Knowing is not enough; we must apply. Willing is not enough; we must do. Goethe ~1800

1. Knowing is not enough; we must apply.Willing is not enough; we must do.Goethe ~1800

2. 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 ecc9h@virginia.edu

3. 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!

4. 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

5. 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

6. 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.”

7. 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.”

8. Table 1: AAMC Reports on Undergraduate Medical Education The Clinical Skills Education of Medical Students

9. 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 21/2 3/3

10. 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%)

11. 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% Communication 19% History-taking 21% No53% Physical Examination 17% Clinical Testing 23% Procedures 26% * Response Rate = 62/142 (44%)

12. AAMC Survey of Curricular Deans2002 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 25 % Paper & Pencil 20 % OSCE/SP 67 % Computer Sim 8 %

13. 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%

14. LCME Table 5: Trends in Final Clinical Skills Assessment Methods (LCME, n =125)

16. Overall Score on 4th Year Clinical Skills Assessment # Students Old Curriculum # Students New Curriculum

17. DUTCH CLINICAL SKILLS OUTCOMES

18. Table 7: Clinical Skills Evaluation Methods Percent of students reporting use of each method: n=839 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

19. UVA: Direct Observation of Clerkship Students 1999-2001 Students reporting that they had NEVER been observed by a faculty member while: taking a history: 51% performing a focused physical exam: 54% performing a complete physical exam: 60% L Howley and WG Wilson, Academic Medicine, 2004

20. A 4th Year Medical StudentUVA 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.”

21. 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)

22. CLERKSHIP CLINICAL SKILLS EDUCATION PROJECT 2005 Overall Student Skill Performance (as judged by faculty observer):

23. Patterns of skill performance on the Arrhythmia Recognition OSCE Did the student perform the critical clinical action? UVa 2008

24. UVA Post-clerkship OSCE data(2008)

25. A Professional Paradigm Shift:From Process to Outcome ~2000 • 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

26. The educational paradigm shift for undergraduate medical education: From…”to know and understand” To…”understand and apply”

27. AAMC Task Force on the Clinical Skills Education of Medical Students2003 Purpose: To initiate the development of a national consensus regarding the teaching & learning of clinical skills in undergraduate medical education.

28. 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

29. 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

30. AAMC Task Force on the Clinical Skills Education of Medical Students Basic 2003-05Preclerkship 2005-08 Six Overall Recommendations: Principles of Skills Education Clinical Skill Education Objectives (#12) A Menu of Skills Clinical Learning Opportunities (Venues of Care) A Developmental Paradigm (Levels of Performance) Essential Programmatic Elements

31. 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

32. 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

33. 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)

34. 9 Challenges & Unfinished Mattersto 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

35. 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/

36. 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”

37. The Medical Student 4-Year Curriculum 1910 • 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

38. The Medical Student 4-Year Curriculum2010 • Anatomy Family Medicine • Physiology Psychiatry • Biochemistry Neurology • Molecular & Cellular Function Emergency Medicine • Embryology Dermatology • Histology Ophthalmology • Microbiology Otolaryngology • Neuroscience Urology • Human Behavior Orthopedics • Genetics Plastic Surgery • Pathology Physical Medicine & Rehabilitation • Pharmacology Cardiology • Physical Diagnosis Gastroenterology • Introduction to Clinical Medicine Rheumatology • Epidemiology Hematology Endocrinology • Surgery Neurosurgery • Medicine Oncology • Pediatrics Geriatrics • Obstetrics & Gynecology Nephrology • Pediatric Specialties Anesthesiology • Radiology Health Policy, Economics….etc…

39. The UME – GMECompetencies Dilemma ACGME 1999 • Patient Care • Medical Knowledge • Practice Based Learning and Improvement • Interpersonal Skills and Communication • Professionalism • Systems-Based Practice

40. The Competencies DilemmaACGME for UGME?? Patient Care: Professionalism Interpersonal Skills & Communication Medical Knowledge Practice Based Learning & Improvement Systems-Based Practice

41. 12 Clinical Competency Domains of Basic Clinical MethodAAMC 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

42. Clinical Methodthe 12 CLINICAL SKILL EDUCATION OBJECTIVES PROFESSIONALISM THE APPLICATION OF SCIENCE TO CLINICAL PROBLEM SOLVING PATIENT ENGAGEMENT & RELATIONSHIP SKILLS CLINICAL HISTORY-TAKING PHYSICAL EXAMINATION CLINICAL TESTING BASIC CLINICAL PROCEDURES CLINICAL INFORMATION MANAGEMENT DIAGNOSIS, DIFFERENTIAL DIAGNOSIS & CLINICAL REASONING INTERVENTION, CURE & PREVENTION PROGNOSIS & CLINICAL OUTCOMES MANAGEMENT THE APPLICATION OF CARE in Practical CONTEXT

44. 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)

45. Teaching & LearningObservation Skill • Subjective view (Communicating and History-taking) • Objective view (Mental & Physical Examination) Learn and practice 4 steps • Observe • Describe • Interpret • Document (Boudreau, et al)

46. CLINICAL EDUCATION DIPLOPIA ***

47. 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

48. Student diplopia issue • Study toward the test versus • Study toward patient care

49. Clinical Education FidelityThis one needs some work… Workplace Learning vs Simulation What setting and method works best for what stage of learning what skills?? And for assessment? • The paper patient • The virtual patient • The mannequin • The standardized patient • The real patient

50. Resident & Faculty DevelopmentThe 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?