Clinical Skills Education

Knowing is not enough; we must apply.

Willing is not enough; we must do.

Goethe

What is skill learning?• Knowledge versus skills education

Why the emphasis on skills education now?• Does curricular emphasis make a difference?

How?• AAMC Task Force recommendations

• Some examples of clinical skills teaching

• Some closing tips for skills teaching

….the accent is upon learner doing!

….upon the application of knowledge and

understanding to an intellectual,

psychomotor or affective activity

Think of anyone (teacher, friend, family

member…) who has been most helpful to

you in developing a skill that you are good

at.

What is the skill?

What did they do to help you learn to do that

skill?

It has a clear and specific purpose It reinforces knowledge and understanding It must be demonstrated well An opportunity to try it out An opportunity to practice it Coaching (observation) and Useful evaluation and helpful feedback Emphasis upon self-directed initiative Guided by an explicit performance standard Guided by a high performance standard Confidence-building opportunity in direct patient care

DOMAIN KNOWLEDGE SKILL

Teacher Role lecture mentor

Activity Center teacher learner

Learning

Opportunity

anytime limited

Learning

Increment

variable size discrete &

well defined

Assessment &

Feedback:

anytime as soon as possible

Setting almost anywhere clinical/simulated

Need for repetition: variable mandatory

Patient care is an applied activity

Performance emphasis is increasing at all levels of our

professional activity

Medical school skills education has been slipping

We want better UME clinical performance outcomes

• LCME: Medical Education Objectives andDocumentation of Students’ Clinical Experience

• USMLE Clinical Skills Examination

• AAMC: Students Clinical Skills Education

• ACGME Postgraduate competencies

• IOM: Medical Error in the caring process

• JCAHO: Hospital Performance Measures

• 3rd Party Payers: Physician Pay-for-Performance

“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.” (1910)

…to provide for the development of the

knowledge, skills and values necessary

to undertake the life-long responsibilities

of a physician….

• It is not explicit in the curriculum

• It is variable within a school

• It is not standardized across schools

• It is not explicitly developmental

over the 4 year curriculum

• It is only loosely connected to GME

expectations

1. Competency-based skill learning objectives 26%

2. Any formal skills curricula 52%

3. Skills curricula in clinical years 13%

4. Explicit list of skills to be learned 21%

5. Clinical skills education facility 59%

6. Standardized patients/assessment 65%

Hepatic size & consistency 77%

Basic CPR 73%

Suture a Laceration 72%

Observe & interpret a Gallop 65%

Interpret spirometry 62%

Do a peak pulmonary flow 52%

Work with a reluctant nurse 52%

Phone: a swallowed penny 45%

Jugular venous pulsation 38%

Simple forearm cast 8%

Skill

Score Above the Median Score Below the Median

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%

“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.”

Does it make any difference in clinical

learner performance outcomes??

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New Curriculum

Old Curriculum

Overall Score on 4th Year Clinical Skills Assessment#

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DUTCH CLINICAL SKILLS OUTCOMES

How do we define basic clinical method?

What are the essential clinical

competencies for UME??

www.aamc.org/meded/clinicalskills/ 2005, 2008

Clinical Competency Domains

=

Medical Education Objectives

#1-3. Three competencies that students bring to

medical school in varying degrees of

development

#4-8. The five elementary competencies

#9-11. The 3 clinical management competencies

#12. The most practical clinical competency

The 3 competencies that students bring in

varying degrees of development to

medical school:

1. Professionalism

2. Patient engagement & communication

3. Scientific knowledge & method

The 5 elementary competencies:

4. Clinical history-taking

5. Mental & physical examination

6. Clinical tests & imaging

7. Basic clinical procedures

8. Clinical information management

The 3 case management competencies:

9. Diagnosis & differential diagnosis

{defining the clinical problem}

10. Clinical Intervention

{caring for the clinical problem}

11. Clinical prognosis

{anticipating and planning for

future healthcare outcomes}

The final universal clinical competency:12. The ability to provide the patient’s

care within the context ofthe patient and their preferences,

family preferences,economic, cultural,

ethical, legal, healthsystem,

and societal preferences and constraints.

1. Professionalism

2. Interpersonal & communication skills

3. Medical knowledge

4. Patient care

5. System-based practice

6. Practice-based learning & improvement

Patient Care

Professionalism

Interpersonal & communication skills

Medical knowledge

System-based practice

Practice-based learning & improvement

Keep in mind the 12 domains of basic clinical method Specifically speaking, there are many basic clinical

skills to teach and learn Choose to your strengths but add on some others Make it case-based if at all possible Please don’t worry about being too basic Know your learners and what they can do In the clinical setting, delegate clinical task doing

whenever you can Encourage others (including your residents) to do the

same

Observe your learners more and give them performance feedback whenever you can

Set up your expectations explicitly ahead of time! Encourage your patients to help out! Encourage yourself and your colleagues to lecture less

and mentor more in the clinical setting Practice makes perfect at all levels Help set higher standards for clinical skills teaching

and learning Make it fun!

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1972-73 1984-85 1995-96

Baylor

Case

Chicago

Cornell

GW

Minnesota

Nebraska

Pittsburg

Tulane

U Mass

UNC

USC

Wisconsin

Average

By the spectrum of clinical care:

Emergency care

Acute care

Critical care

Chronic care

Palliative & terminal care

Wellness & preventive care

Population Care