Improving Efficiency of Clinical Skills Training: A Randomized Trial

BACKGROUND

The rising number of medical students and the impact this has on students’ learning of clinical skills is a matter of concern. Cooperative learning in pairs, called dyad training, might help address this situation.

OBJECTIVE

The aim of this study was to evaluate the effect of dyad training on students’ patient encounter skills.

DESIGN

Experimental, randomized, observer-blinded trial.

PARTICIPANTS

Forty-nine pre-clerkship medical students without prior clinical experience.

INTERVENTION

All students underwent a 4-h course on how to manage patient encounters. Subsequently, the students were randomized into a dyad practice group (n?=?24) or a single practice group (n?=?25). Both groups practiced for 4 h on four different case scenarios, using simulated patients. Students in the dyad group practiced together and took turns as the active participant, whereas students in the single group practiced alone.

MAIN MEASURE

Performance tests of patient encounter skills were conducted 2 weeks after the training by two blinded raters. Students had no clinical training during those weeks. A questionnaire-based evaluation surveyed students’ confidence in their patient management skills.

KEY RESULTS

The dyad group scored significantly higher on the performance test, mean 40.7 % (SD 6.6), than the single group, mean 36.9 % (SD 5.8), P?=?0.04, effect size 0.61. Inter-rater reliability was 0.69. The dyad group expressed significantly higher confidence in managing future clinical patient encounters than the single group, mean 7.6 (SD 0.9) vs. mean 6.5 (SD 1.1), respectively, P?<?0.001, effect size 1.16.

CONCLUSION

Dyad training of pre-clerkship medical students’ patient encounter skills is effective, efficient, and prompts higher confidence in managing future patient encounters compared to training alone. This training format may help maintain high-quality medical training in the face of an increasing number of students in medical schools.     

Teaching medical students the important connection between communication and clinical reasoning

BACKGROUND: Medical students are rarely taught how to integrate communication and clinical reasoning. Not understanding the relation between these skills may lead students to undervalue the connection between psychosocial and biomedical aspects of patient care. OBJECTIVE: To improve medical students' communication and clinical reasoning and their appreciation of how these skills interrelate in medical practice. DESIGN: In 2003, we conducted a randomized trial of a curricular intervention at Johns Hopkins University School of Medicine. In a 6-week course, participants learned communication and clinical reasoning skills in an integrative fashion using small group exercises with role-play, reflection and feedback through a structured iterative reflective process. PARTICIPANTS: Second-year medical students. MEASUREMENTS: All students interviewed standardized patients who evaluated their communication skills in establishing rapport, data gathering and patient education/counseling on a 5-point scale (1=poor; 5=excellent). We assessed clinical reasoning through the number of correct problems listed and differential diagnoses generated and the Diagnostic Thinking Inventory. Students rated the importance of learning these skills in an integrated fashion. RESULTS: Standardized patients rated curricular students more favorably in establishing rapport (4.1 vs 3.9; P=.05). Curricular participants listed more psychosocial history items on their problem lists (65% of curricular students listing > or =1 item vs 44% of controls; P=.008). Groups did not differ significantly in other communication or clinical reasoning measures. Ninety-five percent of participants rated the integration of these skills as important. CONCLUSIONS: Intervention students performed better in certain communication and clinical reasoning skills. These students recognized the importance of biomedical and psychosocial issues in patient care. Educators may wish to teach the integration of these skills early in medical training.     

AHA心肺复苏培训在医学教学中的应用效果

目的 采用AHA基础生命支持课程培训模式对具有一定医学背景的医学生进行心肺复苏培训,与传统教学方法对比分析该培训方法在医学教学中的应用效果.方法 选取80名具有一定医学背景的医学生,随机分成实验组和对照组,采用问卷调查的形式对研究对象进行培训的态度、知识与技能掌握情况进行测评.结果 实验组学生培训的态度、知识、技能测评...     

Teaching Patient-centered Tobacco Intervention to First-year Medical Students

The University of Wisconsin's Tobacco Intervention Basic Skills curriculum (TIBS) was inaugurated to begin training 147 first-year medical students in skills for promoting health behavior change. Learning activities included lecture, demonstration, reading, quiz, role-play exercises, and standardized patient interviews. After TIBS, the 69 students who provided pre- and postintervention data exhibited more therapeutic attitudes and increased knowledge and self-confidence in applying TIBS skills. Two months later, 52% of the 109 posttest respondents had applied TIBS in clinical settings, often for behaviors other than tobacco use. We conclude that medical students can gain from early training on promoting behavior change.     

The Impact of Role Models on Medical Students

OBJECTIVE: To explore the relationship between exposure to clinical role models during medical school and the students' choice of clinical field for residency training, and to estimate the strength of this association. DESIGN: Cross-section study. SETTING: McGill University School of Medicine, Montreal, Canada. PARTICIPANTS: Of the 146 graduating medical students in the class of 1995, 136 participated. MEASUREMENTS AND MAIN RESULTS: Clinical field chosen by students for residency training and the students' assessment of their exposure to and interaction with physician role models were the main measurements. Ninety percent of graduating students had identified a role model or models during medical school. Personality, clinical skills and competence, and teaching ability were most important in the selection of a role model, while research achievements and academic position were least important. Odds ratios between interacting with "sufficient" role models in a given clinical field and choosing that same clinical field for residency were 12.8 for pediatrics, 5.1 for family medicine, 4.7 for internal medicine, and 3.6 for surgery. Most students (63%) received career counseling and advice from their role models. CONCLUSIONS: Exposure to role models in a particular clinical field is strongly associated with medical students' choice of clinical field for residency training. Knowing which characteristics students look for in their role models should help identify the physicians who may be most influential in medical students' career choice.     

I view with alarm (the fall of 1999)

This article emphasizes that medical schools only introduce students to the skills, including cognitive skills, that are needed to solve and manage medical problems. These skills, including cognitive skills, should be perfected during house staff training. The teaching-attending physician is in the key position to be a true teacher. Without the help of excellent teaching-attendings, trainees may not develop proficiency in the skills, including cognitive skills, needed for the practice of medicine.     

The Educational Impact of a Rheumatology Elective

We used a newly developed evaluation strategy to compare the performance of 12 medical residents who received ambulatory care rheumatology training and 12 who received inpatient consultative training. There was no significant difference in the cognitive test scores or the patient examination skills of the 2 groups. The ambulatory care residents saw more patients with common rheumatic diseases and performed more joint aspirations and injections. Both groups performed significantly better in all education impact measurements than did a control group of medical residents who received no formal rheumatology elective training. The control group of residents performed no better than did fourth-year medical students who also had no formal rheumatology elective training. The study demonstrated that formal rheumatology training is essential if medical residents are to achieve adequate skills in rheumatology. This training can be provided through ambulatory care or inpatient-oriented electives.     

Medical students and measuring blood pressure: Results from the American Medical Association Blood Pressure Check Challenge

Blood pressure (BP) measurement is the most common procedure performed in clinical practice. Accurate BP measurement is critical if patient care is to be delivered with the highest quality, as stressed in published guidelines. Physician training in BP measurement is often limited to a brief demonstration during medical school without retraining in residency, fellowship, or clinical practice to maintain skills. One hundred fifty‐nine students from medical schools in 37 states attending the American Medical Association's House of Delegates Meeting in June 2015 were assessed on an 11‐element skillset on BP measurement. Only one student demonstrated proficiency on all 11 skills. The mean number of elements performed properly was 4.1. The findings suggest that changes in medical school curriculum emphasizing BP measurement are needed for medical students to become, and remain, proficient in BP measurement. Measuring BP correctly should be taught and reinforced throughout medical school, residency, and the entire career of clinicians.     

The use of patient partners with back pain to teach undergraduate medical students

OBJECTIVES: To assess the impact of teaching about back pain to medical students using trained patient partners (PP). METHODS: An initial training programme for four PPs (two with sciatica and two with ankylosing spondylitis) followed by teaching to alternate groups of medical students at the Whittington Campus of the Royal Free and University College Medical School (RFUCMS). A control group of students did not receive the PP teaching. All students received standard Whittington Campus rheumatology teaching. Performance in an end of year objective structured clinical examination (OSCE) was compared between the two groups. Student and PP perceptions of the teaching and training were evaluated using focus groups and questionnaires. RESULTS: Students receiving the PP teaching performed significantly better in a summative OSCE, but no difference was seen in analysis of a single station assessing history-taking skills in a patient with back pain. Students felt that the PP teaching improved their ability to elicit information from a patient during the consultation. PPs enjoyed the experience of teaching and felt empowered to self-manage their medical conditions, and were better able to seek medical advice when needed. CONCLUSIONS: Using PPs with back pain to teach medical students has a positive effect on student learning and patient well-being. The feasibility of delivering this programme will depend on faculty resources. The effects on examination performance are small but significant.     

Bedside case presentations

STUDY OBJECTIVE: To determine current attitudes of patients, medical students, housestaff, and clinical faculty toward bedside case presentations. DESIGN: Survey using multiple-choice questionnaire and open comments for students, housestaff, and faculty, and a structured interview of patients. SETTING: Major teaching hospitals on the campus of a midwestern medical school, staffed by full-time faculty. PARTICIPANTS: 136 medical students, 58 housestaff, 66 faculty, and 73 patients. MEASUREMENTS AND MAIN RESULTS: 85% of patients liked the case presentation discussion at the bedside, but 95% of both students and housestaff felt more comfortable with such discussion away from the patient. Attending faculty were about evenly divided in preference, with the younger staff preferring the conference room setting. Most patients (88%) opposed rounds in the hallway. Duration of rounds of one to two hours was felt desirable by most, but 50% of students preferred a duration of less than one hour. For length of new patient case presentation, 60% of learners again favored brevity, less than 5 minutes. CONCLUSIONS: Bedside rounds are an opportunity to sharpen diagnostic skills and to demonstrate the art of medicine. They are undervalued by learners and younger faculty but appreciated by patients. The authors recommend that faculty improve bedside rounds by assessing team members' educational needs, by cultivating sensitivity and respect for the needs of all parties, and by assuring pertinence and brevity of bedside discussion.     

Assessing core clinical competencies required of medical graduates in Taiwan

Medical students are assumed to be competent to provide basic patient care independently on graduation. However, there is a gap between what students are expected to learn and what they have actually learned. This may be due to the lack of clearly defined learning objectives, well-organized curriculum, and properly administered assessment. In an attempt to tackle this problem, we conducted a three-step study. Firstly, we identified the core clinical competencies required of medical graduates in Taiwan. Secondly, we incorporated these clinical competencies into a new medical curriculum. Finally, we identified the most appropriate assessment methods for each clinical competency. In 2004, a set of minimally required clinical competencies for medical undergraduates in Taiwan was developed, which included 92 clinical skills, four communication skills, and seven kinds of attitudes. In order to prepare 3rd and 4th year medical students at Kaohsiung Medical University (KMU) for later clinical work, the medical curriculum committee integrated the teaching and assessment of the core clinical skills identified previously into relevant organ-system blocks of the new curriculum. To identify appropriate assessment methods for each clinical skill, a structured questionnaire of assessment methods based on the Toolbox of Assessment Methods (Accreditation Council for Graduate Medical Education) and The Scottish Doctor (Scottish Deans' Medical Curriculum Group) was developed and distributed to 40 senior clinical faculty members at KMU. Simulations and Models, Standardized Patient Examination (SP), and Objective Structured Clinical Examination (OSCE) were suggested to be most suitable to assess two-thirds of the core clinical skills. These assessment methods are commonly used in American and European medical schools. We believe that the implementation of the new curriculum at KMU accompanied by the use of Simulations and Models, SP, OSCE, and other teaching and assessment methods will help 3rd and 4th year students to prepare better for clinical practice in clerkships.     

Training internists: insights from private practice

University internal medicine training programs concentrate on the traditional curriculum designed to produce well-trained academicians and researchers. Increasingly internists are involved in primary patient care with over two-thirds being office based practitioners. Residency training at these institutions must make available to all residents the opportunity to learn the skills taught by primary care programs. Clinical problem solving, skills in patient-physician negotiations and patient comfort, psychiatric techniques, medical ethics, cost effectiveness analysis, and practice management are areas in which the private practitioner frequently needs help. Feedback from training program graduates in private practice could help identify such deficiencies which could be incorporated into the teaching responsibility of a division of general internal medicine.     

仿真外科训练系统在微创外科的应用

目的 通过比较计算机模拟仿真训练和传统训练模型的训练效果，对模拟仿真训练的有效性和可行性进行评价。方法 17名低年外科医生和24名医学生被随机分成4组，分别受到计算机模拟仿真训练或传统训练模型的训练1h。在接受训练后，他们将在传统训练模型中接受连续缝合测试30min，根据完成缝合的数量和准确性来评价被测试者的能力。结果 无论接受何种训练，低年外科医生的测试结果都优于医学生，尤其在缝合速度方面，无论低年外科医生还是医学生，接受计算机模拟仿真训练的测试结果优于传统训练。结论 计算机模拟仿真训练将可能在腹腔镜外科训练中发挥重要作用。     

Training generalist physicians

To train more generalist physicians, structural changes must be made along the continuum of medical education. Future generalists require in-depth exposure to primary care practice, with substantive experience in the longitudinal management of patient panels and the opportunity to work with successful generalist role models. Clinical training and course work must incorporate a wide range of skills and disciplines, including areas now under-emphasized, such as epidemiology, health services, and psychosocial medicine. Recommendations for structural changes to increase the generalist focus of medical education include: 1) the development within institutions of central authorities, involving departments of internal medicine, family medicine, and pediatrics, in joint efforts to foster all aspects of generalist training, including recruitment, curriculum development, community linkages, innovative approaches to training, and recognition and support for successful generalist teachers; 2) commitment of a minimum of 50% of clinical training to ambulatory care settings at both medical school and residency levels; 3) required longitudinal care experiences for all medical students and a 20% or greater time commitment to longitudinal care for internal medicine, pediatrics, and family medicine residents; and 4) increased numbers of generalist faculty and enhanced teaching skills among faculty in the outpatient environment, to guarantee increased exposure of medical students and residents to generalist role models.     

Teaching patient-centered tobacco intervention to first-year medical students

The University of Wisconsin’s Tobacco Intervention Basic Skills curriculum (TIBS) was inaugurated to begin training 147 first-year medical students in skills for promoting health behavior change. Learning activities included lecture, demonstration, reading, quiz, role-play exercises, and standardized patient interviews. After TIBS, the 69 students who provided pre- and postintervention data exhibited more therapeutic attitudes and increased knowledge and self-confidence in applying TIBS skills. Two months later, 52% of the 109 posttest respondents had applied TIBS in clinical settings, often for behaviors other than tobacco use. We conclude that medical students can gain from early training on promoting behavior change. Many colleagues assisted with this project. Douglas Jorenby, PhD, Pat Kokotailo, MD, Doug Smith, MD, and Laura Zakowski, MD, made many helpful suggestions on the curriculum. Marijka Hambrecht created web pages. Jane Banning, MS, trained the standardized patients. Penny Anderson, June Daws, Michelle Grosch, Mark Johanneck, and Elizabeth Tuschen assisted with administrative arrangements. Marlon Mundt, MA, assisted with statistical analysis. This project was supported by grant 1D16HP00067-01 from the U.S. Health Resources and Services Administration.     

Erosion in medical students’ attitudes about telling patients they are students

OBJECTIVE: To study the attitudes of preclinical and clinical medical students toward the importance of telling patients they are students, and to compare their attitudes with those of patients. METHODS: We conducted a cross-sectional survey of medical students from five Philadelphia medical schools, and a longitudinal follow-up in one medical school, to assess the importance students place on telling patients they are medical students before interacting with them. We asked similar questions of 100 general medical outpatients from two academically affiliated hospitals. MAIN RESULTS: In total, 2,603 students (58%) responded to the cross-sectional survey, 74 (50%) responded to the longitudinal survey, and 100 patients responded to our interview survey (94% response rate). In the cross-sectional survey, there were negligible differences in the importance that patients and medical students placed on informing alert patients that they are interacting with students in nonsurgical settings. In surgical settings involving anesthetized patients, patients placed significantly more importance on being informed of students' roles in their surgery than did students, and preclinical students placed more importance on this than did clinical students. Results from the cross-sectional survey were supported by the longitudinal survey, in which fourth-year medical students placed significantly less importance on informing patients of their student status than the same cohort had done 2 years previously. CONCLUSIONS: Medical students place less importance on informing patients about their student status than patients desire, especially in surgical settings in which the patient is to be anesthetized. Medical students already having completed a clinical rotation stray further from patient ideals than preclinical medical students. These findings suggest that, as medical students advance in their training, they suffer an erosion in their attitudes about telling patients they are students.     

Simulation to enhance patient safety: why aren't we there yet?

The delivery of state-of-the-art medical care is complex, with large numbers of treatment strategies often available to individual patients. It is paramount to ensure that each patient receives optimal treatment in a safe, effective, and timely manner. Evidence suggests that an unacceptably high number of patients currently experience suboptimal care as the result of adverse events and medical error. Simulation-based training reduces medical error, enhances clinical outcomes, and reduces the cost of clinical care. It is surprising that medical simulation is not routinely integrated into the training curricula of all health-care professionals. Simulation enables doctors to practice and hone their technical, communication, decision making, and crisis management skills in a safe and educationally orientated environment. The process can foster the development of interprofessional working skills, leading to enhanced patient outcomes. Selection, credentialing, and revalidation of medical professionals are also possible in a simulation setting, enabling maintenance of standards of practice throughout a medical career. In order for simulation to become a part of the medical curriculum, collaborative efforts are required from academics, physicians, managers, and policy makers alike. Bringing these groups together, while a challenge, can lead to high-level outputs in medical care, which will benefit all.     

Local medical students can be instructors for life-saving first-aid courses for lay people: a descriptive study from Gaza

BackgroundBystanders can initiate a chain of survival in emergency situations by recognising the situation, calling for help, and initiating basic life support (BLS) and first aid. The lay population of Gaza has had little if any access to systematic BLS and CPR training. This study aimed to find out whether medical students could act as instructors to train 3000 lay people in BLS and CPR.MethodsWe selected 82 medical students from Al Azhar University to train as BLS and CPR instructors. Student volunteers who were in their third, fifth, and sixth year of medical school were chosen based on sex (to achieve equal numbers of males and females) and geography (for approximately even geographical distribution). Their training included 12 hours of BLS and CPR skills and 4 hours of didactic instruction, with a view to delivering 1–2 hours of basic training for lay people. Students responded to a written questionnaire with details of their demographics, training experience, motivation, and expectations. Teaching materials and methods were based on the European Resuscitation Council guidelines and followed a similar training model as that at The Arctic University of Norway (UiT). The board of the Faculty of Medicine at Al Azhar University approved the training and the study.Findings82 medical students completed training (mean age 21·7 years [SD 1·25]; 54% [44 of 82] female, 46% [38 of 82] male). Following training, 87% of students (71 of 82) responded to the questionnaire and 76% (62 of 82) took part in training lay people. Of those who completed the questionnaire, five reported having lost family members during Israeli military operations in Gaza (the questionnaire section on demographics included the impact of warfare on the students' lives). Almost two-thirds (54 of 71) had no previous practical first aid training. 49 of 71 (69%) described a sense of belonging and duty to the community as their most important motivation, and 56 of 71 (79%) hoped that their training would contribute to increased capacity and skills in the community's response to emergencies, especially during attacks. 55 training sessions have been completed so far, involving 1222 lay participants, mostly school students (including students at vocational schools) aged 13–20 years (75%; 922 of 1222). 62 student instructors have been active, with a ratio of 5·4 lay trainees to each student instructor. Of the trainees, 45% were male (546 of 1222) and 55 % female (676 of 1222).InterpretationWe have shown that local medical students are willing and capable of being trained as volunteer instructors to teach BLS and CPR, targeting lay people in serious conditions. The effects of such training on local resilience and patient outcomes need further study.FundingThe Palestine Children Relief (PCRF) funded the travel expenses of the trainers and provided medical students with first aid kits.