Creating a win-win for the health system and health Profession's education: a direct observation clinical experience with feedback iN real-time (DOCENT) for low acuity patients in the emergency department

Abstract

Background: Clinical education across the professions is challenged by a lack of recognition for faculty and pressure for patient throughput and revenue generation. These pressures may reduce direct observation of patient care provided by students, a requirement for both billing student-involved services and assessing competence. These same pressures may also limit opportunities for interprofessional education and collaboration.

Methods: An interprofessional group of faculty collaborated in a sequential quality improvement project to identify the best patients and physical location for a student teaching clinic. Patient chief complaint, use of resources, length of stay, estimated severity of illness and student participation and evaluation of the clinic was tracked.

Results: Clinic Optimization and Patient Care: Five hundred and thirty-two emergency department (ED) patients were seen in the first 19 months of the clinic. A clinic located near the ED allowed for patients with higher emergency severity index and greater utilization of imaging. Patients had similar or lower lengths of stay and higher satisfaction than patients who remained in the ED (p < 0.0001). In the second clinic location, from October 2016-June 2019, 644 patients were seen with a total of 667 concerns; the most common concern was musculoskeletal (50.1%). Student Interprofessional Experience: A total of 991 students participated in the clinic: 68.3% (n = 677) medical students, 10.1% (n = 100) physician assistant students, 9.7% (n = 96) undergraduate nursing students, 9.1% (n = 90) physical therapy students, and 2.8% (n = 28) nurse practitioner students. The majority (74.5%, n = 738) of student participants worked with students from other professions. More than 90% of students reported that faculty set a positive learning environment respectful of students. However, 20% of students reported that faculty could improve provision of constructive feedback. Direct Observation: Direct observation of core entrustable professional activities for medical students was possible. Senior medical students were more likely to be observed generating a differential diagnosis or management plan than first year medical students.

Conclusions: Creation of a DOCENT clinic in the emergency department provided opportunities for interprofessional education and observation of student clinical skills, enriching student experience without compromising patient care.

Keywords: Direct observation; Entrustable professional activities; Feedback; Health professions education; Interprofessional collaboration; Learning climate; Undergraduate medical education.

Fig. 1

Satisfaction of DOCENT patients compared to patients who remained in the emergency department

Fig. 2

Emergency severity index for DOCENT patients seen at two different physical locations

Fig. 3

Student opinions (October 2016–June 2019) on key aspects of faculty facilitation (percentage of students responding)

Fig. 4

Percentage of medical students in each year observed completing various clinical skills