Tuesday, July 16, 2013

What's up with intern "Boot Camps"?

A concept that has been percolating in the medical literature boiled over into the mainstream as the New York Times published this story, "Chicago's Intern 'Boot Camp' is a rehearsal for life or death medical issues."

The article describes a new internal medicine intern having to deal with a simulated patient who is critically ill and has alarms going off.

Another intern had to tell a "patient" played by an actor that he had terminal cancer.

The performances of both of the young doctors were evaluated by instructors. The 81 interns in the program must "pass graded tests in procedures and communication skills before being allowed to move ahead."

The boot camp described in the Times piece was the subject of a paper published in Academic Medicine earlier this year. It concluded that "Boot-camp-trained interns all eventually met or exceeded the MPS [minimum passing standard] and performed significantly better than historical control interns on all skills (P < .01), even after controlling for age, gender, and USMLE Step 1 and 2 scores (P < .001)."

Here is how the Mayo Clinic describes its boot camp for fourth year med students, "An intensive 1-week course, Internship Boot Camp has simulated, longitudinal patient-care scenarios that use high-fidelity medical simulation, standardized patients, procedural task trainers, and problem-based learning to help students apply their knowledge and develop a framework for response to the challenges they will face as interns."

They compared survey results from students who had done the boot camp to those who had not and found the boot camp prepared students for internship better than conventional sub-internships did.

Similar "boot camps" are being held in many surgical residencies.

At the University of Connecticut, surgical interns undergo "a 2-month (July and August 2011) boot camp curriculum consisting of two 2½-hour knowledge-based and procedural skills (SimMan) didactic sessions per week and completion of 25 core intensive introductory American College of Surgeons Fundamentals of Surgery web-based self-study modules, followed by a standardized patient clinical skills assessment."

At Baystate Medical Center in Massachusetts new trainees are taught essential skills in patient care and procedures. Over the four year period during which interns experienced the boot camp, "Individual simulation-based Boot Camp performance scores for cognitive and procedural skills assessments in PGY-1 residents [interns] correlate with subjective and objective clinical performance evaluations."

The Department of Surgery at the University ofPennsylvania holds a boot camp for senior students interested in surgical career. The introduction to the abstract describing the program says, "Medical school does not specifically prepare students for surgical internship."

It appears that boot camps are both necessary and effective.

I have one question. Why can't "boot camp" skills be taught in all medical schools?


artiger said...

Makes sense to me. Why not take the last 6 or 8 weeks after match day and just uniformly make them boot camp. It would be more valuable than the last elective rotation or two at that point.

CholeraJoe said...

I agree. My last 6 months of my final year was boot camp back during the Ford adm. Later I saw people coming in as 1st year IM residents who knew next to nothing about critically ill patients. One had never even seen, let alone performed a central line placement.

My last year of med school I was doing liver biopsies and placing dialysis catheters.

Anonymous said...

I've seen a bunch of central lines go in and I'm confident I could do one... but there is no way a 3rd year med student is going to be allowed to place one where I rotate. There is some magical thinking about what is appropriate for a med student vs an intern, and I think it plays into the need for boot camps.

TChanMD said...

I think there is something to be said about building a community and allow the new residents to orient to the new system together. Who knows if it's a direct result of them learning from the bootcamp that helped them with their scores, but maybe it's that they bonded with study-group-mates and that social network helped them through.

Med schools can do the content, but I think it's hard to prep all your students for their diverse eventual careers... We tried in our curriculum studies class - lots of us wanted to design a 1 week bootcamp, and everyone started thinking it would be nice to NOT pick the same group - but the M4 bootcamps had to be so general they could not be specific... While the R1 bootcamps could hone in on objectives because they picked surgical R1s, rather than trying to teach to future-Radiologist, future-Pathologists, future-Rehab specialists and future-Surgeons at the same time!

In most of education, one size does NOT fit all... and I think the R1 bootcamps are a symptom of the limit of our abilities as educators to plan for all contingencies rather than a single program of residents (who, mind you, are hetergenous enough as it is in their skill sets coming from varied backgrounds and clerkship experiences...)

Skeptical Scalpel said...

Thanks for the comments.

TChan, I think Artiger solved your issue. After the match and everyone knows what they are doing and where they are going, basic skills of doctoring could be taught. General things could be focused on for all specialties and then specifics could either be taught by the school or by the residency program if needed.

Every graduating MD should be able to identify a sick patient and at least start to resuscitate him.

Anon, central line insertion can be taught with simulators. Also, I'm with Cholera Joe. Looks like we both did central lines as students. No matter what level you are when you do one for the first time, you have to be supervised by a more experience person. There is no reason that a student could not do this.

Anonymous said...

About central lines: is this really a basic skill for all residents? I've put in more than a thousand myself, but except for surgeons, anesthesiologists, IR, ICU, and ER docs, most physicians will never put in a central line after residency.

It is not just being able to do a procedure, but you have to have the volume and psychomotor skills to be adequate at it.

A few years ago, I worked at a county facility where night-time medical coverage was done by moonlighting IM residents/fellows from the neighboring World-Famous, Top_Level medical campus. After multiple pneumos and other procedural problems, we required that an attending be on hand .

In a teaching hospital with multiple residents, regardless of boot-camp, it would better if the GI fellow (e.g.) just ask for help.

Skeptical Scalpel said...

Anon, I agree that everyone doesn't have to know how to insert a central line. I was just addressing the comment of a different anon above.

I believe there are some basic things that every med school grad should know. The NY Times article was about using a simulator to quiz an intern about resuscitating a patient and also about communicating.

I think most interns should a) know how to do these things and b) be taught these skills in medical school. There are many other basic skills such as how to write a coherent order, how to write a note, how to work up common problems that interns see, how to recognize that a patient is sick or crashing, etc. These should also be taught n med school.

Anonymous said...

"The introduction to the abstract describing the program says, "Medical school does not specifically prepare students for surgical internship.""

I am glad I am not the only one who agrees that we could do with a change in medical education.

Skeptical Scalpel said...

Yes, isn't it interesting that medical school does not prepare the students for surgical internship or even medical internship as the group from Northwestern has pointed out.

What do medical schools prepare their graduates for?

Anonymous said...

Let's largely do away with pre-med and med school. Let's start residency at age 18 -- back to the good old apprentice system. Learn on the job, with occasional pre-med and med school modules mixed in. Graduation from residency occurs when the individual demonstrates competence, however short or long that takes.

Skeptical Scalpel said...

You may be on to something.

artiger said...

In answer to your question yesterday, medical schools prepare their graduates for match day, but not much else.

What is needed is needed is a new Flexner Report. A few things have changed in 100 years, haven't they?

Skeptical Scalpel said...

That wouldn't be a bad idea, but I think Flexner has passed away. :-)

ThirstyScholar said...

As a PGY1 resident in neurosurgery who just attended one of four-five regional boot camps for every neurosurgery resident in the country, I think there are a couple other salient benefits

-uniform training across residency programs. Sure, everyone might suture in an EVD or central line differently, but teaching one basic consensus approach of one good way it can be done is extremely useful. we had every single resident in the country learning from the same syllabus for a weekend (easier to do in our smaller field than perhaps others ...)

-opportunity to learn basic skills from experienced leaders in the field. I was taught how to put in an EVD by a department chairman, basic neuroimaging by a very senior cerebrovascular surgeon, etc. this doesn't happen elsewhere.

-network/social aspects. particularly our field seems to be relatively isolated - small programs taking between 1-4/yr, minimal interaction with other specialties, little interaction between programs except during conferences, this was a truly unique opportunity to get to know future colleagues.

-one other thought: as much as I enjoyed our small, specific, subspecialty focused bootcamp, a general bootcamp for R1s might be quite useful. let the surgeons consult medicine, the EM guys and trauma guys running resuscitation sims, medicine running codes on surgical patients, etc. etc. much more useful than as an M4 when you can pretend you don't need to know the dose of sux/etomidate cold and that you will just look it up if you need it ...

Skeptical Scalpel said...

Thirsty, great comments. Obviously I did not consider your points because I don't have the same perspective as you.

Since neurosurgery is such a narrow field, I would not expect that medical schools will have prepared their students to enter it.

In my defense, I was referring to some of the general topics covered by general surgery and IM boot camps that (it seems to me) might be considered part of a med school curriculum.

Your comments about working together with other specialties in boot camps were quite good.

Justin said...

The end of the 4th of medical school is easily wasted. I was encouraged to slack... People me asking me why I was still in the hospital after 11am. I took it seriously and signed up critical care months and anything operative that I could fit in my schedule, Practiced reading CTs and X-ray's on my own. It just seemed strange that I had to be so self motivated, it was as if the Medical school wasn't that concerned about the product it was sending out.

Skeptical Scalpel said...

Justin, your experience is common. the fourth year of med school is wasted. The first half of the year is consumed with "audition electives" and interviews. The second half means nothing and no one seems to care.

Anonymous said...

As someone who went through "surgical boot camp" as an M4 last year, and set up an inaugural boot camp for the Surgery-matched students in my chief year, I'll say it makes a world of difference to these kids.

My student experience was an 8 week skills-based course in basic laparoscopic and open skills, taught by the surgery faculty, that culminated in a live pig lab where we could perform whatever operations we and our resident mentors wanted to practice.

Unfortunately, the medical school administration didn't support the project at the institution where I finished residency; it was only after our committee showed them that they were behind all the other "leading" schools in this respect that they begrudgingly let us use campus space. However, the boot camp was greatly shortened in length without the live lab component at the end due to lack of funding. The course was taught by resident volunteers (about 75% of the active residents, and 100% of the chief residents). While the students were happy with the immersion, we don't have data on the effectiveness of this course yet.

tl;dr -- the presence of a course doesn't imply uniform training at this point.

Skeptical Scalpel said...

I'm not against boot camps. I just think the new interns might be better served if they learned how to start an IV or talk to a patient while in med school.

I understand the arguments supporting boot camps. It just seems like fourth year of med school is mostly wasted time and the time to teach boot camp skills could easily be found.

Anonymous said...

I agree with your last post, "It just seems like 4th-year of med school is mostly wasted time and the time to teach boot-camp skills could easily be found."

Again, my argument earlier: Get rid of PhD's and the over-focus on "basic science" in medical school--use more MD's or MD/PhD's in the curriculum to teach clinical skills and relevance. The 4th-year of medical school and at least one, of the first two, years of medical school could be revisited with a different curriculum. Tomorrow, students are our medical school are using an OPTIONAL session at lunchtime (1 hour) to learn suturing skills. Why not more time? Because, you know, they don't really need to know this skill--unless you want to be a surgeon. Boot camps will stay as long as curriculum supports the minutiae of part 1 of the boards.

Skeptical Scalpel said...

It would take more than just getting rid of PhDs. All schools, residency programs, specialty boards, and examination providers would have to agree on massive curriculum changes. I don't see that happening anytime soon.

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