Knowing is not enough; we must apply.Willing is not enough; we must do.

Goethe

Clinical Skills EducationConsiderations on…

Why, What & How?Eugene C. Corbett, Jr., M.D., FACPBrodie Professor of MedicineProfessor of NursingUniversity of VirginiaChair, AAMC Task Force on Clinical Skills Education

Agenda

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

In skills education….

….the accent is upon learner doing!

….upon the application of knowledge and understanding to an intellectual, psychomotor or affective activity

What is skill learning?

Reflect on your own skill development…

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?

General Principles of Skills Teaching & Learning

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

Knowledge Acquisition vs Skill Development

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

Why the emphasis on skills education?

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

Competency-based Clinical Performance Outcomes in Medical Education & Practice• LCME: Medical Education Objectives and

Documentation 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

Abraham Flexner

“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)

The Purpose of Undergraduate Medical Education

…to provide for the development of the knowledge, skills and values necessary to undertake the life-long responsibilities

of a physician….

UME Clinical Skills Education:(It looks weak!)

• 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

Some AAMC Medical School Data:

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%

UVA CLINICAL SKILLS SURVEYStudent Self-estimate of Skill

Performance(2003)

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%

UVA Post-clerkship OSCE data(2006)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%

MaintainConfidentiality (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%

A 4th Year Medical Student(2006)

“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.”

Clinical Skills Education, Curricular Emphasis…

Does it make any difference in clinical learner performance outcomes??

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New Curriculum

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Overall Score on 4th Year Clinical Skills Assessment

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DUTCH CLINICAL SKILLS OUTCOMES

AAMC Task Force onClinical Skills

Education,a key consensus issue:

How do we define basic clinical method?

What are the essential clinical competencies for UME??

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

Medical Education:begin with the end in mind…

Clinical Competency Domains

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Medical Education Objectives

12 Clinical Competency Domains of Basic Clinical Method

AAMC 2005

#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

Basic Clinical Method

The 3 competencies that students bring in varying degrees of development to medical school:

1. Professionalism

2. Patient engagement & communication

3. Scientific knowledge & method

Basic Clinical 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

Basic Clinical Method

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}

AAMC 2005

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.

ACGME 1999

1. Professionalism

2. Interpersonal & communication skills

3. Medical knowledge

4. Patient care

5. System-based practice

6. Practice-based learning & improvement

ACGME for UME??

Patient Care

Professionalism

Interpersonal & communication skills

Medical knowledge

System-based practice

Practice-based learning & improvement

How?

What are some examples of skills teaching?

Some practical tips for clinical skills teaching…

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

Some practical tips for clinical skills teaching…

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

Organizing Clinical Skills Education

By the spectrum of clinical care:

Emergency care Acute care

Critical care Chronic care

Palliative & terminal care Wellness & preventive care

Population Care