Pre-Clerkship Clinical Skills Courses in the US, 2010: Results of a National Survey

Pre-Clerkship Clinical Pre-Clerkship Clinical Skills Courses in the US, Skills Courses in the US,

2010: Results of a 2010: Results of a National SurveyNational Survey

Matthew Mintz, MD, FACPMatthew Mintz, MD, FACPAssociate Professor of MedicineAssociate Professor of Medicine

The George Washington University School of The George Washington University School of MedicineMedicine

Pre-Clerkship Clinical Skills Pre-Clerkship Clinical Skills Courses in the US, 2010: Results of Courses in the US, 2010: Results of

a National Surveya National Survey

Julie Taylor, MD, Alpert Medical School at Brown UniversityJulie Taylor, MD, Alpert Medical School at Brown UniversityAlex Mechaber, MD, University of Miami Miller School of Alex Mechaber, MD, University of Miami Miller School of

MedicineMedicineRonald Silvestri, MD, Harvard Medical SchoolRonald Silvestri, MD, Harvard Medical School

Preetha Basaviah, MD, Stanford University School of Preetha Basaviah, MD, Stanford University School of MedicineMedicine

Steven Durning, MD, Uniformed Services University of the Steven Durning, MD, Uniformed Services University of the Health SciencesHealth Sciences

F. Stanford Massie, MD, University of Alabama School of F. Stanford Massie, MD, University of Alabama School of MedicineMedicine

Sara Tariq, MD, University of Arkansas for Medical Sara Tariq, MD, University of Arkansas for Medical SciencesSciences

Wendy Madigosky, MD, MSPH, University of Colorado Wendy Madigosky, MD, MSPH, University of Colorado School of MedicineSchool of Medicine

Andrea Flory, MD The George Washington University Andrea Flory, MD The George Washington University School of MedicineSchool of Medicine

Felise Milan, MD, Albert Einstein College of MedicineFelise Milan, MD, Albert Einstein College of MedicineJeffrey La Rochelle, MD Uniformed Services University of Jeffrey La Rochelle, MD Uniformed Services University of

the Health Sciencesthe Health Sciences

State of the UnionState of the Union

Mid 90’s to Early 2000’s:Mid 90’s to Early 2000’s:Interest Groups and Task Interest Groups and Task

Forces FormForces Form AAMCAAMC

Lewis, J., Antonelli, M., Brown, D. D., Haist, S., Hasbrouck, Lewis, J., Antonelli, M., Brown, D. D., Haist, S., Hasbrouck, C., McArthur, J., et al. (1993). Report of the introduction to C., McArthur, J., et al. (1993). Report of the introduction to clinical medicine task force. Sponsored by AAMC Group on clinical medicine task force. Sponsored by AAMC Group on Educational Affairs Educational Affairs

Council on Medical Student Education Council on Medical Student Education in Pediatrics (COMSEP)in Pediatrics (COMSEP)

Society of Teachers of Family Medicine Society of Teachers of Family Medicine (STFM)(STFM)

Clerkship Directors of Internal Medicine Clerkship Directors of Internal Medicine (CDIM)(CDIM)

Mary Ann Antonelli, MD FACPMary Ann Antonelli, MD FACP

Department of Veterans Affairs Department of Veterans Affairs Pacific IslandsPacific Islands

Health Care System, Honolulu, HIHealth Care System, Honolulu, HI

Earlier SurveysEarlier Surveys

Deloney Linda A. A Comprehensive Overview Deloney Linda A. A Comprehensive Overview of Introduction to Clinical Medicine Courses of Introduction to Clinical Medicine Courses and Course Directors, Chapter IV, November and Course Directors, Chapter IV, November 20032003

Two survey questionnaires were e-mailed to Two survey questionnaires were e-mailed to identified curriculum contacts in 126 identified curriculum contacts in 126 accredited United States MD-granting accredited United States MD-granting medical schools and 16 accredited Canadian medical schools and 16 accredited Canadian medical schools in the spring of 2003.medical schools in the spring of 2003.

48% response rate48% response rate

AAMC Task Force on Clinical Skills Education met in 2003, Recommendations published in 2005

AJM Perspective in 2005AJM Perspective in 2005

Introduction to clinical medicine: A time for consensus and integration-Association of Professors of Medicine Perspective, American Journal of Medicine 2005

Discussed results of CDIM 2003 survey which identified status of ICM course from Clerkship Directors (only some of which were ICM directors)

Letter to Editor re: AJM Letter to Editor re: AJM PerspectivePerspective

Mechaber, Bernstein, Dyrbe, Harper, MassieMechaber, Bernstein, Dyrbe, Harper, Massie 2003 CDIM survey “was a good starting 2003 CDIM survey “was a good starting

point to begin this dialogue, but a more point to begin this dialogue, but a more comprehensive survey of ICM directors is comprehensive survey of ICM directors is likely warranted.”likely warranted.”

““More important, though, a national forum More important, though, a national forum through an organization with a broad through an organization with a broad constituency such as the Association of constituency such as the Association of American Medical Colleges is essential to American Medical Colleges is essential to provide more formal recommendations.”provide more formal recommendations.”

AAMC Task Force On the AAMC Task Force On the Preclerkship Clinical Skills Preclerkship Clinical Skills

Education of Medical Students Education of Medical Students 20052005

Eugene C. Corbett, Jr., M.D. (Chair)Roger L. Berkow, M.D.Lisa B. Bernstein, M.D.Liselotte N. Dyrbye, M.D.Scott A. Fields, M.D.Maryellen E. Gusic, M.D.William R. Harper, M.D.

Starla G. Martinez, M.D.F. Stanford Massie, Jr., M.D.Alex J. Mechaber, M.D.John C. Rogers, M.D., M.P.H, M EdMatthew R. Thomas, M.D

Recommendations For Clinical Recommendations For Clinical Skills Curricula For Undergraduate Skills Curricula For Undergraduate

Medical Education 2008Medical Education 2008AAMC Task Force On the Preclerkship AAMC Task Force On the Preclerkship Clinical Skills Education of Medical StudentsClinical Skills Education of Medical Students


Medical Education 2008Medical Education 20081.1. Adhere to an explicit set of principles to Adhere to an explicit set of principles to

guide the design and implementation of guide the design and implementation of the preclerkship clinical skills curriculum.the preclerkship clinical skills curriculum.

2.2. Implement a clinical curriculum that Implement a clinical curriculum that reflects the developmental nature of skills reflects the developmental nature of skills learning, including the designation of learning, including the designation of expected levels of skill performance.expected levels of skill performance.

3.3. Adopt explicit competency goals which, in Adopt explicit competency goals which, in turn, determine the specific skill turn, determine the specific skill objectives in the preclerkship curriculum.objectives in the preclerkship curriculum.


Medical Education 2008Medical Education 20084.4. Provide sufficient learning opportunities, using a Provide sufficient learning opportunities, using a

variety of healthcare settings, that enable variety of healthcare settings, that enable students to achieve specified preclerkship students to achieve specified preclerkship objectives. objectives.

5.5. Design and implement strategies to assess Design and implement strategies to assess students’ achievement of expected clinical skills students’ achievement of expected clinical skills outcomes.outcomes.

6.6. Provide the program elements critical to the Provide the program elements critical to the success of the preclerkship clinical skills success of the preclerkship clinical skills curriculum: leadership, programmatic curriculum: leadership, programmatic infrastructure, and the resources required for infrastructure, and the resources required for continuous curricular enhancement.continuous curricular enhancement.

MethodsMethods

Several of us (AM, SM, SD, JLR, Several of us (AM, SM, SD, JLR, MM) from CDIM decide to do a MM) from CDIM decide to do a national survey (two actually)national survey (two actually) PCCS Course DirectorsPCCS Course Directors Curricular DeansCurricular Deans

CDIM also agrees to add two CDIM also agrees to add two questions (name and contact info) to questions (name and contact info) to it’s annual survey in 2010 it’s annual survey in 2010

MethodsMethods Dr. Julie Taylor used direct methods to Dr. Julie Taylor used direct methods to

determine PCCS Course Director determine PCCS Course Director names/contact informationnames/contact information HHanded out contact information sheets at the

2010 NEGEA Called US and Canadian medical and

osteopathic schools. By 5/7/2010, this database had contact

information from 158 programs, of which there were 229 names and emails available for the 133 AAMC US medical schools.

MethodsMethods

Dr. Jim Blatt makes Dr. Jim Blatt makes connectionconnection

CDIM group and Dr. CDIM group and Dr. Taylor combine forcesTaylor combine forces

MethodsMethods

Study was approved by the GWUMC IRBStudy was approved by the GWUMC IRB Emails were sent to curricular deans and Emails were sent to curricular deans and

PCCS course directors with link to an PCCS course directors with link to an online surveyonline survey

Instructions given in the email and survey Instructions given in the email and survey to forward to appropriate individual if to forward to appropriate individual if recipient incorrectrecipient incorrect

Reminder email sent to non-respondentsReminder email sent to non-respondents Remaining non-responding schools were Remaining non-responding schools were

contacted directly by research group via contacted directly by research group via phone and/or emailphone and/or email

MethodsMethods Two surveys were sent to 133 AAMC Two surveys were sent to 133 AAMC

member US medical schools. member US medical schools. First survey was sent to curricular deans First survey was sent to curricular deans

Initially, from CurMITT (6/2010) 130/133 Initially, from CurMITT (6/2010) 130/133 names and emailsnames and emails

Direct contact of 3 missing institutionsDirect contact of 3 missing institutions Direct contact of 8 “bounce backs” from first Direct contact of 8 “bounce backs” from first

sent on 10/11sent on 10/11 Contact of correct contact from 1 Contact of correct contact from 1

respondent who was not the correct contact. respondent who was not the correct contact.

MethodsMethods Second survey sent on 10/14 to PCCS course Second survey sent on 10/14 to PCCS course

directors identified from:directors identified from: Dr. Taylor’s data base (229 names/emails)Dr. Taylor’s data base (229 names/emails) CurMITT database (77 additional emails from CurMITT database (77 additional emails from

94/133)94/133) CDIM annual member survey: CDIM annual member survey: 82 (75%) responders

generated 26 new names and emails (updated five emails addresses already in the database)

332 total Curricular Dean Survey- 20 new names/emailsCurricular Dean Survey- 20 new names/emails Attempted to contact initial non-responding Attempted to contact initial non-responding

institutions.institutions.

As an aside……As an aside……

Initial response Initial response remarkable!!remarkable!!

Survey to PCCS course directors Survey to PCCS course directors sent 10/14/2010 sent 10/14/2010

Direct emails to Dr. Mintz suggested Direct emails to Dr. Mintz suggested overwhelming supportoverwhelming support

Impromptu meeting at November Impromptu meeting at November 2010 AAMC meeting in Washington, 2010 AAMC meeting in Washington, DC sets stage for today’s event. DC sets stage for today’s event.

Now, back to the Now, back to the studystudy

Branched LogicBranched Logic For Course Directors survey, in order to For Course Directors survey, in order to

include all directors and co-directors as well include all directors and co-directors as well as not duplicate results for the same course, as not duplicate results for the same course, branched logic was usedbranched logic was used

Baseline demographics and opinion Baseline demographics and opinion questions were to be completed by allquestions were to be completed by all

Organization and Administration questions Organization and Administration questions completed only bycompleted only by Overall directorOverall director Year 1 and Year 2 director where no overall Year 1 and Year 2 director where no overall

director existed. director existed.

Results: Curricular Results: Curricular DeansDeans

80 of the 133 curricular deans responded (60% 80 of the 133 curricular deans responded (60% response rate)response rate)

All schools reported having a PCCS course or All schools reported having a PCCS course or contentcontent

64% PCCS courses managed centrally64% PCCS courses managed centrally 76% reported that curricular time devoted to 76% reported that curricular time devoted to

PCCS courses in the first two years ranged PCCS courses in the first two years ranged from 11% to 30%from 11% to 30%

Though content varied considerably, 90% Though content varied considerably, 90% responded that their school’s PCCS course responded that their school’s PCCS course teaches other curricular elements such as teaches other curricular elements such as professionalism, ethics, and clinical reasoning. professionalism, ethics, and clinical reasoning.




Other:

Palliative care, cultural competency, health systems, prevention, nutrition



Results: PCCS Course Results: PCCS Course DirectorsDirectors

138 PCCS course directors from 92/133 138 PCCS course directors from 92/133 medical schools responded (69% medical schools responded (69% response rate).response rate). 138 completed baseline demographics138 completed baseline demographics106 completed organization and 106 completed organization and administration questionsadministration questions119 completed opinion questions 119 completed opinion questions

Baseline Data or Baseline Data or Demographics Demographics

from PCCS Course from PCCS Course DirectorsDirectors

Results: Course NameResults: Course Name

Bedside DiagnosisBedside Diagnosis

Essentials of Clinical MedicineEssentials of Clinical Medicine

Physical Diagnosis and Clinical Integration (Introduction Physical Diagnosis and Clinical Integration (Introduction to) Clinical Skillsto) Clinical Skills

(Essentials of) Clinical Reasoning(Essentials of) Clinical Reasoning

On DoctoringOn Doctoring

Foundations of Patient Care/Clinical PracticeFoundations of Patient Care/Clinical Practice

Competency Based Apprenticeship in Primary Care Competency Based Apprenticeship in Primary Care Patient Physician SocietyPatient Physician Society

Introduction to the Patient/ to Patient CareIntroduction to the Patient/ to Patient Care

Clinical ContinuumClinical Continuum

Doctoring SkillsDoctoring Skills


91% PCCS course directors are 91% PCCS course directors are physicians (37% general internal medicine, physicians (37% general internal medicine, 24% family medicine, 21% subspecialty, 24% family medicine, 21% subspecialty, and 9% pediatrics). and 9% pediatrics). Wide range of years in current position Wide range of years in current position and variety of academic ranksand variety of academic ranksMany have other educational rolesMany have other educational roles

36% in other PCCS course36% in other PCCS course 38% in Clerkship38% in Clerkship 38% in Residency Program38% in Residency Program


Years in Current PositionYears in Current Position

Academic RankAcademic Rank

Course Course Organization from Organization from

PCCS Course PCCS Course DirectorsDirectors

Course Organization

Curriculum organized by organ system (39%), Discipline based (31%) Other (30%)

Primary Format didactic (20%), PBL (4%), mix of PBL and didactic (58%), and other (18%)

Yearly longitudinal (73%), block module with defined # of weeks (15%), other (12%)

89% stated PCCS course was integrated with basic science courses

Results: Learning and Results: Learning and AssessmentAssessment

87% have developed and use core 87% have developed and use core competenciescompetencies

75% institutions use formal clinical 75% institutions use formal clinical skills curriculum in clinical yearsskills curriculum in clinical years

89% use OSCE’s in PCCS 89% use OSCE’s in PCCS 81% in Clerkships81% in Clerkships

88% have clinical skills training lab88% have clinical skills training lab 83% use in PCCS83% use in PCCS 65% use in Clerkships65% use in Clerkships

Communication with Clerkship Directors

Course Course Administration Administration

from PCCS Course from PCCS Course DirectorsDirectors


2/3 PCCS Courses run by 1-3 faculty


~2/3 PCCS Courses need over 50 faculty to run

Results: Number of Non-Faculty Administrators

(FTE) Three quarters have only 1-3

administrators 1 (24%) 2 (31%) 3(19%) 4(10%) 5(5%) more than 5 (11%)

Results: Percent Full Time Faculty

PCCS Course PCCS Course Directors Opinions Directors Opinions

on a National on a National OrganizationOrganization


87% of PCCS course directors felt that 87% of PCCS course directors felt that a national organization or resource for a national organization or resource for PCCS course directors was needed as PCCS course directors was needed as a way of communicating, sharing, and a way of communicating, sharing, and collaborating. collaborating.

Majority believe AAMC national Majority believe AAMC national meeting would be a good venue for a meeting would be a good venue for a live meetinglive meeting


A national organization for PCCS course directors is needed


I would like such an organization for communication (listserve)


I would like such an organization for:

Agreement

Sharing curricular material 94%

Method of collaboration for research

91%

Share innovations in teaching or other activities

94%

Share testing material (OSCE’s) 91%

Mentoring 73%

Advocacy, i.e. increased funding

78%

Establish competency standards

89%


Do you attend the AAMC National Meeting?

About 50/50


Would the AAMC National Meeting be a good venue?

Over 2/3 said “yes”¼ didn’t careFew said “no”


Other conference attendanceOther conference attendance SGIM 30%, CDIM 12%, STFM 21%, SGIM 30%, CDIM 12%, STFM 21%,

COMSEP 3%, No meetings 27%COMSEP 3%, No meetings 27% 88% would be likely/very likely to attend 88% would be likely/very likely to attend

AAMC with sessions focused on PCCS AAMC with sessions focused on PCCS course (59% first choice)course (59% first choice) Clerkship director meeting in their specialty Clerkship director meeting in their specialty

(66%)(66%) Clerkship director meeting not in specialty Clerkship director meeting not in specialty

(14%)(14%) Entirely new meeting 72% (25% first choice)Entirely new meeting 72% (25% first choice)

Results SummaryResults SummaryFrom the Curricular Deans, PCCS From the Curricular Deans, PCCS

courses:courses: Exist at virtually all US medical Exist at virtually all US medical

schoolsschools Usually managed by the Dean’s Usually managed by the Dean’s

officeoffice Account for more than 10% of total Account for more than 10% of total

curricular time curricular time Include topics beyond interviewing Include topics beyond interviewing

and physical examination. and physical examination.

Results SummaryResults SummaryPCCS directors:PCCS directors: Come from a variety of medical specialtiesCome from a variety of medical specialties Few supervise many faculty with little Few supervise many faculty with little

administrative supportadministrative support Strongly desire a national forum to Strongly desire a national forum to

collaborate collaborate

PCCS coursesPCCS courses Have a variety of namesHave a variety of names Differ in organization and formatsDiffer in organization and formats Many utilize clinical skills labMany utilize clinical skills lab

LimitationsLimitations

Survey data, not actual curriculumSurvey data, not actual curriculum Limited to 133 AAMC schoolsLimited to 133 AAMC schools Response rate decent, but fell just Response rate decent, but fell just

short of the 70% desiredshort of the 70% desired

ThanksThanksJulie Taylor, MD, Alpert Medical School at Brown Julie Taylor, MD, Alpert Medical School at Brown

UniversityUniversityAlex Mechaber, MD, University of Miami Miller School of Alex Mechaber, MD, University of Miami Miller School of

MedicineMedicineRonald Silvestri, MD, Harvard Medical SchoolRonald Silvestri, MD, Harvard Medical School

Preetha Basaviah, MD, Stanford University School of Preetha Basaviah, MD, Stanford University School of MedicineMedicine

Steven Durning, MD, Uniformed Services University of the Steven Durning, MD, Uniformed Services University of the Health SciencesHealth Sciences

F. Stanford Massie, MD, University of Alabama School of F. Stanford Massie, MD, University of Alabama School of MedicineMedicine

Sara Tariq, MD, University of Arkansas for Medical Sara Tariq, MD, University of Arkansas for Medical SciencesSciences

Wendy Madigosky, MD, MSPH, University of Colorado Wendy Madigosky, MD, MSPH, University of Colorado School of MedicineSchool of Medicine

Andrea Flory, MD The George Washington University Andrea Flory, MD The George Washington University School of MedicineSchool of Medicine

Felise Milan, MD, Albert Einstein College of MedicineFelise Milan, MD, Albert Einstein College of MedicineJeffrey La Rochelle, MD Uniformed Services University of Jeffrey La Rochelle, MD Uniformed Services University of

the Health Sciencesthe Health Sciences

Additional ThanksAdditional Thanks

Dr. Benjamin BlattDr. Benjamin Blatt CDIMCDIM GEA/NEGEAGEA/NEGEA Curricular Deans and PCCS Course Curricular Deans and PCCS Course

DirectorsDirectors

Questions/Questions/DiscussionDiscussion

Documents

Pre-Clerkship Clinical Skills Courses in the US, 2010: Results of a National Survey