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

Directors of Clinical Skills Courses (DOCS) 2nd Annual MeetingNovember 3, 2012

Who Are We?

• Wendy S. Madigosky MD MSPHAssociate Professor of Family MedicineDirector, Foundations of Doctoring CurriculumUniversity of Colorado School of Medicine

• Jean Hudson MD, FCFPAssistant Professor of Family MedicineUniversity of Toronto

Who Are We?• Cate Nicholas EdD, MS, PA

Director of Simulation EducationDirector of the Standardized Patient Program Clinical Simulation LaboratoryFletcher Allen Health Care/University of Vermont

• Gordon L. Woods, MD, MHPEAssociate Professor of Medicine & College MasterTexas Tech University Health Sciences CenterPaul L. Foster School of Medicine

Workshop Objectives

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 outs11:10-11:25 Summary and synthesis11:25-11:30 Closing

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

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.

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

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

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

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

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

Ready or not? Expectations of faculty and medical students for clinical skills preparation for clerkships Discussion

• 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

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

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

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.