Reality Check: Bridging the Gap Between Clinical Skills Curricula and Actual Practice

1. Reality Check: Bridging the Gap Between Clinical Skills Curricula and Actual Practice Directors of Clinical Skills Courses (DOCS) 2nd Annual Meeting November 3, 2012

2. Who Are We? • Wendy S. Madigosky MD MSPH Associate Professor of Family Medicine Director, Foundations of Doctoring Curriculum University of Colorado School of Medicine • Jean Hudson MD, FCFP Assistant Professor of Family Medicine University of Toronto

3. Who Are We? • Cate Nicholas EdD, MS, PA Director of Simulation Education Director of the Standardized Patient Program           Clinical Simulation Laboratory Fletcher Allen Health Care/University of Vermont • Gordon L. Woods, MD, MHPE Associate Professor of Medicine & College Master Texas Tech University Health Sciences Center Paul L. Foster School of Medicine

4. Workshop Objectives • Understand concepts from the literaturerelated to the development of clinical skills in the pre-clinical years and the applicability of these skills to the clinical workplace. • Identify the differences between the learning experience in the clinical skills course and the clinical workplace. • Identify interventions at the student, faculty and curricular level to address the differences.

5. Agenda 10:05-10:15 Background • Review of concepts from the literature 10:15-10:30 Clarification of the problem • Facilitated discussion, articulating the gap 10:30-10:50 Breakout session • Table work with assigned questions 10:50-11:10 Table report outs 11:10-11:25 Summary and synthesis 11:25-11:30 Closing

6. How do we answer this question? • Assumption = Pre-clerkship context • patient history taking, communication, physical exam, documentation, oral presentation, early clinical reasoning • Principal Stakeholders: • Faculty in the clinical skills program (UME) • Curriculum of the University • Preceptors in community • Students in the course and in the community • others

7. Selected articles (System, Community teacher and the Curriculum) • Issenberg SB, McGaghie WC. Clinical skills training--practice makes perfect.Med Educ. 2002 Mar;36(3):210-1 • Lie D, Boker J, Dow E. Attributes of effective community preceptors for pre-clerkship medical students.Med Teach. 2009 Mar;31(3):251-9. • Wenrich M, Jackson MB, Scherpbier AJ, Wolfhagen IH, Ramsey PG, Goldstein EA. Ready or not? Expectations of faculty and medical students for clinical skills preparation for clerkships.Med Educ Online. 2010 Aug 6;15.

8. Clinical Skills training-Practice makes perfect principles to follow- Issenberg • Inclusion of clinical skills training across the four years of curriculum • How best to go about it? “Students and faculty do not appreciate the difference between the acquisition of cognitive knowledge and clinical skills” Need intense, deliberate practice in a focussed domain • Establish learning outcomes • Organize the clinical skills throughout the curriculum • Specify the competency level required at each stage of learning • Implement instructional delivery methods • Evaluation and Assessment

9. Attributes of effective community preceptors for pre-clerkship medical students D. Lie • What is different from the community preceptors for clerkship students? • Site visits over 3 years (University of California) • Preclerkship students most value independence in patient assessment, time spent by preceptors teaching, and receiving feedback • Study became a needs assessment for faculty development of community based preceptors of pre clerkship students

10. Pre-clerkship student evaluations of community preceptors • My preceptor was: • Well informed about my learning needs • Observed me with at least one patient • Provided feedback on my clinical skills • Encouraged me to present my ideas • Seemed comfortable working with a medical student • Took time to teach • Excellent role model • Allowed me to interview patients • Used the internet for teaching patient care

11. Ready or not? Expectations of faculty and medical students for clinical skills preparation for clerkships M. Wenrich • Results- Preclinical faculty and students had higher expectations than clerkship faculty for degree of preparation in most basic skills • Guided bedside learning- history taking, physical examination, communication skills, oral case presentation, and write-ups and introduction to clinical reasoning

12. Extent of Clinical skills preparation perceived as appropriate for students for start of clerkships

13. Ready or not? Expectations of faculty and medical students for clinical skills preparation for clerkshipsDiscussion • Results suggest a program in transition • Alignment and integration • Communication with and from preclinical and clerkship faculty about expectations for clinical skills and proficiency at the start of clerkships

14. Started the conversation • Highlight the complexities of the question • Just touching on a few facets • Will lead into deeper discussion at the tables

15. Table Reports Faculty • Faculty development • Preclinical and preceptors need to understand each others curricular goals • Match learning activities to outcomes • Set up office hours instead of defaulting to email Students • Embrace the gap • Name the differences • Give students responsibility for their own skills development Preceptors • Keep it simple • Create helpful hints for preceptors, do faculty development • Develop positive reinforcement from students/awards • Help students become autonomous-give students responsibility for their own skills development Curriculum/Modalities • Learn a through and systematic H&P at first and then learn how to adapt to clinical variations with explicit learning activities

16. Synthesis and Summary • Embrace the gap- name the issues and provide students with the skills through formal curriculum and instruction to maintain "best practices" and learn and value what is unique to the clinical environment (the “in practice.”) • Fill the gap-clinical skills faculty and preceptors need to be well versed and on board with each others curricular goals and learning outcomes so they can support each others work. Clinical skills education and mentoring needs to be connected across medical education from UGME through GME. • Identify the gap- Bring the patient into this conversation.