Antimicrobial Stewardship: A Modified Team-Based Learning Curriculum With Timeouts for the Inpatient Medicine Clerkship.

Abstract

Purpose: Medical students are typically introduced to the principle of antimicrobial stewardship in their preclinical years. However, they are often inadequately prepared to participate in the clinical application of stewardship principles when they begin clinical clerkships. 1 While stewardship is an evolving practice, students should be reintroduced and exposed to stewardship principles frequently and identify practical skills to optimize stewardship. In addition, students should be familiar with resources, such as practice guidelines and local antibiograms, as optimal therapies and resistance patterns often change. 2 A timeout is a stepwise approach to evaluating the need for antibiotics and the optimal use of antibiotics. Timeouts are a common tool implemented by hospitals to monitor and manage the use of antibiotics. We propose that teaching clinical medical students to perform timeouts can lead to increased comfort with clinical decision making as it relates to antimicrobial stewardship. Approach: We implemented a modified team-based learning (TBL) curriculum to teach medical students to perform timeouts focusing on common inpatient infections. This curriculum was integrated into the inpatient medicine clerkship orientation for third-year medical students. Students received the following presession materials: (1) a prereading assignment covering basic antimicrobial stewardship principles and a summary of guideline-directed management for common inpatient infections, and (2) a readiness test consisting of multiple-choice questions. The in-person session was 1.5 hours, led by 1 instructor and 1 facilitator, given to 25 to 30 third-year medical students during the required inpatient medicine clerkship orientation occurring 6 times per academic year. The instructor begins the session reviewing the readiness test with the group, then students divide into small groups of 4–5 to work through 2 clinical cases using the timeout framework throughout the case. The instructor and facilitator were available to assist the small groups with problem-solving and clarification. Each timeout case and learning points were discussed with the large group at the end of each case, highlighting different approaches to problem-solving and providing real-time feedback. Outcomes: Surveys completed during the pilot academic year 2017–2018 revealed that over 90% of students agreed or strongly agreed that the learning activity would help their performance on the inpatient medicine clerkship (n = 121). Over 75% of students reported an improved understanding of the purpose of a timeout, and 85% reported an improved ability to participate in completing an antibiotic timeout. Qualitative survey data indicated that students valued both the presession reading materials and interactive nature of the learning activity, which provided a useful review of common inpatient infections and helpful tools for applying the principles of antimicrobial stewardship to clinical cases. Discussion: The modified TBL session, focused on teaching antimicrobial stewardship through the structured framework of a timeout, was an effective teaching strategy in introducing and applying basic stewardship principles. Survey data from this study indicate that medical students find value in learning how to perform a timeout during this interactive session. This skill may translate to the early adoption of stewardship principles, self-guided learning, improved patient outcomes, and the lifelong practice of antimicrobial stewardship. However, further study is needed to determine the long-term effects of antimicrobial use and the most optimal modality to teach this skill set. Significance: A modified TBL curriculum shows promise as an effective teaching modality for antimicrobial stewardship. Formal instruction in how to perform timeouts should be an essential component of the curriculum for clinical medical students as they begin their medicine clerkships to promote and reinforce the practice of these skills early in their careers. Acknowledgments: The authors would like to thank Dr. Clarence Braddock for his support and mentorship in the medical education fellowship program at the University of California, Los Angeles.