AAMC Project on the Clinical Education of Medical Students

1. AAMC Project on the Clinical Education of Medical Students Education Policy Committee 12/01/2005

2. Background • Five reports (3 AAMC, 1 AMA, 1 Macy Foundation) from the 80’s and 90’s commented on a need to improve the clinical skills education of medical students. • Two reports based on Petersdorf scholarships (Nutter and Whitcomb, 2001; Corbett, 2004) catalyzed national efforts to improve clinical education in medical school. • AAMC formed a Task Force on Clinical Skills Teaching in response to Corbett’s work in 2002-2003.

3. Background • Corbett EC and Whitcomb M: The AAMC Project on the Clinical Education of Medical Students. Clinical Skills Education. Washington , DC: AAMC, 2004.

4. The Problem • Clinical skills education in medical school is largely unstructured and unspecified. • Clinical skills education is not conducted with the same rigor as is clinical knowledge education. • Medical students are increasingly marginalized in the clinical environment where skills must be acquired. • A fourth year spent in electives does little to enhance basic clinical skills.

5. The Response Thus Far • Medical educators are developing alternative methods to impart clinical skills (standardized patients, computer simulations, body models). • Explicit and detailed clinical skills curricula are being developed (largely in Europe). • Licensure and certification bodies are incorporating evaluation of clinical skills into their exams.

6. Project Objectives • To document the status of clinical skills education in US medical schools. • To identify model approaches for teaching clinical skills. • To develop principles to guide the design of an ideal clinical skills curriculum. • To make recommendations for improving under-graduate clinical skills education.

7. Secondary Objectives • Dissemination of information on the state of clinical skills education. • Promote a national dialogue about evaluating and improving clinical skills education. • Assist individual schools in efforts to improve clinical skills education. • Promote a national dialogue on the integration of clinical skills curricula across the continuum of undergraduate and graduate med ed.

8. Project Activities • 1. Literature and database review (LCME surveys, AAMC Graduate Questionnaire, CurrMIT). • 2. Review of historical reports of clinical skills ed. • 3. Email survey of US and Canadian curricular deans. • 4. Site visits to six US and 4 European medical schools. • 5. Attendance at national and international med ed meetings. • 6. Development of consensus regarding CSE with national clerkship organizations

9. Observations • Status of Clinical Skills Education • There are no curricular standards for CSE. • There is tremendous variability in CSE. • Few schools approach CSE as a four-year continuum. • Only a few schools have explicit CSE standards, and those that do have variable standards.

10. Observations • Status of Clinical Skills Education • Most schools provide some formal CSE in Y1 and Y2, but vary hugely in how CSE is accomplished and assessed, and who participates. • Schools assume that students acquire clinical skills during clerkships, but do not assess this. • No explicit clinical skills developmental process bridges the continuum of undergraduate and graduate med ed.

11. Observations • Clinical Skills Assessment • Few schools have an organized approach for assessing CS in a developmental manner. • Most assess CS at some time, but do not systematically relate the assessment to objectives. • Standardized patient programs are used by 67 schools. • Paper exams are used to assess skills by 20%. • Only 25 schools use direct faculty observation in the assessment of CS.

12. Observations • Clinical Skills Assessment • About 50% of clerkships use standardized patients or OCSEs for student evaluation. • Students and schools vary in reports of faculty involvement in CS assessment!!! • Schools with established skills programs do assess often, with a higher proportion of faculty and peer assessment.

13. Observations • Clinical Skills Centers • 34 schools had a clinical skills center in place. • 9 indicated that establishment was in process. • US centers focus on H&P skills. • European centers also assess clinical testing and procedural skills. • Centers vary widely in their methods for teaching and assessment, and in the frequency of encounters.

14. Observations • Clinical Skills Centers • Some centers continuously coordinate CSE within curriculum (central planning). • Some centers act as a resource for departmental assessment activities (States’ rights). • Feedback is variable, often not by faculty, and generally summative, rather than formative. • Clinical faculty participation is extremely variable, and often limited to a few true believers.

15. Observations • Clinical Skills Centers • Few centers have a customized remediation program to address individual student needs. • Most participation occurs in Years 1 & 2. • Most centers have a medical director. • Few centers allow self-directed education by students. • Almost no centers serve as resources for faculty development. • Programs evaluate themselves, but their performance databases are opaque.

16. Summary • CSE in US schools is largely an implicit process, with wide variability in emphasis and methods. • There is no national consensus on what comprises basic CSE. • Formal attention to skills development is under-standardized, or even substandard. • Emphasis on CSE has been diminishing over recent decades.

17. Summary • Essential elements for effective CSE are: • - a skilled and willing teacher • - a prepared and motivated student • - an informed and willing patient • - time for repeated skills practice with several patients • - an attitude of shared professional responsibility toward the patient by teacher and student • - time and opportunity for effective feedback

18. The Gritty Nub • There must be a thorough delineation of the CS that need to be taught, and of how and when CS should be learned, as students progress through the curriculum. • Policies and procedures that support and reward participating clinical faculty are mandatory. • Identification of a core group of committed, competent, responsible clinical faculty is essential. • A national dialogue, and consensus, would be extremely helpful to resolution of deficiencies in CSE.