Knowing is not enough we must apply Willing

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

Clinical Skills Education Considerations on… Why, What & How? Eugene C. Corbett, Jr. , M. D. , FACP Brodie Professor of Medicine Professor of Nursing University of Virginia Chair, AAMC Task Force on Clinical Skills Education

Agenda n What is skill learning? q n Why the emphasis on skills education now? q n Knowledge versus skills education Does curricular emphasis make a difference? How? q q q 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 n n n 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 • 3 rd 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 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% 26%

UVA CLINICAL SKILLS SURVEY Student Self-estimate of Skill Performance (2003) n n n n n Hepatic size & consistency Basic CPR Suture a Laceration Observe & interpret a Gallop Interpret spirometry Do a peak pulmonary flow Work with a reluctant nurse Phone: a swallowed penny Jugular venous pulsation Simple forearm cast 77% 73% 72% 65% 62% 52% 45% 38% 8%

UVA Post-clerkship OSCE data (2006) Score Above the Median Score Below the Median Skill 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%

A 4 th 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… n Does it make any difference in clinical learner performance outcomes? ?

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

DUTCH CLINICAL SKILLS OUTCOMES

AAMC Task Force on Clinical 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 = 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 of the patient and their preferences, family preferences, economic, cultural, ethical, legal, healthsystem, and societal preferences and constraints.

ACGME 1999 1. 2. 3. 4. 5. 6. Professionalism Interpersonal & communication skills Medical knowledge Patient care System-based practice 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… n n n n 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… n n n n 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!

Organizing Clinical Skills Education By the spectrum of clinical care: Emergency care n Acute care n Critical care n Chronic care n Palliative & terminal care n Wellness & preventive care n Population Care n