Paving the road to residency

Capstone course builds confidence in critical decision-making, hones hands-on skills of tomorrow’s physicians


Every summer, at teaching hospitals across the country, newly minted MDs formally begin introducing themselves as “doctors.”
Despite years of preparation, it’s a steep learning curve — going from student, observer and helper, to being an on-call resident, writing orders and managing high-acuity patients through long nights.
Given significant changes in U.S. residency training — and reduction of hospital duty hours — residents are facing new challenges. Nationally, medical schools are thinking beyond the four-year experience and trying to offer more seamless transitions to residency. To help graduating students hit the ground running, School of Medicine faculty created “Capstone,” a four-week, robust hands-on course.
“We are convinced it makes an impact at the outset of internship,” said course co- founder L. Michael Brunt, MD, professor of surgery. “This is an important first step leading to more specialized curriculum development that will better prepare our students for residency training.”
Through morning didactic sessions and afternoon procedure workshops, students cover many of the situations they soon will encounter in real life. Theoretical lectures are replaced with practical application, taking students’ accumulated knowledge — from first-year anatomy to third-year clerkships — and putting it all together.
Here, they begin thinking like independent physicians, focusing on day-to-day tasks and in-the-moment decision-making, such as juggling multiple patients or choosing the right medication dosages. The students refine technical skills — suturing, placing a central intravenous line, or inserting a chest tube — procedures that, in some cases, they’ve only observed. Specialty-specific breakout sessions further reinforce essential clinical competencies.
Capstone, created three years ago as a two-week elective by Brunt and Thomas M. De Fer, MD, professor of medicine, continues to evolve based on student and faculty feedback.
“Capstone provides a ‘just-in-time’ learning experience for medical students who are a few months away from being an intern,” DeFer said. “That’s always been anxiety-provoking, but, until courses like this, it was just something that they had to work through as best as they could and hopefully not make too many mistakes along the way.
“Our students do get a lot of these educational elements earlier in the curriculum, but it’s always a challenge to retain it all. This course provides practical information in one fell swoop at a time when they need it the most and are most receptive.”
As part of the core curriculum in 2014–15, the four-week session will run twice, with each of the many procedural workshops offered multiple times, to accommodate the entire medical class. Hundreds of faculty and house staff members from many disciplines are involved in the program. Coordination is a year-round logistical challenge headed by Julie Woodhouse, assistant director of the Howard & Joyce Wood Simulation Center.
“Capstone is one of our success stories. The whole school comes together and contributes to it,” said Michael M. Awad, MD, PhD, associate dean for medical student education.
Capstone topics address the curricula of modern medicine — patient safety, emergency management, end-of-life care, informed consent, ethics, working in a team, communication, and sign-outs and handoffs, among many others. In addition, the class gives students tips to manage their personal wellness (dealing with stress, time management and sleep deprivation).
Rated particularly high among students are the “mock page” sessions. Nurses call in a scenario, i.e., “the patient had surgery yesterday and is now running a fever,” and students are forced to think through the next steps.
Capstone students recently completed pre- and post-course questionnaires assessing their ability to handle clinical problems, procedures and patient-care tasks. In all categories, students rated their abilities markedly higher post-course.
“The thing many of us felt the most apprehension about was getting that call in the middle of the night about a patient who wasn’t doing well,” said Linda Jin, MD, now a first-year surgical resident at Barnes-Jewish Hospital. “Even through fourth year, most of our education is focused on understanding pathophysiology and knowing what is in the literature.
“Capstone helped us synthesize our knowledge so we can apply it in a practical way. It was also so useful to have a forum to practice saying things like ‘I’d like a chest X-ray, CBC and BMP now’ in a safe environment. One week into my intern year, I said those exact things. I’m glad I had a chance to do a practice run.”        
Deb Parker

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