Ramon Reddick, MD, admitted to being a bit nervous considering it had been a while since he had assisted a patient. His fourth year of medical school was dedicated to finding a residency, and there was little time for clinical rotations.
But it all came back to Reddick, a new internal medicine pediatrics resident at the University of Cincinnati Medical Center and the UC College of Medicine. He along with his colleagues spent a day in eight two-hour mini clinical sessions with standardized patients and physician preceptors in mock exam rooms in the College of Medicine’s Simulation Center.
One hundred twenty residents were scored on their ability to render a differential diagnosis and nearly every other aspect of the patient encounter as part of the college’s Baseline Resident Assessment of Clinical Knowledge or BRACK. The program was piloted at UC in 2011 and designed to gather data on incoming residents’ knowledge to help inform patient care and safety on day one of clinical service.
Traditionally, residents across the nation begin their clinical service during July.
"A lot of us were apprehensive that we had forgotten most of the medical knowledge we obtained during medical school,” says Reddick. "This gave us a wake-up call and reminded us of areas which needed improvement while also boosting our confidence with the constructive feedback. After completing the assessment I was very reassured that I can successfully create differentials, read EKGs and thoroughly assess and treat patients. I thought the patient encounters were great.”
During the BRACK orientation, the residents learn what types of cases they will review and what skills they are being tested on while scenarios of patient-doctor encounters are displayed and discussed in detail. This will help residents understand how their interactions should flow with mock patients and physician evaluators.
The sessions are videotaped and reviewed by faculty and then shared with residents and their program directors after the assessments are complete, explains Amy Bunger, PhD, principal investigator for BRACK and associate professor in the UC Department of Medical Education.
"We really like 15-minute sessions because unfortunately it replicates the practice of medicine right now,” says Bunger. "That’s how much time you have for a patient. What we are trying to help them see is how do you build quality communication and decision-making in very short tight packages?”
Bunger, also assistant designated institutional official for UC Medical Center and UC Health, says one mock scenario shows the transfer of a patient at high risk of death from one physician to another.
"A patient comes into the emergency room and they are going to admit that patient,” says Bunger. "How will those two physicians talk to one another? What do I need you to pay attention to as a physician? That can be called a transition of care. You need to be decisive, focused and orderly.”
Residents are evaluated in various areas including: professionalism; the ability to perform a physical and obtain a medical history; review a patient’s symptoms and order the appropriate tests; correctly interpret test results; and communicate a proper treatment, says Paul Wojciechowski, MD, co-principal investigator for BRACK and anesthesiology residency program director.
"We can identify incoming residents who can potentially have significant issues either in clinical knowledge or in professional skills that we can address up front to help them throughout their residency,” says Jaime Lewis, assistant professor of surgery and a faculty member supporting BRACK.
"So it allows us to talk to that resident and let them know each of us have strengths and weaknesses and allow them to see some of the areas where they may be weak compared to other residents in their program and provide them with the tools they need along with individuals who can assist them with any of those areas of weakness.
"It also allows us to identify residents who need a little less assistance and could maybe help some of their colleagues,” says Lewis.
Wojciechowski notes that this year BRACK also includes scenarios to help residents consider cost-effectiveness when ordering procedures for patients.
"We are trying in medicine overall to use our resources only when we need them,” says Wojciechowski. "So that means ordering fewer lab tests and requesting only the things we think are necessary to help us help the patient. We added a question helps the residents think about ordering the tests that they need versus ordering more tests than they need.”
Erin McDonough, MD, associate professor and director for the residency program in the Department of Emergency Medicine, has evaluated new residents as part of BRACK for the past seven years. She says one of the biggest benefits of BRACK is the simulated patient-physician encounters refresh the memories of residents on a lot of core medical topics.
"The fourth-year of medical school has a lot of elective time toward the end of it where the medical students have the opportunity to do global health trips and more special interest rotations,” says McDonough. "These cases in BRACK essentially cover the bread-and-butter of medicine for things they are going to encounter on the floor in the emergency department or in the office. It really provides a good opportunity to refresh their memories and allow them to ask questions and review core content before getting started.
"Everybody is in new roles in July whether a first-year resident or a fourth-year resident so we as faculty provide a lot more guidance and supervision,” says McDonough "Whereas at the end of the year everyone is more comfortable in their roles and can be given a little more autonomy. In July, we definitely provide more direct, hands-on supervision to make sure our residents are learning and that our patients are getting excellent care.”