The component skills of the clinical transaction*—the ability to take a comprehensive and accurate clinical history, to perform a thorough and nuanced physical examination, to engage in sequential clinical reasoning using all relevant clinical and laboratory data, and to clearly and compassionately communicate with patients and other providers—are critical to a successful therapeutic outcome. Although practicing physicians can spend an entire career mastering these skills, medical schools traditionally limit formal instruction in clinical transaction skills to the preclinical years, when students learn to interview patients, take a complete medical history, and perform a comprehensive physical examination.
As students move on to clerkships and begin applying these skills to encounters with patients with unknown problems, they are evaluated using standardized patient encounters and bedside assessments. But few schools have coordinated curricula that focus on advancing nascent clinical skills and helping students better understand how to apply them in specific clinical situations.1
Such curricula are needed. Even with dedicated preclinical courses in physical diagnosis, students often enter clerkships without the necessary clinical skills. In a national survey of clerkship directors, one third reported that students were not adequately prepared in basic interviewing and physical examination techniques when they began their clinical rotations.2 Furthermore, an assessment of three consecutive entering classes of internal medicine residents found that, while they demonstrated at least minimal competency in history-taking and communication skills, they did not demonstrate competence in performing focused physical examinations.3
The Liaison Committee on Medical Education (LCME), which accredits medical education programs for students at medical schools in the United States and Canada, requires schools to specify problems that the school determines students should encounter during clerkships and other clinical courses. Although these LCME standards have existed for several years, few schools have provided structured clinical experiences focused on a set of specific clinical problems. Typically, a student’s case mix is determined by the near-random process of assigning students to patients as they are admitted to the hospital. This serves to distribute workload, but it is unlikely to ensure that each student sees all prescribed problems.4 Furthermore, the complex illnesses of many patients admitted to our university hospitals go beyond what we expect a graduating medical student to manage independently.
The LCME also requires that each school provide assessment opportunities for students to demonstrate, on direct observation, attainment of the clinical skills outlined in the school’s list of educational objectives. Reports from students in the early 1980s, however, indicate that most graduated with little, if any, recall of being directly observed.5 This improved with the addition of standardized patient (SP) examinations,6 but substantial improvements in performance on these examinations, as might be predicted with increased observation and feedback, have yet to be reported. While general educational principles and research on deliberate practice indicate that performance can be improved with immediate, focused feedback,7 the structure of clinical teaching in the third and fourth years of medical school rarely follows such a focused approach. It is not surprising, then, that scores on SP examinations have not increased, given the unsystematic assignment of patients, the mismatch between the complexity of those patients’ illnesses and the relatively straightforward diagnoses in SP examinations, and the provision of direct observation primarily during summative assessments as opposed to formative ones.
What is needed is a structured, predictable clinical curriculum that ensures that each student has learning opportunities for a given set of problems, opportunities for feedback in managing those problems, and an SP examination comprising similar cases that provides both formative and summative information. The Clinical Transaction Project (CTP) at Vanderbilt University School of Medicine was developed to address these needs. Initiated in 2004, the CTP is a coordinated and integrated program of instruction that occurs during the traditional clerkships of the clinical years and is designed to ensure that our students graduate with the competence to manage common patient complaints. This desired goal led us to format the program around presenting problems as opposed to established diagnoses. We feel that this enhances the utility of the program. Patients with both acute and chronic illness can and do present with these problems. In the case of chronic illness, the preexisting illnesses instructively confront students with real-world complexity of the type they will face once they graduate.
The CTP seeks to advance clinical transaction skills beyond those acquired during the basic physical diagnosis course and to help students develop a reflective approach to learning that includes self-assessment and self-direction, which are themselves critical skills in the career-long maintenance of clinical competence. This article represents a progress report on our efforts.
Issues of Importance for Program Development
A number of issues must be considered for a program of this nature to be implemented and reach maturity. These are listed in Table 1, along with a description of each one’s progress within our program. The following discussion addresses selected elements in the table.
Vanderbilt’s CTP is based on the premise that, although there are generally applicable clinical skills, the skill of solving clinical problems is not generalizable across medical disciplines. The premise derives from pioneering research of Elstein et al8 and other groups,9–11 which has shown that clinical problem solving and diagnostic decision making are case-specific and perhaps knowledge-dependent. With such research in mind, the planning group at Vanderbilt concluded that students needed advanced instruction in clinical transaction skills not in isolation, but in a variety of clinical contexts. A multidisciplinary group of master clinical teachers (described below) and clerkship directors used an informal Delphi selection process to create a list of presenting problems that represented the broad spectrum of clinical medicine. Criteria for selection included that (1) the problems and their underlying etiologies should be common and should represent the foundation of clinical practice, (2) we could reasonably expect upper-level students to be able to manage these problems competently, (3) each problem could be assigned to one or more clerkships, where specialty-specific expertise could inform and guide the learning process, and (4) teaching faculty could envision instructional sessions with patients encountered in their specialties. The initial candidate list of 130 presenting problems was narrowed down during three selection rounds (in which participants rated each problem as “must include,” “might include,” or “do not include”) to 22: twice the number of master clinical teachers and a manageable starting point for the program. After three years of experience with those 22 problems, the planning group reassessed and modified the list. Table 2 shows the 25 presenting problems currently used in the CTP.
To increase the likelihood that students will encounter real patients with these presenting problems, primary responsibility for instruction of each problem was assigned to a specific core clerkship (see Table 2) based on the frequency with which the problem occurs in that discipline. While students may care for patients with a certain presenting problem in more than one clerkship, the assignment of specific responsibility ensures that all students acquire experience with all problems as they complete their required rotations. All of these clerkships occur during the third year of our curriculum except emergency medicine, which is a fourth-year requirement.
To provide guidance to students and faculty, specific learning objectives were developed for each of the presenting problems. The learning objectives are derived from the Association of American Medical Colleges (AAMC) monograph on clinical skills12 and are similar to those in the manual of the Clerkship Directors in Internal Medicine/Society of General Internal Medicine.13 In general, the objectives include prerequisite basic science knowledge; knowledge of the pathophysiology specific to the problem; the history, physical examination, and diagnostic measures of special importance to the problem; and the initial management plan.
Master clinical teachers
The financial pressures under which academic health centers operate have been increasingly transmitted to individual faculty members, who must devote their time to revenue-generating activities, such as clinical practice and externally supported research.14 To create a core group of faculty committed to clinical teaching, Vanderbilt developed, even before the CTP was developed, the Master Clinical Teacher Program. The school of medicine pays each master clinical teacher $50,000, thereby reserving a portion of his or her time (equivalent to the fraction this contribution makes of the faculty member’s total compensation) exclusively for teaching. Because faculty salaries vary, $50,000 buys varying amounts of teaching time. Most clerkship directors are also master clinical teachers; their administrative duties are compensated from departmental resources, as are indirect costs. The activities of all required clerkships occur primarily, if not exclusively, at the Vanderbilt University Medical Center. Therefore, all the master clinical teachers are based at the medical center.
The number of master clinical teachers has been determined by balancing the program’s needs and its budget constraints. With the implementation of the CTP, we added four master clinical teachers to the original seven. Since then, two more have been added for a current total of 13 master clinical teachers. As seen in Table 2, the number of master clinical teachers needed per clerkship is determined by the number of presenting problems assigned to that clerkship.
In fulfilling CTP responsibilities, each master clinical teacher focuses his or her effort on teaching the skills associated with the presenting problems assigned to his or her clerkship. The specific role of each master clinical teacher varies from clerkship to clerkship and depends on the instructional approach used by the clerkship, as discussed below. In addition to their own teaching, the master clinical teachers also coordinate the teaching efforts of their departmental colleagues as it relates to the CTP.
In addition to these CTP-specific teaching responsibilities, each master clinical teacher meets four times during the third year with a group of 8 to 10 students. These two-hour sessions give students the opportunity to discuss situations they have encountered on their rotations that are troubling from a moral, ethical, or medical standpoint. We hope that the chance to process such situations with peers and respected mentors will help sustain professional ideals and will create in our students the habits of reflective practice. The master clinical teachers are also expected to meet with their students individually to monitor their general and CTP-related progress.
At this stage in the development of the CTP, no effort has been made to require a standardized approach to instruction, because no clear evidence exists as to which approach is optimum or whether there even is a single optimum approach for all problems. Current approaches include direct observation of students as they interact with real or simulated patients, discussions about the problems in small groups and lectures, and focused opportunities for students to observe master clinical teachers or other experienced clinicians as they evaluate patients with the presenting problems.
Each clerkship determines its instructional approaches based on the structure of the clerkship, faculty and patient resources, the experience of the master clinical teachers, and the nature of the problem itself. The approaches are outlined in Table 2, which reflects significant variation from one clerkship to the next. For example, in obstetrics–gynecology, students are observed and receive one-on-one feedback as they evaluate real patients in a special teaching clinic supervised by a master clinical teacher. In psychiatry, the group of students and a faculty member observe via a one-way mirror as an individual student interacts with a real patient. Surgery uses bedside instruction with real patients and focused instruction with standardized patients. On the medicine clerkship, students are observed at the bedside by faculty preceptors and also under a two-station formative SP exercise at the end of the clerkship in which each standardized patient portrays one of the CTP problems.
As we develop validated measures of competence in managing the CTP problems, we believe that we shall be better equipped to compare the different approaches and to determine whether one method of instruction is clearly superior to others.
Instruction relating specifically to the presenting problems supplements and does not replace the learning opportunities students have traditionally had while on clerkships. Students receive feedback, but they do not receive a formal grade specific to their performance in the clinical transaction activities. Clerkship grades at Vanderbilt are based both on objective measures of knowledge and on the integrated subjective assessments of housestaff and attending faculty. Assessment of student performance in the CTP is but one of the subjective components of a student’s grade.
Web-based learning portfolio
An informatics team at Vanderbilt has developed a Web-based learning portfolio that supports clinical learning.15 Each student has an individual portfolio that automatically documents his or her clinical experience by directly downloading all entries the student makes in the Vanderbilt electronic patient record. This is accomplished in a manner that complies with the privacy rule of the 1996 Health Insurance Portability and Accountability Act. (Confidentiality issues prevent data collection at our Veterans Administration Medical Center.)
The portfolio, which lists the 25 presenting problems with their associated learning objectives, gives master clinical teachers access to notes created by the 8 to 10 students they mentor, allowing them to provide feedback either verbally during individual meetings or electronically through annotations in the portfolio. Students are also able to request electronically that their attending physicians critique selected entries. Studies by Spickard et al15 demonstrate that the system enhances attending feedback and facilitates communication between students and teachers. Although this feedback system is widely used on the medicine and pediatric services, other services have been slower to adopt it.
The CTP remains a work in progress. Its ongoing refinement is enhanced by monthly meetings of the master clinical teachers, clerkship directors, members of the medical school administration including the dean of the school, and members of the Office for Teaching and Learning in Medicine. These meetings provide not only a setting for program development and evaluation but also a forum for interdisciplinary discussion regarding the totality of the required clinical experience. They also provide an opportunity for faculty development, with discussion of relevant literature and exchange of best practices from the experience of the master clinical teachers themselves. Finally, the meetings serve to maintain the esprit and commitment of the core faculty.
Currently, the greatest need for program development is in the area of student assessment. As noted above, the CTP seeks to develop in students a reflective approach to learning that emphasizes self-direction. Thus, one goal is to provide reliable feedback that students can use to determine their own needs and direct their own development. To date, this has been accomplished primarily by seasoned clinicians who give immediate feedback to students after observing them evaluate real or simulated patients. Although this feedback is immensely valuable, it lacks consistency and definition. Objective, standardized assessment tools are required to meet both the students’ formative needs and the institution’s summative needs.
Currently, we are studying the efficacy of various assessment methods for schoolwide implementation. Developing these tools will require collective judgments about what ought to be assessed and the quality of performance expected of all students. The CTP planning group will identify the most significant diagnoses for each presenting problem, recognizing that each of these diagnoses will have its own differential based on the age of the patient and acuteness of the situation. The group will also identify critical actions4 that students must take in working through the differential diagnosis for each age/acuteness cluster. This groundwork will allow us to create a variety of assessment tools that include student entries into the electronic medical record, other aspects of the student learning portfolio, performance with real and standardized patients, and exercises using clinical reasoning software.
The master clinical teachers are currently discussing different strategies for the application of these assessments. One option is to administer a comprehensive SP assessment after the clerkships, as described by other schools.4,16,17 This would allow students to use the fourth year to remediate any identified weaknesses. Another is to allow students to make an appointment at the assessment center when they feel they are ready to be assessed on one or more presenting problems. Although this latter approach is more complicated logistically and administratively, it better supports the goal of self-direction.
The Clinical Transaction Project in Perspective
The CTP at Vanderbilt is a focused component of a broader clinical curriculum that addresses the wide range of issues needed to prepare students for postgraduate training and clinical practice. It specifically seeks to enhance students’ skills in carrying out the clinical transaction as embodied in the physician–patient interaction. In their report on clinical skills education as part of the AAMC Project on the Clinical Education of Medical Students, Corbett and Whitcomb1 noted that “[v]ery few schools appear to approach clinical skills education as an explicit developmental process throughout the four years of the curriculum.” Clerkship directors find that students have suboptimal clinical skills when they enter clerkships,2 and residency directors find deficiencies in the clinical skills of new residents.3 Wilkerson and Lee,18 interpreting the results of their studies on the clinical skills of fourth-year students, suggest that although students may have attained technical competence in certain aspects of the clinical examination, the students are deficient in applying those skills to individual cases. The authors cite the need to help students identify aspects of the physical examination that are essential in specific clinical situations.
Embedded within the clerkship curriculum of the third and fourth years, the CTP addresses the problems noted above by setting instruction within the context of a wide variety of specific presenting problems. This directed curriculum recognizes that different presenting problems and their associated reasoning processes call on distinct constellations of clinical skills and knowledge bases. Rather than leaving students’ experiences to chance, as traditionally occurs during clerkships,19 the CTP adds consistency to the clinical years by ensuring that students will gain practice and experience with a full set of clinical skills and reasoning paradigms determined by our faculty to be important in the development of all physicians.
While the program has succeeded thus far in stimulating the development of problem-specific instruction, we recognize the need to create valid and reliable assessment tools. These will provide formative information to guide our students in their self-directed efforts and summative information for our institution to document student achievement, measure program effectiveness, guide future program development, and demonstrate fulfillment of accreditation requirements.
In addition to building these tools, next steps for the CTP include integrating its objectives with the general educational objectives that underpin the curriculum as a whole. As the objectives for the CTP are further refined, we will need to review our school’s educational objectives, based on the AAMC’s Medical School Objectives Project, to ensure that the CTP objectives are adequately represented. We have also recently appointed a group of master science teachers who will systematically review our preclinical curriculum to ensure that our students are gaining the prerequisite biomedical knowledge and adopting a scholarly, scientifically grounded approach to managing patients.
Although not specifically designed for this purpose, the CTP has added value by building bridges between the traditionally isolated, sequenced, specialty-directed clerkships. In the past, each specialty used its allotted time to teach its discipline with little attention to what was taught in other clerkships. As an integrated overlay to the regular curriculum, the CTP has stimulated the faculty associated with the project to hold robust interdisciplinary discussions about the totality of the clinical curriculum, to share best practices, and to coordinate teaching efforts across clerkships.
The master clinical teachers’ monthly meetings are also a lively and effective forum for professional development. The risk that other clinical teachers may feel slighted by what seems to be an exclusive program seems not to have occurred. We have not noted any increased difficulty in recruiting clinical teachers, and student evaluations of nonmaster clinical teachers remain very high. In addition, Vanderbilt recognizes outstanding teachers in a variety of ways. All faculty are eligible for student- and peer-nominated teaching awards, as well as for induction into our Academy of Excellence in Teaching. The Master Clinical Teacher Program has provided special recognition to our most gifted teachers and elevated the teaching mission of the medical school.
Vanderbilt’s CTP, with its core interdisciplinary group of experienced clinical teachers and educators, is based on principles of effective education and research about the development of clinical competence. It assures patients that our graduates will have had instructive exposure to a wide variety of common presenting problems. The systematic, objective assessments we are planning will give students the feedback they need to determine their own learning needs, faculty the information they need to evaluate the program’s effectiveness, and the institution the data it needs to document the fulfillment of accreditation requirements.
The authors wish to acknowledge support received for the initiation of the Clinical Transaction Project at the Vanderbilt School of Medicine from the Arthur Vining Davis Foundation as administered by the New York Academy of Medicine and the Association of American Medical Colleges.