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Knowing is not enough; we must apply.
Willing is not enough; we must do.
Goethe ~1800
Directors of Clinical Skills Courses
Back to the Future:
Clinical Skills Education
…some food for thought
Eugene C. Corbett Jr., M.D., M.A.C.P.
Brodie Professor Emeritus of Medicine, Nursing
University of Virginia School of Medicine
[email protected]
Plenary Agenda
• You & me
• A William Wordsworth idea
• Some historical perspective on clinical skills
education
• Hedgehogs & Foxes
• Some workshop food-for-thought
• Some thanking to do!
Directors of Clinical Skills Courses:
Your work is most essential !!
My heart leaps up when I behold
A rainbow in the sky.
So it was when my life began;
So is it now I am a man;
So be it when I grow old,
Or let me die!
The Child is the Father of the Man;
And I could wish my days to be
Bound each to each by natural piety.
William Wordsworth 1802
Thomas Bond 1752
“Realizing that the student “must Join Examples with Study, before he can
be sufficiently qualified to prescribe for the sick, for Language and
Books alone Can never give him Adequate Ideas of Diseases and the
best methods of Treating them”, [Thomas] Bond now argued
successfully in behalf of his bedside training for the medical
students…The writer of these sensible words fitly became our first
professor of clinical medicine, with unobstructed access to the one
hundred and thirty patients then in the hospital wards.”
U Penn, by A. Flexner, 1910
Abraham Flexner 1910
“On the pedagogic side, modern medicine, like all scientific
teaching, is characterized by activity. The student no longer
merely watches, listens, memorizes: he does. His own activities in
the laboratory and in the clinic are the main factors in his
instruction and discipline. An education in medicine nowadays
involves both learning and learning how; the student cannot
effectively know, unless he knows how.”
William Osler 1910
“In what may be called the natural method of teaching, the student begins
with the patient, continues with the patient, and ends his studies with the
patient, using books and lectures as tools, as means to an end. The student
starts, in fact, as a practitioner, as an observer of disordered machines,
with the structure and orderly functions of which he is perfectly familiar.
Teach him how to observe, give him plenty of facts to observe and the
lessons will come out of the facts themselves. For the junior student in
medicine and surgery it is a safe rule to have no teaching without a patient
for a text, and the best teaching is that taught by the patient himself. The
whole art of medicine is in observation, as the old motto goes, but to
educate the eye to see, the ear to hear and the finger to feel takes time,
and to make a beginning, to start a man on the right path, is all that we can
do. We expect too much of the student and we try to teach him too much.
Give him good methods and a proper point of view, and all other things will
be added, as his experience grows.”
Table 1: AAMC Reports on Undergraduate Medical Education
The Clinical Skills Education of Medical Students
REPORT
QUOTE
Future Directions for Medical Education
(AMA, 1982)[1]
The sum of required clinical clerkship experiences should be
acquisition by each student of the clinical skills necessary to provide
general medical care under supervision (pg 14)
Physicians for the 21st Century
The GPEP Report
Working Group on Fundamental Skills
(AAMC, 1984) 2
The clinical skills of graduating students fall considerably short of
what could be achieved (pg 3).
Medical faculties should develop procedures and incorporate explicit
criteria for the systematic evaluation of students’ clinical performance
(pg 17).
Clinical Education and the Doctor of
Tomorrow
(Macy/NYAS, 1988) 3
Require medical students to pass comprehensive, performance-based
clinical examinations. (pg 112)
ACME-TRI Report
Educating Medical Students
(AAMC, 1992) 4
Formally assess clinical skills (pg 26)
The Education of Medical Students: Ten
Stories of Curriculum Change
(AAMC/Milbank Mem Fund, 2000) 5
...at the time of graduation, medical students too often lack
fundamental clinical skills that they should have acquired during their
clinical education (pg 1)
...changes in the clinical environments where medicine is learned have
undermined the quality of the teaching that occurs in those
environments (pg 8).
The AAMC Project on the Clinical
Education of Medical Students
(2001) 6
In most schools, there is inadequate attention paid to ensuring that
students acquire fundamental clinical skills
(pg 9).
(a major concern) The lack of adequate teaching of fundamental
clinical skills, including rigorously conducted formative assessments
of students performances (pg 13).
AAMC Survey of Curriculum Deans
2002
For what years of your medical school curriculum is there an explicit clinical skills
curriculum?
Dean’s Survey 10/02:
Year 1
2
Year 2
19
Year 3
8
Year 4
3
AAMC Curriculum Database 2000:
“clinical skills sessions” 3/1 9/2 2/3
“clinical skills courses” 3/1 21/23/3
AAMC Survey of Curriculum Deans
2002
Do you have a specific list of medical school objectives with which to
organize and guide clinical skills education?
{This is used by the minority of schools despite LCME influences}
Dean’s Survey:
17/62 (27%)
LCME ’02 Data:
15/59 (25%)
AAMC Survey of Curriculum Deans*
Does your medical school have a document that specifies the clinical
skills that all students are expected to acquire before graduation?
Yes
44%
No
53%
Communication
History-taking
Physical Examination
Clinical Testing
Procedures
* Response Rate = 62/142 (44%)
19%
21%
17%
23%
26%
AAMC Survey of Curricular Deans
2002
In your medical school, is there a formal clinical skills assessment in
year 3 or 4?
Dean’s Survey: 36/53 (68%)
LCME ’02 data: 71/125 (57%)
Direct Observation
Paper & Pencil
OSCE/SP
Computer Sim
25 %
20 %
67 %
8 %
AAMC Survey of Curriculum Deans
2002
Does your medical school have a special facility that is dedicated to the
teaching & assessment of clinical skills? n = 57/62
Yes
59% (3 shared)
No
23%
Not yet 15%
LCME
Table 5: Trends in Final Clinical Skills Assessment Methods (LCME, n =125)
METHOD
93-94
94-95
98-99
01-02
Direct
Observation
13
15
16
25
Paper &
Pencil
23
22
12
20
SP/OSCE
26
32
49
67
Computer
Simulation
5
3
7
8
Oral
Examination
11
5
No data
No data
800
700
600
500
400
300
200
100
0
1972-73
1984-85
1995-96
Baylor
Case
Chicago
Cornell
GW
Minnesota
Nebraska
Pittsburg
Tulane
U Mass
UNC
USC
Wisconsin
Average
00
-1
95
5
-9
90
0
-9
85
5
-8
80
0
-8
75
5
-7
70
0
-7
65
5
-6
60
0
-6
55
5
-5
50
0
-5
45
5
-4
40
25
New Curriculum
20
15
10
#
Students
25
Old Curriculum
20
15
#
Students
Overall Score on 4th Year Clinical Skills Assessment
35
30
10
5
0
35
30
5
0
00
-1
95
5
-9
90
0
-9
85
5
-8
80
0
-8
75
5
-7
70
0
-7
65
5
-6
60
0
-6
55
5
-5
50
0
-5
45
5
-4
40
DUTCH CLINICAL SKILLS OUTCOMES
Table 7: Clinical Skills Evaluation Methods
Percent of students reporting use of each method: n=839
Total
Traditional
Frequency
School
Skills-Oriented
School
Differenc
e
p value
METHOD
Resident Observation
749
87%
92%
0.03
NBME Shelf Exam
747
89%
89%
>.05
Faculty Observation
719
81%
92%
<.0001
Oral Examination
683
80%
83%
>.05
Multiple Choice Exam
682
79%
86%
0.01
OSCE
481
42%
80%
<.0001
Computer Case
Simulation
444
39%
75%
<.0001
Peer Evaluation
215
15%
43%
<.0001
Computer Skill
Simulation
131
12%
21%
.0004
Four schools in each group:
(Traditional= no skills center, maybe a skills document or skills assessment: AECOM, Gtwn, TxAM, Va)
(Clinical Skills-oriented= skills center + skills document + skills assessment: Brown, MSSM, UConn, UFla)
Data from 2002 AAMC Graduation Questionnaire, question #13
UVA: Direct Observation of Clerkship
Students 1999-2001
Students reporting that they had NEVER been observed by
a faculty member while:
1. taking a history: 51%
2. performing a focused physical exam: 54%
3. performing a complete physical exam: 60%
L Howley and WG Wilson, Academic Medicine, 2004
A 4th Year Medical Student
UVA 2004
“While in medical school we are continually encouraged to
master a common body of knowledge, we are not as
expected to master clinical skills. After reviewing my
performance on videotape, I realize that I also have to
master the skills of the patient encounter.”
CLERKSHIP CLINICAL SKILLS
EDUCATION PROJECT
2004
How often is there opportunity for skill practice in the clerkship?
(student opinion asked at the time of the assessment)
70%
60%
50%
Aseptic Technique
Blood Pressure
Info Mastery
Peak Flow
40%
30%
20%
10%
es
or
m
21
11
-
20
or
et
im
tim
es
110
ti m
e
tic
ac
Pr
0
es
0%
CLERKSHIP CLINICAL SKILLS
EDUCATION PROJECT
2005
Overall Student Skill Performance (as judged by faculty
observer):
100%
75%
50%
December
April
25%
0%
e
y
e
e
am Flow
am riag
ur
ter niqu
x
s
x
s
s
E
E
a
e
T
k
h
M
ee
ye
Pr
C
ec
ea
ne
n
o
l
E
T
P
o
d
f
a
K
ic
In
Ph
lo o
i on
pt
B
s
e
i
c
As
De
ac
ap
it y
Patterns of skill performance on the
Arrhythmia Recognition OSCE
Did the student perform the critical clinical action?
UVa 2008
Critical Action
performed
Critical Action
omitted
37.8%
62.2%
Higher scoring
students
31.1%
17.8 %
13.3 %
Lower scoring
students
68.99.8%
20.0 %
48.9 %
UVA Post-clerkship OSCE data
(2008)
Score Above the Median
Score Below the Median
Skill
Critical Action
Correct
Critical Action
Incorrect
Critical Action
Correct
Critical Action
Incorrect
Detect an Arrhythmia (n=45)
17.8%
13.3%
20%
48.9%
Maintain Aseptic Technique
(n=110)
1.8%
46.4%
0%
51.8%
Measure Blood Pressure
(n=119)
35.3%
10.1%
28.6%
26.0%
Maintain
Confidentiality (n=118)
22.0%
0%
4.3%
73.7%
Perform an ECG (n=26)
3.8%
42.3%
0%
53.9%
Phone Triage an Infant with
Fever (n=23)
26.1%
21.7%
0%
52.2%
Communicate Through an
Interpreter (n=41)
4.9%
21.9%
9.8%
63.4%
Manage a Medical Error
(n=46)
26.1%
21.7%
2.2%
50.0%
Examine Child’s Ears (n=33)
30.3%
18.2%
0%
51.5%
Auscultate the Second Heart
Sound (n=33)
30.3%
6.1%
9.1%
54.5%
A Professional Paradigm Shift:
From Process to Outcome ~2000
•
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•
AAMC: Clinical Skills Education
NBME Clinical Skills Examination
LCME: Explicit Objectives of Medical Education
LCME: Students’ Clinical Experience
ACGME: Postgraduate Competencies
IOM: Medical Error
JCAHO: Hospital Performance Measures
3rd Party Payors: Physician Performance
The educational paradigm shift for
undergraduate medical education:
From…”to know and understand”
To…”understand and apply”
AAMC Task Force on the Clinical Skills
Education of Medical Students
2003
Purpose:
To initiate the development of a
national consensus regarding the
teaching & learning of clinical skills in
undergraduate medical education.
AAMC Task Force on the Clinical Skills
Education of Medical Students 2003
•
American Academy on Physician & Patient (AAPP)
•
Alliance for Clinical Education (ACE)
•
Association of Directors of Medical Student Education in Psychiatry
(ADMSEP)
•
Association of Professors of Gynecology & Obstetrics (APGO)
•
Association for Surgical Education (ASE)
•
Clerkship Directors in Internal Medicine (CDIM)
•
Consortium of Neurology Clerkship Directors (CNCD, AAN)
•
Council of Medical Student Education in Pediatrics (COMSEP)
•
Society of Teachers of Family Medicine (STFM)
& the AAMC
What is a “Clinical Skill” ?
A CLINICAL SKILL IS A DISCRETE AND
OBSERVABLE ACT OF CLINICAL CARE
• It involves learner PERFORMANCE
• It requires that a trained OBSERVER
determine professional competency
AAMC Task Force
on the Clinical Skills Education
of Medical Students
Basic 2003-05
Preclerkship 2005-08
Six Overall Recommendations:
1. Principles of Skills Education
2. Clinical Skill Education Objectives (#12)
3. A Menu of Skills
4. Clinical Learning Opportunities (Venues of Care)
5. A Developmental Paradigm (Levels of Performance)
6. Essential Programmatic Elements
A Clinical Skills Curriculum:
Eight Essentials for Learning How to Do
AAMC Clinical Skills Monographs 2005, 2008
•
•
•
•
•
•
•
•
1. Learning Objectives (clinical method)
2. A List of Specific Skills for Learning
3. Teachers/Mentors, and the modeling influence
4. Encourage & model Self-directed Learning
5. Learning & Repetitive Practice Opportunities
6. A Skills Assessment Process
7 A Skills Remediation Plan
8 A 4-year Developmental Education Strategy
DOCS Workshop Themes
•
•
•
•
•
Competencies & Strategies for Teaching Clinical Skills
Challenges & Solutions for Faculty Development
Clinical Skills & Science: Research & Evaluation
Clinical Skills Curricula vs Clinical Practice
Foundations for Case-Based Clinical Skills Examinations
Hedgehogs and Foxes
“The fox knows many things, but the hedgehog knows one big
thing.”
Archilochus 7 b.c.e.
“Isaiah Berlin divides writers and thinkers into two categories:
hedgehogs who view the world through the lens of a single
defining idea, and foxes who who draw on a wide variety of
experiences…”
Wikipedia 2012
(see The Hedgehog and the Fox. Isaiah Berlin, 1953)
9 Challenges & Unfinished Matters
to consider…
•
•
•
•
•
•
•
•
•
What skills to teach & learn
Levels of skill learning: keep it simple
Beware the Snippet Syndrome
Bass akwards: observation skill
Workplace learning diplopia
A clinical fidelity matter
UGME-GME competency continuity
A student diplopia challenge
Resident & faculty development
What specific clinical skills
should be learned in UME?
There are hundreds!
see AAMC Task Force Recommendations Appendices
2005 (~500), 2008 (~170)
https://www.aamc.org/initiatives/clinicalskills/
Levels of Clinical Skill Ability
There’s Bloom’s Taxonomy, Miller’s Pyramid, Dreyfus
Levels, Pangaro’s RIME,
And then there’s this…
•“Needs to do”
•“Nice to do”
•“Nuts to do”
The Medical Student 4-Year Curriculum
1910
•
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•
•
•
•
•
•
•
Anatomy
Physiology
Chemistry
Embryology
Histology
Bacteriology
Pathology
Hygiene
Materia Medica
•
•
•
•
•
•
•
•
Physical Diagnosis
General etiology & Symptomatology
Minor surgery & bandaging
Medicine (incl dermatology, nervous & mental, diseases of children, dispensary medicine)
Surgery (incl ophthalmology, laryngology, genitourinary, orthopedics)
Obstetrics & Gynecology
Preventive Medicine
Therapeutics
The Medical Student 4-Year Curriculum
2010
•
•
•
•
•
•
•
•
•
•
•
•
•
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•
Anatomy
Physiology
Biochemistry
Molecular & Cellular Function
Embryology
Histology
Microbiology
Neuroscience
Human Behavior
Genetics
Pathology
Pharmacology
Physical Diagnosis
Introduction to Clinical Medicine
Epidemiology
•
•
•
•
•
•
Surgery
Medicine
Pediatrics
Obstetrics & Gynecology
Pediatric Specialties
Radiology
Family Medicine
Psychiatry
Neurology
Emergency Medicine
Dermatology
Ophthalmology
Otolaryngology
Urology
Orthopedics
Plastic Surgery
Physical Medicine & Rehabilitation
Cardiology
Gastroenterology
Rheumatology
Hematology
Endocrinology
Neurosurgery
Oncology
Geriatrics
Nephrology
Anesthesiology
Health Policy, Economics….etc…
The UME – GME
Competencies Dilemma
ACGME 1999
•Patient Care
•Medical Knowledge
•Practice Based Learning and Improvement
•Interpersonal Skills and Communication
•Professionalism
•Systems-Based Practice
The Competencies Dilemma
ACGME for UGME??
Patient Care:
Professionalism
Interpersonal Skills & Communication
Medical Knowledge
Practice Based Learning & Improvement
Systems-Based Practice
12 Clinical Competency Domains
of Basic Clinical Method
AAMC 2005
#1-3. Three competencies that students bring to
medical school in varying degrees of
development
#4-8. The 5 elementary clinical method
competencies
#9-11. The 3 clinical reasoning & management
competencies
#12. Placing clinical care within practical context:
personal preferences, family circumstances, economics,
cultural factors, healthsystem, ethical & legal contexts
Clinical Method
the 12 CLINICAL SKILL EDUCATION OBJECTIVES
1.
2.
3.
PROFESSIONALISM
THE APPLICATION OF SCIENCE TO CLINICAL PROBLEM SOLVING
PATIENT ENGAGEMENT & RELATIONSHIP SKILLS
1.
2.
3.
4.
5.
CLINICAL HISTORY-TAKING
PHYSICAL EXAMINATION
CLINICAL TESTING
BASIC CLINICAL PROCEDURES
CLINICAL INFORMATION MANAGEMENT
6.
7.
8.
DIAGNOSIS, DIFFERENTIAL DIAGNOSIS & CLINICAL REASONING
INTERVENTION, CURE & PREVENTION
PROGNOSIS & CLINICAL OUTCOMES MANAGEMENT
1.
THE APPLICATION OF CARE in Practical CONTEXT
ACGME Competencies
AAMC Clinical Skills Task Force
Professionalism
•
Interpersonal & Communication Skills
• Patient Engagement & Communication
Medical Knowledge
• Application of Scientific Knowledge & Method
Patient Care
• History-taking
• Mental and Physical Examination
• Clinical Testing
• Clinical Procedures
• Clinical Information Management
• Diagnosis
• Clinical Intervention
• Prognosis
System-based Practice
• Putting Care in Practical Context
Practice-based Learning & Improvement
•
Professionalism
The development and practice of a set of personal and professional attributes
that enable the independent performance of the responsibilities of a physician
and the ability to adapt to the evolving practice of medicine. These include an
attitude of:
a)
Humanism, compassion and empathy,
b)
Collegiality and interdisciplinary collaboration,
c)
Continuing and lifelong self education,
d)
Awareness of a personal response to one's personal and
profession limits,
e)
Community and social service,
f)
Ethical personal and professional conduct,
g)
Legal standards and conduct,
h)
Economic awareness in clinical practice,
i)
Cultural competency in clinical practice and professional
Self-directed Learning & Self-assessment are embedded within each of the
preceding competencies, preparing the student for Practice-based Learning &
Improvement
Patient Observation Skill
…a must!
• Did you observe this…or that?
versus
• What did you observe?
This needs to begin and advance in the preclerkship curriculum!!
(see Boudreau references)
Teaching & Learning
Observation Skill
• Subjective view (Communicating and History-taking)
• Objective view (Mental & Physical Examination)
Learn and practice 4 steps
• Observe
• Describe
• Interpret
• Document
(Boudreau, et al)
CLINICAL EDUCATION
DIPLOPIA
***
Medical Education:
Medical Practice:
Case-Based
Learning
Individual Patient
Care
Skill Education
Objectives
Clinical Practice
Competencies
Basic Clinical Skill
Learning
Clinical Skill
Expertise
Clinical Education Diplopia:
Student Workplace Learning Settings
• Contemporary Venues of Care:
– Emergency care
– Acute inpatient care
– Acute outpatient care
– Intensive care
– Chronic care
– Preventive & wellness care
– End of Life care
– Population care
Student diplopia issue
• Study toward the test
versus
• Study toward patient care
Clinical Education Fidelity
This one needs some work…
Workplace Learning vs Simulation
What setting and method works best for what stage
of learning what skills?? And for assessment?
1.
2.
3.
4.
5.
The paper patient
The virtual patient
The mannequin
The standardized patient
The real patient
Resident & Faculty Development
The Hedgehogs & Foxes idea…
What is the implication that this notion raises
with respect to the teaching and learning of
basic clinical skills??
For the Learner?
For the Teacher?
Back to the future…
•
•
•
•
•
•
•
•
•
•
Let’s stick together!!
Give greater emphasis to the teaching & learning of clinical method skills.
Expand students clinical development time and the opportunity for
repetitive practice throughout the 4 years, including
Better integration of teaching, assessment and feedback elements.
Enhance and expand workplace learning opportunities across the spectrum
of society’s contemporary care needs (foundation building)
Re-establish the primacy of mentoring in skills education. Work with the
Learning Communities movement??
Work on connecting UGME and GME…from the bottom up!!
More emphasis and action with respect to measuring our educational
outcomes.
Consider building in interprofessional & teamwork skill learning
Keep electronic communication methods in perspective
Thank You !!!
•
•
•
•
Matt Mintz & DOCS
Mike Whitcomb & the AAMC 2002
Fred McCurdy & ACE 2003
Many national & international clinical education
colleagues
• Seven National Clerkship organizations plus
Clinical Skills Recommendations 2005
American Academy on Communication in Healthcare (AACH)
Auguste Fortin, Beth Lown, Dennis Novak
Alliance for Clinical Education (ACE)
Fred McCurdy, Louis Pangaro
Association of Directors of Medical Student Education in Psychiatry (ADMSEP)
Amy Brodkey, Julia Frank, Frederick Sierles
Association of Professors of Gynecology & Obstetrics (APGO)
Susan Cox, Diane Magrane
Association for Surgical Education (ASE)
Kimberly Anderson
Clerkship Directors in Internal Medicine (CDIM)
Lynn Cleary
Consortium of Neurology Clerkship Directors (CNCD)
Vern Juel, Joanne Lynn
Council on Medical Student Education in Pediatrics (COMSEP)
Bruce Morgenstern, Sandra Sanguino, Ben Siegel
Society of Teachers in Family Medicine (STFM)
Heidi Chumley
AAMC: Deborah Danoff, Mike Whitcomb
Preclerkship Skills Recommendations 2008
Clerkship Directors in Internal Medicine (CDIM)
Lisa Bernstein, Liselotte Dyrbye, William Harper,
Stanford Massie, Alex Mechaber, Matthew Thomas
Council on Medical Student Education in Pediatrics (COMSEP)
Roger Berkow, Mary Ellen Gusic, Starla Martinez
Society of Teachers in Family Medicine (STFM)
Scott Fields, John Rogers
Clinical Skills Education
It is necessary to call into council the
views of our predecessors in order that
we may profit from whatever is sound in
their views and avoid their errors.
Aristotle