The Perioperative Care Clerkship for Future Primary Care Doctors and Surgeons

Proposal to the Acdemy of Medical Educators
Kathryn Rouine-Rapp, MD

As part of curriculum development, we plan several curriculum innovations specific to the student's Perioperative Care Clerkship including:

• Development of standardized patients in collaboration with standardized patient trainer Bernie Miller. One patient will have a history of chronic pain, require surgery and subsequent management of both acute and chronic pain. The evaluation of pain as a symptom is a clear area of improvement for UCSF medical students, as judged by a recent clinical practice exam with standardized patients.
• Develop up to six web-based teaching modules. We will consult with the Dean's Office Educational Technology Coordinator Kevin Souza to design both written and video portions. These modules will describe preoperative assessment of patients with common coexisting diseases who are scheduled for surgery. One of the web-based modules will be developed in collaboration with Bree Johnston, MD, MPH and will address the issue of postoperative delirium in the elderly. Another will include perioperative management of thromboembolism prophylaxis and anticoagulation and will be developed in collaboration with Julie Hambleton, MD. Other modules will include management of common postoperative complications, both immediate and delayed, and will be developed in collaboration with physicians designated by
  H. Quinny Cheng, MD, Director of the Medical Consult Service. A medical student, funded by the project, will play an essential role as a member of the teaching-module curriculum development team.

The goals of this curriculum development project are defined by objectives for the student and will include the following:

• Develop the knowledge and skills necessary to explain what aspects of a patient's medical status should be used preoperatively to assess perioperative risk. The student will be able to formulate a plan for patients with common coexisting diseases, such as coronary artery disease, that will minimize risk. Through participation with the Medical Consult Service, the student will be able to develop and observe implementation of a plan that includes the postoperative period.
• Recognize and manage common problems that occur postoperatively during recovery from anesthesia and surgery. These problems include tachycardia, hypertension, hypotension, blood loss, fluid management, and airway compromise.
• Explain the options for pain control in the PACU and after discharge to patient care locations. He/she will be able to describe the use of an epidural catheter for pain control, list the contraindications and complications, and list the drug options available for delivery via the catheter. He/she will also list intravenous and oral analgesic medication options, including doses and side effects, and the use of Patient Controlled Analgesia. After achieving these objectives, the medical student will be able to discuss options for control of pain and the impact of adequate pain control on perioperative morbidity with his/her future patients.
• Recognize that delirium is a common presentation of disease in the elderly and is associated with adverse outcomes. The student will be able to explain the difference between delirium and other diagnoses, such as dementia and depression, and identify risk factors for delirium such as immobility and surgery. Particular emphasis will be placed on identification of the risk factors for delirium in the elderly.
• Interview a standardized patient who has chronic pain and is scheduled to undergo surgery, thereby allowing the student to develop a plan to control acute pain in a patient with chronic pain. The student will assess the level of chronic analgesic use in the patient, discuss options for control of pain with the patient, and explain his/her plan for follow-up of the patient during the perioperative period.
• Describe a plan for anticoagulation during the perioperative period in a patient who requires chronic anticoagulation therapy. In addition, he/she will be able to describe the risk factors for development of perioperative thromboembolism.

Specific and measurable educational objectives will be developed for each component of this project, including cognitive, affective, and psychomotor factors. Some sample objectives include:

• Each student will summarize the perioperative cardiac risk assessment and develop a plan to minimize this risk for one patient by week four of the rotation.
• Additional measurement and documentation instruments include the development of a pre and post knowledge test for students.
• We will design a clinical skill inventory and clinical practice examination for the evaluation of patients in the PREPARE Clinic.
• We will obtain formative feedback from students before and after implementation of curriculum innovations. We already have used formative feedback from fourth-year medical students to identify areas of improvement for the four-week clerkship schedule.
• We will develop a clinical skill inventory to use as a checklist during the student interview of the standardized patient with chronic pain who is scheduled to undergo surgery.

For further information, please contact:
Kathryn Rouine-Rapp, MD: rouinerk@anesthesia.ucsf.edu