Clinical skills development is an essential component of the education of a competent physician.1 However, the mentoring and practice of basic skills such as the physical examination in medical schools have suffered as a result of the current emphasis on an ever-expanding body of medical knowledge and new technologies.2–9 The task of skills learning in the clerkship year is additionally complicated by limited time for bedside teaching.10,11 Generally, students have fewer opportunities to perform initial patient evaluations and instead focus on patient management. Shifts in health care delivery systems, the continuing decrease of financial support for medical education, and the proliferation of a variety of financial, legal, and regulatory restrictions on medical practice additionally affect decisions about curricula in schools of medicine.12–16 In turn, these shifts ultimately influence the caliber of medical education and students' ability to meaningfully participate in and learn from directly caring for patients.
A growing body of literature reflects concern for students' skill development and deficiencies in the performance of basic skills.17–25 In response to this concern, medical schools are using a variety of curricular strategies designed to enhance the teaching of basic clinical skills. Some are undertaking major reorganization and creating smaller learning communities within which more continuous and mentored relationships can develop to facilitate improved clinical skills education.26–28 Other schools are implementing learning portfolios and clinical skills passports to encourage and document students' clinical learning opportunities.29–31 Many institutions are also developing clinical skills and simulation centers to better enhance students' basic skill learning.15 In concert with national medical licensure bodies, most schools are implementing clinical-skills-assessment programs.24,25,31
In the early 1990s, concern existed among faculty at the University of Virginia (UVA) School of Medicine that communication and physical examination skills were not being sufficiently taught in a way that allowed students to practice and receive feedback on their abilities. In addition, faculty recognized the need to improve ambulatory care education in the undergraduate medical curriculum. As a result of these concerns, UVA instituted a number of curricular innovations, including its first one-month outpatient clerkship, a combined effort of the departments of family medicine and internal medicine. Shortly thereafter, the school of medicine also developed 12 objectives as an overarching guide for medical student education.32
Interested faculty recruited by the clerkship directors in medicine and family medicine created a series of 11 hands-on clinical skills workshops. These workshops were offered within the structure of the original ambulatory clerkship. The goal of these workshops was to prepare students to more effectively participate in office-based care. Examples of workshop skills included examination of the shoulder and knee, ECG interpretation, and antibiotic selection. When separate one-month ambulatory clerkships in family medicine and internal medicine were established in 1999, the number of clinical skills workshops was doubled. In 2003, the department of pediatrics joined in an interdisciplinary effort to further enhance clinical skills education in the clerkship year. With funding from the Bureau of Health Professions of the Health Resources and Services Administration, this consortium, named the Clerkship Clinical Skills Education Program (CCSEP), further expanded workshops into the pediatric clerkship while also developing a clinical-skills-assessment process. This paper describes our 14-year experience with the workshop program.
The Workshop Program
Clinical skills workshops provide all clerkship students the opportunity to improve their competence and confidence in the performance of basic clinical skills. When selecting workshop skills, clerkship faculty review basic skill-development course materials from years one and two of the curriculum, along with clerkship lectures and other skills training activities. Workshop skills are selected by consensus among clerkship directors to ensure that each skill is important for all medical students, that the workshop session complements other skill teaching in the curriculum, and that the skill workshop serves to further advance students' skill development.
Monthly workshop sessions allow all third-year students to practice skills on each other, with standardized patients, or with models in a small-group setting of 12 to 15 students. Students receive direct feedback from faculty on their skill performance. When possible, workshops are scheduled early in the clerkship. This offers students a more lengthy period of time to hone their skill performance in the patient-care setting of each clerkship. During both the family medicine and ambulatory internal medicine clerkships, two and a half days of the four-week experience are dedicated to workshop sessions. Pediatric skills workshops are woven throughout the clerkship time. Annually, the workshop curriculum is reviewed by course directors and the CCSEP to ensure that workshops are complementary and not redundant.
Clinical skills workshops are designed using the following nine guidelines:
▪ The format and content are designed to emphasize skill transfer between teacher and student with interactive student participation throughout the duration of the workshop.
▪ Each session focuses on a specific clinical skill.
▪ Faculty instructors are selected on the basis of skill expertise and teaching interest.
▪ The clinical content is case based.
▪ The format and content is planned with flexibility so that it can change in response to evaluation.
▪ Workshops are given in a 60- to 120-minute time period.
▪ Formative program evaluation occurs after each session, and reports are provided to workshop faculty at regular intervals throughout the year.
▪ Student attendance is expected.
▪ At least two faculty are trained to teach each workshop.
In total, 36 workshops have been developed and taught during the past 14 years. Five workshops have been discontinued for reasons such as the integration of new workshops within a limited teaching schedule, redundancy with respect to skills taught elsewhere in the curriculum, and loss of primary teaching faculty to other commitments. Currently, 31 workshops are taught to all third-year clerkship students. Descriptions of each workshop can be found in Appendix 1.
As an example, an ophthalmoscopic skills workshop occurs during the ambulatory internal medicine clerkship. The goal of this session is to advance each student's ability to examine the undilated eye with the standard ophthalmoscope. During this two-hour workshop, the student performs a series of seven observation exercises on colleagues that demonstrate techniques for examination of the cornea, anterior chamber, and retina. During each exercise, students are asked to describe what they observe. Throughout the workshop exercises, faculty engage each student in individual validation of their observations. Students who have successfully accomplished an observation exercise are asked to assist colleagues who have not yet done so. Faculty also repetitively engage the students in discussions about the clinical significance of each set of observations. This workshop begins with a review of fundamentals taught in the first year: the use of both types of lenses, the ideal positions of the doctor and patient, and careful visualization of the disc. In addition, faculty verify each student's findings of venous pulsations, arteriovenous crossings, and physiologic cup characteristics.
Continuing Workshop Improvement
In an effort to continually improve the workshop program, students are required to rate the overall value of each workshop. For the family medicine and ambulatory internal medicine clerkships, students rate the workshops online using a four-point scale (1 = poor, 4 = excellent) and provide descriptive comments. Ratings of the pediatrics workshops are completed on hard copy using the same scale. All three clerkships use the same rating scale for each workshop. Data are analyzed regularly, and reports are provided to workshop faculty and clerkship directors. Adjustments to workshops occur in response to constructive evaluative themes.
A summary of numeric scores and evaluative themes was developed from 420 students' workshop evaluations from July 2003 to April 2006. Individual workshop summary scores ranged between 2.9 and 3.9, with 70% of workshops consistently rated at 3.5 or above. Content analysis was performed on student comments for each workshop. Eighty percent of student comments reflect strengths of the skills sessions. Three broad themes dominate the qualitative analysis: skill of the workshop faculty, workshop content and process, and areas for workshop improvement.
Skill of the workshop faculty.
Students commented frequently on how proficient the workshop faculty are in teaching their specific subject matter. Students reported valuing faculty ability to “make the subject matter come to life.” They appreciated the systematic teaching and the immediate feedback and remediation they receive. Additionally, students benefited from faculty enthusiasm for teaching.
Workshop content and process.
Students highlighted that three items directly affect the learning that takes place in the sessions: the interactive nature of the workshops, the clinical applicability and relevance of the specific skills learned, and the dedicated practice time and repetition provided. Students especially appreciated the case-based nature of many of the workshops and the opportunity to further develop skills that were taught earlier in medical school. Students also welcomed being introduced to new skills to which they had not been explicitly exposed thus far in the curriculum. These included the pediatric ear exam, adolescent interview, telephone triage, and health care economics. Students reported that after the workshop teaching, they used workshop resource materials in the clinical setting to further enhance their practice and learning.
Areas for improvement.
The constructive suggestions provided by the students are among the most valuable for curricular improvement. For example, if a workshop was perceived as a lecture, adjustments are made to achieve greater student interaction, incorporate case-based application, and increase student practice time. If a workshop skill overlaps with teaching in other areas of the curriculum, efforts are made to advance the level of students' skill learning or emphasize new skill material. In instances where students commented on workshop length or scheduling difficulties, program staff adjusts the schedule for a more appropriate workshop length or placement of workshops within the clerkship schedule to maximize practice time.
Students' Clinical Skills Performance
Ninety-nine percent of UVA medical students have passed the United States Medical Licensing Examination Step 2 clinical skills examination since its inception in 2005. Also, since 2002, 98.5% of students have performed satisfactorily on the internal end-of-clerkship long-case clinical skills examination. Because the introduction of these performance measures occurred after the commencement of the workshop program, long-term data that directly link workshop teaching to student skill performance are not available. However, analysis of pilot data from a new student performance assessment specific to basic clinical skills learning shows the potential influence of workshop teaching on student performance. Table 1 compares students who had taken the workshop before the skills assessment with those who had not. For the knee exam and pediatric ear-exam skills, students who attended the workshop had a statistically significantly higher mean score than students who did not attend the workshop (P < .05). Except for the breaking bad news skill, the mean score for students who attended the other workshops were higher than for students who did not attend workshops, indicating a general trend towards a higher mean score for students who did attend.
Of related interest, student performance on the National Board of Medical Examiners Internal Medicine Subject Examination has also increased significantly since the inception of the clerkship clinical skills workshop program and the ambulatory clerkships. Figure 1 illustrates the association between the increased subject exam scores and the start of these activities in 1993–1994 and a second increase in subject exam scores after the number of workshops doubled in 1999.
There is a national movement to enhance clinical skills education in the undergraduate medical curriculum.15,33,34 We believe that the UVA Clerkship Clinical Skills Workshop Program, a component of the Clerkship Clinical Skills Education Program, is an effective curricular innovation for addressing this need. Its development and expansion have continued because of student, faculty, and administrative support and the firm belief that it provides students a unique opportunity to learn and practice basic clinical-skill mastery across a range of skills.
The timing of this program during the clerkship year also offers skill instruction and practice when it is most likely to contribute to accelerated clinical learning. Pairing individualized instruction of discipline-specific skills with patient encounters within the corresponding clerkship serves to better reinforce students' skill development. Increased student–teacher interaction and skill practice time offered by the workshop program allow students not only to strengthen their basic skill ability, but also to contribute more effectively in ongoing patient-care activities. This model reflects Dewey's35 adult learning principle that the opportunity to apply ideas within a learner's experience allows for more enduring development of practice ability.
This workshop program contrasts in magnitude with some of the more robust curricular changes that several other institutions have accomplished, such as the creation of smaller learning communities within a medical school or the use of a formal competency-based curriculum.26,29 In schools where major systemic changes are not feasible, a skills workshop program such as this one offers a practical method for incrementally expanding skill learning in the clerkship year while integrating advanced skill activities within an existing curricular framework.
Students consistently report that the workshop learning experience increases their ability to perform common clinical skills, increases their confidence in performing such activities, and increases their desire to practice this kind of skills learning. Additionally, preliminary data from our new clinical-skills-assessment program suggest that at least for some of these workshops, better student skill performance may be directly linked to workshop participation. Indeed, similar outcomes have been observed by others.36 We can only speculate on the longitudinal improvement in student performance on the Internal Medicine Subject Examination with the establishment and subsequent expansion of the skills workshop program. This improvement is perhaps as much a reflection of the associated expansion of ambulatory clerkship time. However, we have no data that provide sufficient insight into this unexpected improvement in students' clinical knowledge. Further studies are needed to better enable us to determine the influence of these skills workshops on long-term clinical performance outcomes.
Similar to students, our faculty continue to enthusiastically support this program. Despite the lack of specific financial incentives for participating as a workshop teacher, and with dissimilar departmental crediting for this clinical education activity, faculty interest has continued, with little faculty turnover, since the inception of the program in 1993. Most of our initial workshop faculty continue as teachers. It is likely that the once-a-month workshop schedule offers sufficient flexibility for continued faculty participation. Faculty cherish the opportunity to engage every clerkship student in learning a specific skill that closely matches their own clinical interests and expertise. Additionally, a standardized, transparent evaluation process allows workshop faculty to receive feedback that encourages them to continually improve their teaching.
Future plans include expansion of this program to involve all of the clerkship disciplines. Our ultimate intent is to create an integrated four-year clinical skills curriculum to better arrange skill-learning opportunities along a developmental continuum. We believe that this is achievable through incremental and strategically placed skill practice and performance-assessment activities. To this end, the clinical skills workshop program remains foundational in this educational work-in-progress.
The authors thank Emil R. Petrusa, PhD, professor, Department of Medical Education and Administration, Vanderbilt University, for manuscript review; and Michael F. Rein, MD, professor of medicine, University of Virginia, for Clerkship National Board of Medical Examiners subject examination data.
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