Goldstein, Erika A. MD, MPH; MacLaren, Carol F. PhD; Smith, Sherilyn MD; Mengert, Terry J. MD; Maestas, Ramoncita R. MD; Foy, Hugh M. MD; Wenrich, Marjorie D. MPH; Ramsey, Paul G. MD
In this article, we describe the recent formation and operation of a curriculum at our school that emphasizes bedside teaching and role modeling and focuses on enhancing fundamental clinical skills and professionalism.
Substantial evidence suggests that U.S. medical schools devote inadequate attention to teaching fundamental clinical skills.1–17 Existing studies have not assessed whether inadequate education at one level of training affects skills at subsequent levels. If there is such a “cascade” effect, then medical school may be the most critical period for developing important habits, attitudes, and clinical reasoning approaches to medicine and may influence subsequent clinical competence among practicing physicians. Studies of physicians in practice show discrepancies between what they say is important among basic clinical skills, such as physical examination and history taking, and their training in these areas,18–20 and some studies document skill deficiencies among board-certified physicians in practice.21
Calls for reform in medical education have occurred frequently and regularly since the 1910 Flexner Report22–29 but have not focused directly on improving fundamental clinical skills. Diverse concerns cited have included declining time for and attention to teaching medical students, the effects on medical education of the changing nature of medicine, and inadequate attention to contemporary issues like managed care.30–33 Concomitant with calls for reform, medical educators have sought over the past 15 years to modify and improve curricular and teaching approaches.32,34–39 Often, however, these attempts to improve the curriculum relate to specific issues relevant to the contemporary health care environment, such as incorporating understanding about managed care, rather than focusing on fundamental clinical skills.
Inadequate attention to teaching students fundamental clinical skills may relate directly to the failure of clinical faculty to focus their efforts on bedside teaching.2 Although bedside teaching has been a mainstay of medical education since Osler, it has declined substantially in recent years.40–44 Perceived factors contributing to the decline in bedside teaching are teacher related (such as declining bedside teaching skills), teaching-climate related (such as time constraints and lack of rewards for teaching), system related (such as short patient stays), and patient related (such as perceived patient discomfort being discussed by a large team).44
As a result of the decline in bedside teaching and expansion in the size of many medical schools, students have less exposure to real patients, observe their teachers’ modeling skills less frequently, and are themselves observed less frequently. In a recent survey associated with field trials for the United States Medical Licensing Examination (USMLE) clinical skills examination, 4% of students said they had never taken a history or conducted a physical examination under the observation of a faculty member, and 20% said they had been directly observed only two or fewer times.45
Addressing the Problem: The College System
To ensure that its curriculum is up-to-date, the University of Washington (UW) School of Medicine undertook a comprehensive curriculum review from 1998 to 2001. Several areas were identified for improvement that mirror areas identified nationally as problematic. First- and second-year students needed better introductory development in fundamental skill areas, including patient-interviewing skills, physical examination skills, and clinical problem solving, as well as in areas related to professional development, such as ethics and professionalism. In the third and fourth years, the need for more consistent and centralized attention to educational content and further refinement of clinical skills was identified as well as the need for better patient mix, teaching materials, and evaluation. An area for improvement at all levels of training was the need to personalize the medical school experience for students in the setting of a large, regionally decentralized medical school.
The curriculum review pinpointed five areas of focus for further attention to address these deficiencies—enhancing skills development, engaging the student, improving curriculum management and oversight, addressing specific content areas, and enhancing faculty development and teaching skills. The first two areas, engaging the student and enhancing skills development, were key to the development of a new organizational and curricular structure.
This new structure, called the College system, was the primary innovation that emerged from the curriculum review. The foundation of the Colleges is a core of 30 clinical teachers who commit a substantial portion of their time to teach and mentor medical students, as well as develop and assess the curriculum. The fundamental tools of the Colleges are the development and use of explicit benchmarks concerning core clinical skills. The new structure addresses the problems identified at our own school and also addresses many of the structural and curricular problems identified nationally. The College approach to teaching and evaluating clinical skills that we describe here represents a major change for U.S. medical schools, many of which have grown dramatically in size over the last 50 years46 and have lost a clear focus on fundamental skills.
Regional medical school structure.
The UW School of Medicine provides medical education for students from five states (Washington, Wyoming, Alaska, Montana, and Idaho).47 In this “WWAMI” program, students are accepted as “in-state students” from each member state, and for the first year of medical school, medical education is offered at the home universities of each of these states, in close collaboration with faculty based in Seattle. All medical students (approximately 180 per class) spend their second year in Seattle. For the third and fourth years, all students, independent of their states of origin, can spend all or a portion of their education at clinical clerkship sites throughout the region in addition to the Seattle-based clerkship locations.
Goals of the Colleges.
The fundamental goals of the Colleges are to oversee a four-year integrated curriculum of clinical skills and professionalism and to provide better mentoring for students. Five clinical competency domains are delineated for continuous attention at increasingly advanced levels, with developmental benchmarks for each level of training: communication skills (including patient interviewing skills), diagnostic and physical examination skills, clinical reasoning skills and interpretation skills (including written and oral communication), professionalism and ethics, and biomedical informatics skills.
Central to the model is a one-on-one relationship between each medical student and a College faculty mentor. This relationship continues across the student’s tenure in medical school, and involves a combination of teaching, mentoring, and monitoring of the student’s progress. In addition to the one-on-one relationship, each student works within a small-group setting with his or her mentor, and has an identity within his or her College as well (Figure 1). Finally, each student functions in relationship to his or her entire medical school class; one of the goals of individual mentorship is to guide the student to take advantage of the skills and expertise of the school’s very large number of clinical and research-oriented faculty.
Integration of the mentor and teacher role is a key aspect of the model. The College faculty have four closely interrelated functions:
* They create continuity for the students throughout their medical school tenure, overseeing clinical skills and professional development and paying close attention to building upon skills the students have learned in prior stages of development.
* They are actively involved in developing curricula for and teaching the students they mentor in the second year of a two-year Introduction to Clinical Medicine course.
* They are responsible for defining benchmarks for the progressive expansion and refinement of basic skills in the first two years and working in concert with the clerkship faculty to develop benchmarks for the clinical years.
* They provide a continuous personal faculty contact for students.
The following assumptions underlie the educational approach used in the Colleges:
* Students will learn best when new knowledge and skills are built onto the foundation of what they have already learned.
* An integrated curriculum of clinical skills and professionalism—with explicitly stated, iterative, progressive, and consistently monitored expectations throughout the four years—will most effectively support learning and skills development and provide students with a structure for lifelong learning.
* Assessment should be consistently formative and reflective in nature as well as summative.
Because new knowledge builds on existing core knowledge, both learning and evaluation are placed in the context of a progressive and iterative structure in which reference is constantly made back to prior principles and core knowledge.48,49 A close relationship between learning and assessment enhances students’ acquisition of fundamental clinical skills, especially when performance evaluations are tied closely to desired knowledge, skills, and behaviors.
During the process of curriculum development, the College faculty adapted the Sequenced Performance Inventory and Reflective Assessment of Learning (SPIRAL) framework for use in thinking about student development and in approaching expectations for student performance.50,51 This framework focuses on developmentally appropriate standards to assess, interpret, and provide feedback on students’ performance, based on the normal progression of students’ development from beginning to advanced skill levels.50 Areas evaluated are interviewing (data collection and communication techniques), physical examination, oral case presentation, clinical reasoning, documentation, educational conduct, ethics, and standards of professional behavior. Table 1 shows the four performance levels adapted for our setting and three of the evaluation areas and criteria used for giving feedback to second-year students in their clinical tutorials. Performance standards and expectations have been developed for each year. However, there is fluidity across levels and years, anticipating that most students will progress at an average rate but that some will progress faster and others more slowly. Within the competency-based curriculum, students know what is expected of them at each developmental stage, and understand how they are accountable.
Implementation: Structure of the Colleges
A College director (EAG), appointed by the dean (PGR), devotes 75% of her time to the position and also serves as a College head. The associate dean for student affairs (CAM) is the administrative head of the Colleges. The dean, the associate dean for student affairs, and the College director were directly involved in recruiting and appointing the remaining four College heads (SS, TJM, RRM, HMF). Selection criteria included excellent teaching skills, commitment to education, and willingness to dedicate 50% of their time. A balance was sought among College heads for specialty, gender, and stage of career. Funding is provided by the dean’s office.
The College heads jointly recruited and selected the remaining 25 College faculty. Prerequisites were demonstrated excellence in teaching and clinical skills, a genuine interest in students, a commitment to patient-centered care, and a willingness to actively participate in continuous development and evaluation of the curriculum. Of over 80 clinical faculty who applied, 25 were selected as representatives of the best clinician–teachers at the medical school. Each commits 25% of his or her time to clinical skills teaching and mentoring, with salary funding for that time from the dean’s office.
The 30 permanent faculty have five-year appointments. Distribution of clinical departments among the College faculty are family medicine (seven faculty), internal medicine, including emergency medicine and dermatology (ten faculty), pediatrics (five faculty), surgery (two faculty), and one faculty member each from anesthesiology, neurology, obstetrics and gynecology, otolaryngology, rehabilitation medicine, and psychiatry. The gender split is 16 women and 14 men.
Three UW teaching hospitals in Seattle were selected to serve as the primary sites for teaching: the UW Medical Center, Harborview Medical Center, and Puget Sound VA Health Care System-Seattle. At each of these hospitals, at which students and mentors see patients (rotating quarterly), rooms were identified for teaching sessions; a patient interview coordinator was hired to identify, approach, and obtain permission from patients for teaching; and a process was developed for credentialing College faculty. In addition, a pediatric tutorial was added that offers the students experiences with children and familiarity with the Children’s Hospital & Regional Medical Center in Seattle.
Assignment, communication, and involvement with students.
Each entering student is assigned to one of five Colleges and a faculty mentor within that College. Students from all medical school classes are represented in each College. The College system was fully implemented across all medical school classes in 2004–2005. Each faculty mentor now advises and counsels 24–30 students—typically six in each class—who are followed across their medical school tenure.
To provide structure and substance to the mentoring relationship, students maintain a Web-based learning portfolio,52–54 which measures students’ progress against learning objectives and developmental benchmarks in the five competency domains.
The role of the College faculty and the nature and intensity of interactions between College faculty and students vary over each student’s tenure in medical school; they are briefly described below.
* Year one: Students and their mentors initiate a dialogue and planning through meetings or, for students at the regional WWAMI universities, via telephone and videoconferencing. The goals are to become acquainted, review the clinical skills and professionalism curriculum for the first year—including developmental benchmarks—and discuss students’ learning goals for the year. Peer counseling meetings of paired College faculty and their students from all years occur once each quarter.
* Year two: The College mentor serves as the Introduction to Clinical Medicine II (ICM II) teacher for his or her group of six second-year students. In addition to the ICM-II lectures and small-group exercises on a variety of topics that took place prior to the College structure, all second-year students now also spend one-half day each week with their faculty mentor and small group, seeing patients at the bedside and learning and practicing clinical skills. This component of the curriculum replaces a previous clinical tutorial system in which each student saw one patient every four to six weeks, one-on-one, with a member of a widely dispersed faculty of community and hospital-based physicians.During one tutorial per month, students learn history-taking and physical examination techniques linked to the organ system they are studying in the classroom, thus providing a clinical link to the basic sciences. For the remaining three tutorials each month, two of the six students in each group perform a complete history and physical examination on a patient. During the history and physical, the mentor either alternates between the two patient rooms, observing the students and providing feedback, or else observes a complete history and physical examination by a single student. The responsible students then present the patient’s history and physical at the bedside to the other members of their tutorial group and mentor. The mentor and students then debrief and discuss the case as a group. The mentor gives feedback to the individual student and instruction to the entire group, with opportunities for all students to review physical examination findings on the patient. Discussions also focus on the patient’s experience, recommendations, and perceptions concerning communication and professionalism. Presenting students submit write-ups, and mentors provide written comments. A strong emphasis in these tutorials is on practicing, enhancing, and refining basic skills while maintaining a constant focus on the patient at the center of the clinical experience. All students are observed for part or all of a history and physical examination at least six times during second year.Throughout the year, students have a minimum of 26 half-day sessions with their mentor and small group (ten in fall, eight in winter, and eight in spring), where they learn history and physical examination skills or work together in small groups. Some mentors also schedule additional sessions with their group or with individual students. This compares to an average of six or seven clinical sessions total in previous years that varied in duration from 15 minutes to three hours, depending on the individual preceptor. Students now also have special-topic tutorials with their College tutorial group throughout the year as well, such as pediatrics, geriatrics, and psychiatry tutorials.College mentors regularly review the students’ portfolios, including write-ups from patient presentations, written reflections, and learning goals. The College mentors meet individually with students to review second-year goals and developmental benchmarks, develop and discuss the student’s learning goals, and review and discuss other work and overall academic progress. The time commitment for counseling and mentoring students varies throughout the year and student-to-student. The combination of weekly small-group teaching sessions at the bedside and individual meetings creates a close working relationship and provides insights into each student’s strengths, weaknesses, goals, and approaches to learning objectives as student and mentor prepare for the clinical years.
* Clinical years: All students complete some clinical rotations in Seattle and are accessible to their College mentors. When completing clerkships out of the Seattle area, each student interacts with his or her College mentor via telephone and e-mail. The learning portfolios, available electronically to both students and mentors, also provide a means of continuous contact.During year three, each student and his or her mentor review overall goals and developmental benchmarks for clinical skills and professionalism and individualize learning objectives for the third year based on their shared assessment of the student’s strengths, weaknesses, and learning needs. This may include working with his or her mentor at the beginning of each required clerkship to review benchmarks and adjust learning objectives as needed, meeting or talking with his or her mentor to review progress against benchmarks, confirming and discussing completion of a required mini-clinical evaluation exercise (mini-CEX) focused on a key skill area for that clerkship,55–57 and discussing the student’s clerkship experience. At the end of the clerkship, student–mentor teams may again review achievement of learning goals, plan for the next clerkship, and revise learning goals as needed. The mentor also works with students in peer counseling sessions and in evaluating students’ progress in other aspects of the curriculum. The frequency and amount of time that students and faculty devote to reviewing and revising learning goals vary considerably mentor-to-mentor and student-to-student. In order to facilitate these interactions, an electronic reminder system has been developed for faculty mentors that addresses and reviews important milestones within the third and fourth years. College faculty regularly receive these e-mails as a prompt to contact their students and as a reminder of important areas and topics to cover.Each required clerkship has a faculty liaison from the Colleges who is a member of that department and specialty. The faculty liaison works with the clerkship director and other faculty in that department in identifying and developing third-year benchmarks, curricula, and appropriate topics of professionalism and specific areas of clinical skills to address in the clerkship.During the fourth year, students continue to meet or talk with their College mentors during rotations to review goals and benchmarks for clinical skills and professionalism, and to review and adjust their learning goals as needed. Mentors also help students finalize career plans, review progress in residency applications and other areas, and work with students in peer counseling sessions along with students from years one through three.
College faculty activities.
The College heads meet biweekly, and each College head and faculty within their College meet monthly, in addition to monthly meetings of the entire College faculty. The College faculty develop educational materials for the first- and second-year ICM curricula and formal skills assessments, and assist in the development of curricula focused on advancing clinical skills through third- and fourth-year clerkships. The College faculty hold regular faculty development sessions to review history-taking and physical examination skills unique to the organ systems taught in ICM II.
Involvement of College faculty in curriculum development.
Each College faculty member belongs to one or more working groups. Areas of responsibility for these groups include (1) Web-based learning portfolios; (2) professionalism and ethics; (3) benchmark and curriculum development in several areas, such as physical examination, communication skills, and clinical reasoning; (4) mentoring; (5) student feedback and evaluation; and (6) program evaluation. These working groups assume chief responsibility for setting direction, developing materials, and presenting their work for evaluation and discussion by all College faculty.
The College faculty work on curriculum development continuously, using a competency-based model and developmental standards. Development of benchmarks in each of the competency domains emanates from working directly with students in the educational setting, and from collaborating with colleagues with relevant expertise, including those directing basic science courses and clinical clerkships. This process—developing benchmarks, making modifications based on what experience with the students suggests, and further collaboration with colleagues—permits a continuous quality improvement approach in which modifications are responses to the actual needs of the students and encourage a constant engagement of the College faculty in the curriculum development and review process. Continuous interaction is maintained between curriculum development and delivery, benchmarks, and feedback and evaluation.
Implementation: Tools for skill development and assessment
The UW School of Medicine’s curriculum review identified the use of performance benchmarks as essential tools for producing desired learning outcomes. Benchmarks help students to efficiently gather and thoroughly perform reliable and accurate patient histories and physical examinations and incorporate analytically sound clinical reasoning. Benchmarks also serve as the basis for observation of student work and standardized evaluations.
Students in years one and two receive performance benchmarks for competency domains at predesignated points. Each set of benchmarks builds upon those at previous stages of development. The benchmarks describe what students should learn and the level to which they will be held accountable in clinical examinations designed to evaluate their skill levels. In the second year, benchmarks have been developed for each organ system in the physical examination as well as other clinical skills domains, including the medical interview, written documentation, oral case presentation, clinical reasoning, and professionalism. Chest examination benchmarks for second-year students are shown as an example in List 1, and professionalism benchmarks for second-year students are shown in List 2.
In the clinical years, the benchmarks are being developed and/or refined and will serve as the basis for the relevant curriculum in each required clerkship and elective. The benchmarks will also provide the basis for individualized feedback between student and mentor. Third-year developmental benchmarks for required clerkships will focus on one organ system and/or basic skill and at least one relevant professionalism topic. Each required clerkship topic will be structured around curriculum, benchmarks, an observed component via a mini-CEX, and evaluation.
The student learning portfolio.
The student learning portfolio serves as a key focus for ongoing discussions between the student and his or her College faculty. The major purposes of the portfolio are to provide a repository for written work, to share selected and required work with the College mentor and student colleagues, to allow the College mentor to track the student’s progress, to serve as a notebook for e-mail communication with students in other classes, and to maintain a record of evaluations and grades. By the end of year four, the personal portfolio components will include the student’s entire record of accomplishment, including documentation of learning objectives, write-ups and reflective exercises, formative feedback and summative evaluative information (including mini-CEX evaluations), learning recommendations, and achievement summaries written by the student’s College mentor. In short, the portfolio documents the student’s progress. As they review their work over time, the portfolio gives the students a mechanism for measuring their own progress.
The mini-CEX is a formal observation by a faculty member of a focused clinical encounter with a consented patient.55–57 Each required clerkship and highly subscribed elective takes responsibility for at least one mini-CEX, focusing on physical examination, history-taking, and clinical reasoning in the organ system area for which it has primary responsibility.
A required objective structured clinical examination (OSCE)58–60 is taken at the end of the second year and at the beginning of the fourth year, following completion of the third-year required clerkships. Competencies assessed in OSCEs relate directly to benchmarks that the students have been responsible for mastering. Each second-year student must pass the second-year OSCE before beginning the required clerkships. Beginning in the 2004–05 academic year, each beginning fourth-year student in the College-based curriculum must pass the fourth-year OSCE to graduate. Remediation, which is required of any student who fails to pass either OSCE, is the responsibility of the student’s College mentor and the College head. Remediation may take one or more of the following forms: review/discussion of the topic with one’s mentor; review of written materials; repeating portions of the physical examination tested in the OSCE; or repeating an OSCE station.
Students complete reflective exercises in each year of medical school. In the first year, students have limited reflections related to continuity of care, done in conjunction with clinical experiences and discussions with a preceptor. One reflection focuses on patient-centered continuity issues, one on physician-centered continuity issues, and one on personal perspectives. In the second year, students have one or two reflective exercises per quarter linked to specific learning experiences focused on long-term care, alcohol and substance abuse, life-threatening and terminal illnesses, and human sexuality. When this article went to press, discussions were under way between each required-clerkship director and College faculty liaison to develop reflective exercises concerning a relevant aspect of professionalism, with the goal of incorporating these into the third- and fourth-year curricula.
The Value of the College System
As the health care environment has become more complex, some of the greatest costs to medical education have resulted from fragmentation of physicians’ time and attention. Related costs include declines in true bedside teaching and clinical interactions involving faculty, student, and patient, and a loss of attention to training in basic clinical skills. As the faculties of many U.S. medical schools have grown dramatically in their size and expertise, the advantages of a more personalized approach to education have often been lost.
The impulse to overload the medical school curriculum is strong, and teaching of basic clinical skills has suffered as breadth replaces depth. Although in mid-2004 the USMLE instituted a clinical skills examination mandatory for all medical students graduating in or after 2005, and although a large majority of Americans consider good clinical and communication skills critical for physicians, there are few indications that the teaching of fundamental clinical skills receives the attention that ultimately results in sound clinical practice. In addition, with a few exceptions, relatively few medical schools have instituted competency-based curricula that ensure mastery of fundamental clinical skills.38,61–62 If implemented, competency-based curricula achieve full meaning only when closely tied to teaching, observation, and evaluation. Understanding this will become increasingly important in medical schools, since we anticipate that undergraduate medical education will increasingly move to a competency-based model, following the example of graduate medical education.63–65
In undertaking its curriculum reform, the UW School of Medicine prospectively made clinical skills enhancement and professionalism key areas for attention. That focus does not replace the need to address the enormous challenge of teaching the rapidly changing knowledge base needed to practice medicine. Rather, it provides a foundation for the integration of clinical skills and knowledge that leads to competence. The College system integrates what students learn in the classroom with their first sustained clinical exposure. It provides a personal, ongoing relationship with a faculty member who is dedicated to teaching a relatively small group of students and who will work with them throughout their medical school tenure. It establishes basic principles and tools through which knowledge can be structured, imparted, and learned at increasingly deeper levels. Immersion in developmental principles and tools, in which developmental levels are made explicit and tied to core competencies, along with close attention and teaching from a faculty mentor, sets the stage for students to learn to gauge their own developmental progress and to carry out increasingly independent learning as they advance through training and practice.
While learning communities, variously known as societies, colleges, docent units, and by other descriptors, have been initiated nationally, ours is one of the few to combine a comprehensive, ongoing curricular role with a mentoring role.35,66 Further, our approach is the only one we know of in a four-year setting that combines intensive bedside teaching and role modeling, supported by explicit benchmarks, with mentoring, in which the mentors both support the medical students and teach and reflect with them on their clinical skills development over the course of their medical school training. The importance of continuity in primary care has been well recognized.67–70 Continuity in teaching and evaluation of fundamental clinical skills should also be a top priority. Perhaps most important, mentors, who represent the most expert teachers at our institution, serve as role models for their students, mirroring the combination of clinical skills, empathetic behavior, and professionalism that characterizes the competent physician in the context of direct patient care.
A significant aspect of the College structure is its focus on training students to internalize and utilize a variety of learning tools. In the first year, students are introduced to competency domains and explicit benchmarks that define those areas in which deepening, progressive attention throughout medical school will be focused. In the second year, skill learning is initiated in these domains at the bedside and under the supervision of a teacher/mentor, along with broad attention to the structure of medical interviewing, presentation, and clinical reasoning. Students can then carry this structure and the core of fundamental knowledge they have learned in years one and two into their clinical years, where they experience broadened care settings, more complex patient histories, and additional higher-level evaluation and management competencies.
Medical education has moved increasingly away from inpatient settings over the last two decades. With its focus on bedside teaching, the College structure goes against the contemporary grain and reinstitutes the inpatient setting as a learning environment for students during formative clinical training and in preparation for training in other care settings. Where the ambulatory setting is conducive to one-on-one teaching, the inpatient setting is conducive to weekly small-group bedside teaching. The inpatient setting gives students an early opportunity to learn focused history-taking, review complex physical examination findings, and initiate clinical reasoning. Since patients are selected and approached prior to the bedside encounter and because patient “turnover” is relatively rapid, a planned approach is possible in which patient histories can reflect the basic science topic or organ system being studied in the classroom. The College approach facilitates this integration, which is not possible when clinical skills are taught by hundreds of physicians in widely diverse ambulatory practices. Conversations between patients, students, and faculty in the College system can focus on issues around the core competency of professionalism and what is important to patients when they see clinicians. With the solid foundation they obtain during the second year, students can expand their clinical experience in years three and four to other care settings.
A key to promoting teaching of fundamental clinical skills rests on providing funding for individuals to teach and on investing in a core of teachers who are themselves fully invested in the curriculum. Identifying this core of expert teachers, ensuring financial support for their teaching activities, providing them with a combined teaching/mentoring role, giving them a strong voice in curriculum development and revision, coalescing them into a core group of fellow educators who interact on a regular basis, and giving continuous system-wide attention to the importance of teaching create an environment that refocuses the school’s most precious resources on teaching and evaluating core clinical skills. At our school, the commitment of dean’s funds to support these faculty and to releasing them from departmental obligations for the percentage of time designated for teaching and mentoring activities are essential elements to the success of this approach.
The University of Washington’s College system is still young but has worked remarkably well to date. Evaluative data currently being gathered will provide future information concerning the effects of the College system on students’ performance, satisfaction with their education, and the evolution of the third- and fourth-year curricula. Other schools may profit from using this approach, or may develop variations that satisfy their own needs. We believe, however, that a successful system will consider the need to focus on fundamental clinical skills in a continuous manner across all four years of medical school, to incorporate effective and structured bedside teaching, to use a competency-based model, to commit time and money to an expert group of clinical teachers, and to develop a sustained, dynamic structure of learning that students can internalize for use throughout their careers.
The authors gratefully acknowledge the Josiah Macy, Jr. Foundation, The New York Academy of Medicine, and the Association of American Medical Colleges for their support through the national project titled “Enhancing Education for the Clinical Transaction.” This article does not necessarily reflect the opinions or policies of these organizations.
The authors also gratefully acknowledge the 25 members of the College faculty who work as partners with the authors in the University of Washington School of Medicine College program; Dr. Kelly Fryer-Edwards, assistant professor in the Department of Medical History and Ethics, University of Washington School of Medicine for her contributions to the professionalism working group and benchmarks; and Dr. James P. LoGerfo, professor of medicine, University of Washington School of Medicine, for his review and critique of the manuscript.
1Holmboe ES. Faculty and the observation of trainees’ clinical skills: problems and opportunities. Acad Med. 2004;79:16–22.
2Nutter D, Whitcomb M. The AAMC Project on the Clinical Education of Medical Students. Washington, DC: Association of American Medical Colleges, 2001.
3Novack DH, Volk G, Drossman DA, Lipkin M. Medical interviewing and interpersonal skills teaching in the U.S. medical schools. Progress, problems, and promise. JAMA. 1993;269:2101–5.
4Engum SA. Do you know your students’ basic clinical skills exposure? Am J Surg. 2003;186:175–81.
5Meuleman JR, Harward MP. Assessing medical interview performance. Effect of interns’ gender and month of training. Arch Intern Med. 1992;152:1677–80.
6Pfeiffer C, Madray H, Ardolino A, Williams J. The rise and fall of students’ skill in obtaining a medical history. Med Educ. 1998;32:283–8.
7Wilson BE. Performance-based assessment of internal medicine interns: evaluation of baseline clinical and communication skills. Acad Med. 2002;77:1158.
8York NL, Niehaus AH, Markwell SJ, Folse JR. Evaluation of students’ physical examination skills during their surgery clerkship. Am J Surg. 1999;177:240–3.
9Johnson JE, Carpenter JL. Medical house staff performance in physical examination. Arch Intern Med. 1986;146:937-41.
10Dunnington G, Reisner E, Wizke D, et al. Teaching and evaluation of physical examination skills on the surgical clerkship. Teach Learn Med. 1992;4:110–4.
11Wilkerson L, Lee M. Assessing physical examination skills of senior medical students: knowing how versus knowing when. Acad Med. 2003;78:S30–2.
12Ortiz-Neu C, Walters CA, Tenenbaum J, Colliver JA, Schmidt HJ. Error patterns of 3rd-year medical students on the cardiovascular physical examination. Teach Learn Med. 2001;13:161–6.
13Connell KJ, Sinacore JM, Schmid FR, Chang RW, Perlman SG. Assessment of clinical competence of medical students by using standardized patients with musculoskeletal problems. Arthritis Rheum. 1993;36:394–400.
14Freedman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. J Bone Joint Surg Am. 1998;80:1421–7.
15Mangione S. Cardiac auscultatory skills of physicians-in-training: a comparison of three English-speaking countries. Am J Med. 2001;110:210–6.
16Mangione S, Nieman LZ. Cardiac auscultatory skills of internal medicine and family practice trainees. A comparison of diagnostic proficiency. JAMA. 1997;278:717–22.
17Sullivan AM, Lakoma MD, Block SD. The status of medical education in end-of-life care: A national report. J Gen Intern Med. 2003;18:685–95.
18Kern DC, Parrino TA, Korst DR. The lasting value of clinical skills. JAMA. 1985;254:70–6.
19Wigton RS, Nicholas JA, Blank LL. Procedural skills of the general internist. A survey of 2500 physicians. Ann Intern Med. 1989;111:1023–34.
20Rolfe IE, Sanson-Fisher RW. Translating learning principles into practice: a new strategy for learning clinical skills. Med Educ. 2002;36:345–52.
21Paauw DS, Wenrich MD, Curtis JR, Carline JD, Ramsey PG. Ability of primary care physicians to recognize physical findings associated with HIV infection. JAMA. 1995;274:1380–2.
22Flexner A. Medical Education in the United States and Canada. A Report to the Carnegie Foundation for the Advancement of Teaching. Bulletin No. 4. Boston: Updyke, 1910.
23W.C. Rappleye (director). Medical Education: Final Report of the Commission on Medical Education. New York: Association of American Medical Colleges, 1932.
24Muller S (chairman). Physicians for the twenty-first century: report of the project panel on the general professional education of the physician and college preparation for medicine. J Med Educ. 1984;59 (11 Pt 2):1-208.
25Educating medical students. Assessing change in medical education—the road to implementation (ACME-TRI report). Acad Med. 1993;68(6 suppl):S1–46.
26Christakis NA. The similarity and frequency of proposals to reform U.S. medical education: constant concerns. JAMA. 1995;274:706–11.
27Bloom S. Structure and ideology in medical education: an analysis of resistance to change. J H Soc Behav. 1988;29:294–306.
28Enarson C, Burg FD. An overview of reform initiatives in medical education. JAMA. 1992;268:1141–3.
29Regan-Smith MG. “Reform without change”: Update, 1998. Acad Med. 1998;73:505–7.
30Cantor JC, Cohen AB, Barker DC, Shuster AL, Reynolds RC. Medical educators’ views on medical education reform. JAMA. 1991;265:1002–6.
31Blumenthal D, Thier SO. Managed care and medical education: the new fundamentals. JAMA. 1996;276:725–7.
32Halpern R, Lee MY, Boulter PR, Phillips RR. A synthesis of nine major reports on physicians’ competencies for the emerging practice environment. Acad Med. 2001;76:606–15.
33Jones R, Higgs R, deAngelis C, Prideaux D. Changing face of medical curricula. Lancet. 2001;357:699–703.
34Cohen J, Dannefer EF, Seidel HM, et al. Medical education change: a detailed study of six medical schools. Med Educ. 1994;28:350–60.
35Irby DM, Wilkerson L. Educational innovations in academic medicine and environmental trends. J Gen Intern Med. 2003;18:370–6.
36Rabowitz HK, Babbott D, Bastacky S, Pascoe JM, Patel KK, Pye KL, et al. Innovative approaches to educating medical students for practice in a changing health care environment: the national UME-21 project. Acad Med. 2001;76:587–97.
37Meyer GS, Potter A, Gary N. A national survey to define a core curriculum to prepare physicians for managed care practice. Acad Med. 1997;72:669–76.
38Seifer SD. Recent and emerging trends in undergraduate medical education: curricular responses to a rapidly changing health care system. West J Med. 1998;168:400–11.
39Kenneth Ludmerer. Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care. New York: Oxford University Press, 1999.
40LaCombe MA. On bedside teaching. Ann Intern Med. 1997;126:217–20.
41Nair BR, Coughlan JL, Hensley MJ. Student and patient perspectives on bedside teaching. Med Educ. 1997;31:341–6.
42Shankel SW, Mazzaferri EL. Teaching the resident in internal medicine. Present practices and suggestions for the future. JAMA. 1986;256:725–9.
43Ramani S. Twelve tips to improve bedside teaching. Med Teach. 2003;25:112–5.
44Ramani S, Orlander JD, Strunin L, Barber TW. Whither bedside teaching? A focus-group study of clinical teachers. Acad Med. 2003;78:384–90.
47Ramsey PG, Coombs JB, Hunt DD, Marshall SG, Wenrich MD. From concept to culture: the WWAMI program at the University of Washington School of Medicine. Acad Med. 2001;76:765–75.
48Harden RM, Stamper N. What is a spiral curriculum? Med Teach. 1999;21:141–3.
49Harden RM, Davis MH, Crosby JR. The new Dundee medical curriculum: a whole that is greater than the sum of the parts. Med Educ. 1997;31:264–71.
50Olson L, Schieve AD, Ruit KG, Vari RC. Measuring inter-rater reliability of the sequenced performance inventory and reflective assessment of learning (SPIRAL). Acad Med. 2003;78:844–50.
51Olson L, Schieve D, Pangaro LN. Complementary developmental approaches to assessing medical students—SPIRAL and RIME. Presented at the annual meeting of the Association of American Medical Colleges, November 10, 2002, San Francisco, CA.
52Snadden D, Thomas M. The use of portfolio learning in medical education. Med Teach. 1998;20:192–208.
53Supiano MA, Fantone JC, Grum C. A web-based geriatrics portfolio to document medical students’ learning outcomes. Acad Med. 2002;77:937–8.
54Derstine PL. Implementing goals for non-cognitive outcomes within a basic science course. Acad Med. 2002;77:931–2.
55Norcini JJ, Blank LL, Duffy FD, Fortna GS. The mini-CEX: a method for assessing clinical skills. Ann Intern Med. 2003;138:476–81.
56Kogan JR, Bellini LM, Shea JA. Implementation of the mini-CEX to evaluate medical students’ clinical skills. Acad Med. 2002;77:1156–7.
57Norcini JJ, Blank LL, Arnold GK, Kimball HR. The mini-CEX (clinical evaluation exercise): a preliminary investigation. Ann Intern Med. 1995;123:795–9.
58Duerson MC, Romrell LJ, Stevens CB. Impacting faculty teaching and student performance: nine years’ experience with the objective structured clinical examination. Teach Learn Med. 2000;12:176–82.
59Yedidia MJ, Gillespie CC, Kachur E, et al. Effect of communications training on medical student performance. JAMA. 2003 Sep 3;290:1157–65.
60Kowlowitz V, Hoole AJ, Sloane PD. Implementing the objective structured clinical examination in a traditional medical school. Acad Med. 1991;66:345–7.
61Smith SR, Dollase RH, Boss JA. Assessing students′ performances in a competency-based curriculum. Acad Med. 2003;78:97–107.
62Carraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin C. Shifting paradigms: from Flexner to competencies. Acad Med. 2002;77:361–7.
64Batalden P, Leach D, Swing S, Dreyfus H, Dreyfus S. General competencies and accreditation in graduate medical education. Health Aff (Millwood). 2002;21:103–11.
66Arnold L, Graves L, Drees BM, Friedland ML. University of Missouri –Kansas City School of Medicine. Acad Med. 2000;75(9 suppl):S191–5.
67Love MM, Mainous AG 3rd, Talbert JC, Hager GL. Continuity of care and the physician-patient relationship: the importance of continuity for adult patients with asthma. J Fam Pract. 2000;49:998–1004.
68Foster EM. Does the continuum of care improve the timing of follow-up services? J Am Acad Child Adolesc Psychiatry. 1998;37:805–14.
69Safran DG, Montgomery JE, Chang H, Murphy J, Rogers WH. Switching doctors: predictors of voluntary disenrollment from a primary physician’s practice. J Fam Pract. 2001;50:130–6.
70Mainous AG 3rd, Gill JM. The importance of continuity of care in the likelihood of future hospitalization: is site of care equivalent to a primary clinician? Am J Public Health. 1998;88:1539–41.