An innovative approach to developing the reflective skills of medical students

Background  

Development of the reflective skills of medical students is an acknowledged objective of medical education.     

A step-wise role playing approach for teaching patient counseling skills to medical students

We describe a step-wise role playing approach to bedside teaching during the clinical training of medical students. The objective of this approach is to teach them the skills which are required to practice patient-centered medicine. "Patient-centered medicine" refers to a style of practice which relates to patients' needs rather than to the doctor's own plan, and which moves from professional control to patient empowerment.Our approach is based on: (a) interviews with real patients, and (b) re-play of doctor--patient encounters in small group teaching sessions using the instructor (a physician) as a simulated patient, while a student assumes the role of the physician. The objective of the simulation is to assess the student's ability to provide health-related information, involve patients in making clinical decisions and plan their management in a manner which suits their preferences and lifestyle. The medical background of the instructor who simulates the patient eliminates barriers in communication and allows these objectives to be easily accomplished. The discussion which follows, attempts to: (a) identify discrepancies between the optimal counseling which was offered to the simulated patient and that offered to the real patient; and (b) show that although inevitable, these discrepancies are not irreducible.We have no formal evaluation of our approach in terms of whether it achieved its objective, produced changes in students' attitudes and bedside manners, or in terms of students' ratings of the teaching approach. However, student participation and occasional verbal feedback have indicated that the teaching intervention may be a valid contribution to the clinical training of medical students and that it may be of use for other clinical instructors.     

医学生临床沟通技能课程设置及效果自评

目的 有效提高医学生的医患沟通技能.方法 北京协和医学院2009年3月至2011年10月期间对165名八年制高年级医学生教授临床沟通课程,使用学生自评问卷的方式对教学效果进行评估.结果 医学生在课后大部分临床沟通技能高于课前,大部分医患沟通能力评分高于课前,以患者为中心的理念得到强化.课程整体满意度为96.2％.结论 临床沟通技能课程达到了提高沟通技能的目的,沟通技能的客观考核方式需要进一步探索.     

A pilot project to study the use of ultrasonography for teaching physical examination to medical students

The purpose of this study was to study the use of ultrasound as an aid to teaching physical examination. Five medical students were given a 1-week course in ultrasound, and were then assigned to clinical rotations to perform ultrasound and physical examinations on patients. Basic ultrasound skills were assessed by having each student scan the same normal model at the conclusion of the first week and at the conclusion of the project. Clinical cases were presented to a preceptor, and the ultrasound images were graded on a five-point scale. At the end of the first week, the mean grade of ultrasound examinations performed on the control model was 3.2, improving to 4.4 at the end of the project. Grading of ultrasound exams performed during the first clinical week averaged 4.1, improving to 4.5 at the end of the project. An exit survey indicated a favorable response to using ultrasound as an educational tool.     

A standardized patient enrolled in medical school considers the national clinical skills examination.

The National Board of Medical Examiners' recent decision to include a clinical skills examination as part of the licensing requirements for U.S. medical graduates has generated widespread discussion about the role of standardized patients in medical education. The author demonstrates that while specific clinical skills can and should be integrated into the medical school curriculum, any assessment of these skills using interactions with standardized patients must allow for a fuller range of responses and immediate, multifaceted feedback (content, process, and patient satisfaction) than would be allowed in the proposed Step 2 Clinical Skills. The presence of a national examination would pressure medical schools to adopt the very limited model of patient-physician interaction favored by the National Board of Medical Examiners. In addition, the author argues that the cost of registering for the examination and traveling to one of the few test sites on borrowed money is not justified to verify skills that may be reliably assessed locally.     

Reflective writing in the teaching of communication skills for medical students—A systematic review

ObjectiveTo analyse the use, assessment, and measured outcomes of reflective writing (RW) in teaching communication to medical students.MethodsSystematic search of seven electronic databases, focused on using RW in teaching communication skills. Three reviewers selected and prepared the synthesis of the studies. The synthesis was based on thematic analysis using Braun and Clarke’s approach.ResultsWe identified 1325 studies, reviewed 101 full-text articles, and included 12 articles in the analysis. The four themes identified showed that RW is not a stand-alone practice. RW is blended with other teaching strategies. Through RW, students identified structural, emotional, and relational aspects and challenges of communication. Only a few studies found a positive correlation between reflective ability and communication skillsConclusionRW can be integrated with various teaching methods, at all stages of learning, to stimulate discussion of interpersonal and intrapersonal topics. Through RW, students explore theirs and their patient’s emotions, values, behaviours, and needs identifying challenges and practices relevant to communication. Practice implications: RW can address different structural, relational, and emotional issues that are relevant to communication learning. Further educational development and high-quality empirical research on the use of RW and unique outcomes are needed to support communication skills learning.     

Teaching inpatient communication skills to medical students: an innovative strategy.

At the University of Washington, a group of medical educators defined a set of communication skills, or "benchmarks," that are expected of second-year medical students conducting history and physical examinations on hospitalized patients. In order to teach the skills listed in the communication benchmarks, an educational strategy was devised that included training sessions for 30 medical teachers and the development of an innovative videotape tool used to train the teachers and their students. The benchmarks were designed in 2003 for the developmental level of the students and were based on key communication concepts and essential elements of medical communication. A set of five short videotaped scenarios was developed that illustrated various segments of a student history and physical examination. Each scenario consisted of an "OK" version of communication and a "better" version of the same scenario. The video scenarios were used in teaching sessions to help students identify effective communication techniques and to stimulate discussion about the communication benchmarks. After the training sessions, teachers and students were surveyed to assess the effectiveness of the educational methods. The majority of students felt that the educational design stimulated discussion and improved their understanding of communication skills. Faculty found the educational design useful and 95% felt that the curriculum and videotape contributed to their own education. The development of communication benchmarks illustrated with short videotaped scenarios contrasting "OK" with "better" communication skills is a useful technique that is transferable to other institutions.     

Evaluation of computer case simulations for teaching clinical pathology to second-year medical students

A computer-assisted learning program for teaching clinical pathology to second year medical students has been developed and evaluated. These programs are designed to be used as supplements to formal lectures, laboratory exercises, and small group discussions. Students are given case histories and asked to select differential diagnoses, order and interpret laboratory and diagnostic tests, and make final diagnostic conclusions. In some cases, laboratory monitoring of treatment, e.g., drug therapy, is emphasized. The performance of the student is objectively evaluated during each stage. In addition, the amount spent for each workup is recorded with penalties given for excess or inappropriate test ordering. Separate evaluations are performed to assess the effectiveness of these programs as an alternative teaching format to (1) formal lectures and reading assignments, and (2) faculty-directed small group discussions. It is concluded that the computer-assisted learning method is equivalent to lectures and group discussions and is a format that is well accepted by students.     

An investigation of construct validity of humanistic clinical skills on a medical licensure examination

Objective

To test construct validity of humanistic clinical skills measured by a medical licensure performance examination using multitrait-multimethod confirmatory factor analysis.

Methods

Two hundred and twenty-seven third- and fourth-year undergraduate osteopathic medical students in 2007-2008 were randomly sampled. The Global Patient Assessment Tool (GPAT), designed to assess professionalism, interpersonal relationship, and doctor-patient communication was tested under two measurement methods: standard examination ratings and peer performance ratings of the same examinee. Two concurrent validity factors (data gathering and written patient notes) were included.

Results

Convergent validity was supported under the two methods of scoring. Moderate to strong correlations among trait factors indicated weak discriminate validity. Method effects were indicated. The relationship between GPAT and two concurrent validity factors indicate measures of relatively different constructs.

Conclusion

Evidence of construct validity for the GPAT indicate scores should be interpreted as measuring a humanistic clinical skills construct consisting of homogeneous measures of professionalism, interpersonal relationship, and physician-patient communication. Findings are consistent with the interpretation and use of the GPAT as an important part of medical licensure examinations.

Practical implications

The implications to medical licensure standardized-patient examinations are discussed in terms of the GPAT as a valid measure of medical students’ humanistic clinical skills.     

Teaching medical students and residents skills for delivering bad news: a review of strategies.

Although delivering bad news is something that occurs daily in most medical practices, the majority of clinicians have not received formal training in this essential and important communication task. A variety of models are currently being used in medical education to teach skills for delivering bad news. The goals of this article are (1) to describe these available models, including their advantages and disadvantages and evaluations of their effectiveness; and (2) to serve as a guide to medical educators who are initiating or refining curriculum for medical students and residents. Based on a review of the literature and the authors' own experiences, they conclude that curricular efforts to teach these skills should include multiple sessions and opportunities for demonstration, reflection, discussion, practice, and feedback.     

Implementation of the mini-CEX to evaluate medical students' clinical skills.

OBJECTIVE: The majority of medicine clerkships use faculty and resident summative ratings to assess medical students' clinical skills. Still, many medical students complete training without ever being observed performing a clinical skill. The mini-CEX is method of clinical skills assessment developed by the American Board of Internal Medicine for graduate medical education. The brief, focused encounters are feasible and produce scores with adequate reproducibility if enough observations are made.(1) The mini-CEX has been used in the medicine core clerkship, being performed once to augment feedback by faculty evaluators in the inpatient setting.(2) However, additional study is needed to address at least two feasibility issues if the mini-CEX is to be used as a measurement tool: (1) multiple settings (inpatient and outpatient) and (2) resident-completed evaluations. Our objective was to determine the feasibility of having students receive multiple mini-CEX's in both the inpatient and outpatient settings from resident and faculty evaluators. DESCRIPTION: We introduced the mini-CEX into our nine-week medicine clerkship (six weeks inpatient and three weeks outpatient) in July 2001. The clerkship uses four inpatient clinical sites and 16 outpatient practices. Inpatient faculty rotate on two-week blocks and residents on four-week blocks. At our clerkship orientation, each student (n = 39) received a booklet of ten adapted mini-CEX forms. In the mini-CEX, students are observed conducting a focused history and physical examination and then receive immediate feedback. Students are rated in seven competencies (interviewing, physical examination, professionalism, clinical judgment, counseling, organization, and overall clinical competence) using a nine-point rating scale (1 = unsatisfactory and 9 = superior). Our students were instructed to collect nine evaluations: three from faculty (one every two weeks), three from residents (one every two weeks), and three from their out-patient attendings (one per week). Students and evaluators were asked to rate their satisfaction with the exercise using a nine-point scale (1 = low and 9 = high). Students were asked to turn in their booklets the day of the exam. Prior to implementation, we reviewed the mini-CEX forms and rationale for use with residents and inpatient faculty. Similar information was mailed to outpatient faculty preceptors. DISCUSSION: Booklets were received from 32 students. The mean number of evaluations completed per student was 7.3 (range 2-9), for a total of 232 evaluations. Faculty completed 58% of the evaluations; 68% were from the inpatient setting. The observation and feedback took an average of 21 minutes and 8 minutes, respectively. Satisfaction with the exercise was rated by faculty/residents as 7.2 and by students as 6.8. We believe these findings support the feasibility of collecting multiple mini-CEX assessments from both inpatient and outpatient sites using faculty and resident evaluators. The feasibility of collecting multiple assessments is important if the mini-CEX is to be a reproducible assessment of clinical skills. Having established feasibility, we plan to look at the reproducibility and validity of mini-CEX scores in order to determine if it can be used as a formal means of clinical skills assessment. We also plan to evaluate the impact on the quality and specificity of end-of-clerkship summative ratings.     

Isolated rural general practice as the focus for teaching core clinical rotations to pre-registration medical students

Background  

Earlier studies have successfully demonstrated that medical students can achieve success in core clinical rotations with long term attachments in small groups to rural general / family practices.     

German developments in teaching psychosomatics and psychotherapy to medical students.

The necessities for a reform of teaching German medical students were manifold. With the help of those doctors responsible for primary care and by founding a society representing all behavioural scientists within medical teaching it was possible to firmly institutionalize psychosomatics and psychotherapy within the new Medical Approbation Law. It is too early to assess the impact of this drastic reform but some of its advantages are already obvious.     

U.S. and Canadian internal medicine clerkship directors' opinions about teaching procedural and interpretive skills to medical students.

PURPOSE: Although medical students gain experience in performing procedures during their clinical clerkships, which skills they should acquire remains unclear. The authors sought opinions from internal medicine clerkship directors regarding procedural and interpretive skills students should and do learn during clerkships. METHOD: In 2002, the 123 members of the Clerkship Directors in Internal Medicine (CDIM) were confidentially surveyed using a 79-item questionnaire about the appropriateness of 20 procedural skills, demographics, clerkship characteristics, and curricula in procedural skills. Participants had the choice of completing a mailed paper questionnaire or an electronic version on the CDIM's Web site. After univariate analysis, adjusted comparisons among participants were made using linear regression. RESULTS: Surveys were completed by 89 clerkship directors (72%). Most thought that students should be taught 17 of 20 procedural skills. However, the majority thought students do not learn five of these skills. Over 80% of respondents thought students should learn: chest x-ray interpretation, electrocardiogram interpretation, phlebotomy, throat culture, blood culture, urinalysis, Pap smear, central line placement, peripheral blood smear. However, the majority thought students do not learn five of these skills. The mean of skills that should be taught and are learned were 15 (standard deviation [SD] = 3) and 12 (SD = 4), respectively. About half used formal teaching in procedures (44%), used logs (51%) and tested competency (45%). CONCLUSIONS: CDIM members thought medical students should be taught a variety of procedural skills but thought students fail to learn many. These findings may help prioritize which procedures to teach. It may be helpful to develop standardized curricular materials on teaching procedures.     

An interpersonal model for teaching psychiatry to medical students

Many medical students and hospital physicians hold negative images of psychiatry, perhaps because of unnecessarily complex teaching models used at the undergraduate level. The interpersonal teaching model described here allows physical symptoms to be related to interpersonal relationships. This helps the practitioner detect nonpsychotic emotional illness in medical patients. With the aid of a three-question screening test, students learned to recognize emotional illness in medical patients and to arrange psychiatric consultations. Student response to the model has been positive, and students have carried the screening skills with them to other rotations.     

A core syllabus for the teaching of neuroanatomy to medical students

There is increasingly a call for clinical relevance in the teaching of biomedical sciences within all health care courses. However, this presupposes that there is a clear understanding of what can be considered core material within the curricula. To date, the anatomical sciences have been relatively poorly served by the development of core syllabuses, particularly for specialized core syllabuses such as neuroanatomy. One of the aims of the International Federation of Associations of Anatomists (IFAA) and of the European Federation for Experimental Morphology (EFEM) is to formulate, on an international scale, core syllabuses for all branches of the anatomical sciences using Delphi Panels consisting of anatomists, scientists, and clinicians to initially evaluate syllabus content. In this article, the findings of a Delphi Panel for neuroanatomy are provided. These findings will subsequently be published on the IFAA website to enable anatomical (and other cognate learned) societies and individual anatomists, clinicians, and students to freely comment upon, and elaborate and amend, the syllabuses. The aim is to set internationally recognized standards and thus to provide guidelines concerning neuroanatomical knowledge when engaged in course development. Clin. Anat. 28:706–716, 2015. © 2015 Wiley Periodicals, Inc.     

Overcoming barriers to teaching the behavioral and social sciences to medical students.

Most U.S. medical schools offer courses in the behavioral and social sciences (BSS), but their implementation is frequently impeded by problems. First, medical students often fail to perceive the relevance of the BSS for clinical practice. Second, the BSS are vaguely defined and the multiplicity of the topics that they include creates confusion about teaching priorities. Third, there is a lack of qualified teachers, because physicians may have received little or no instruction in the BSS, while behavioral and social scientists lack experience in clinical medicine. The authors propose an approach that may be useful in overcoming these problems and in shaping a BSS curriculum according to the institutional values of various medical schools. This approach originates from insights gathered during their attempts to teach various BSS topics at four Israeli medical schools. They suggest that medical faculties (1) adopt an integrative approach to learning the biomedical, behavioral, and social sciences using Engel's "biopsychosocial model" as a link between the BSS and clinical practice, (2) define a hierarchy of learning objectives and assign the highest priority to acquisition of clinically relevant skills, and (3) develop clinical role models through teacher training programs. This approach emphasizes the clinical relevance of the BSS, defines learning priorities, and promotes cooperation between clinical faculty and behavioral scientists.