6. doi:
10.1097/ACM.0000000000000586. PubMed PMID:
25470310.
29

30. Thank You
30