Anxiety in medical students has been recognized in the literature for many years1–3 and may center around first patient encounters and first physical examinations performed on actual patients.4 Data suggest that students feel most prepared when clinical skills are introduced early in their curriculum, and that students typically value opportunities to interview and examine patients, as opposed to passive learning via lectures.5–7 Approaches to better prepare medical students include improving students’ physical diagnosis8,9 and communication skills.10–12 Additional research supports the importance of mentoring relationships in alleviating medical student anxiety.13,14 Many of these studies focus on changes either to a particular course or to the medical school curriculum during the clinical years. However, medical student anxiety is often most prevalent when first entering the clinical years (i.e., at the beginning of the third year of a traditional four-year medical school curriculum).
The University of Washington School of Medicine (UWSOM) developed a competency-based College approach to the early introduction of clinical skills to medical students, which is currently in its fourth year of practice. The Colleges provide a consistent faculty mentor/advisor to each student, who oversees and teaches a four-year curriculum of clinical skills and professionalism including a restructured introduction to clinical medicine II (ICM II) course in the second year. The ICM II course includes one morning a week throughout the second year of medical school, in which each faculty member teaches clinical skills and professionalism to their group of 6 students in an inpatient, bedside setting.15
The goal of our current study is to determine whether the College system and the revised ICM II course are improving comfort level with clinical skills for medical students entering their third year clinical rotations. Our hypothesis is that those third-year students exposed to the College system will have an improved comfort level in the core clinical skills, as compared to those third-year students who were not exposed to the College system and revised ICM II course during their second year. These core clinical skills consist of proper physical examination techniques, relevant history taking and communication skills, and experience in the patient care setting.
The design is a nonrandomized, prospective cohort study conducted from 2003–2005. The target population consisted of two cohorts of medical students at the UWSOM: those third year students who entered medical school in 2000 (E-00), and those third year students who entered medical school in 2001 (E-01) or 2002 (E-02). The E-00 students completed the second year of medical school and entered the third year prior to the curriculum changes that are the subject of this study. Both the E-01 and E-02 students participated in the College system and the revised ICM II course during their second year of medical school. Students were identified as being members of a certain class based upon UWSOM-compiled e-mail lists. Those members of a third year class who were not involved in third year clinical clerkships (e.g., MD/PhD students and those students who had expanded their medical school curriculum) were requested to not fill out the survey. The survey instrument was developed as an anonymous, web-based questionnaire (Table 1) with multiple-choice questions using a 5-point Likert scale and grouped in the following categories: history taking skills, physical examination techniques, communication skills, and patient care.
In March 2003, an e-mail was sent to the E-00 third year class requesting completion of a brief, anonymous online survey. Two follow-up emails were sent over the next month. In March 2004 and 2005, emails were sent to the current third year class (E-01 and E-02, respectively) requesting completion of the survey. Responses were compiled and the results from each cohort were compared using the one-tailed Wilcoxon-Mann-Whitney nonparametric test for ordinal data in Matlab (Mathworks, Inc., Natick, MA).
The Institutional Review Board, Human Subjects Division, of the UWSOM exempted this study from further review in March 2003 (exemption reference number 03–6855-X.) No funding sources were used for this study.
Overall, 99 of 135 (73%) respondents from the E-00 class, 95/128 (74%) from the E-01 class and 94 of 129 (73%) from the E-02 class completed the survey. The results of the survey are shown in Table 2 along with the p values for the Wilcoxon-Mann-Whitney test comparing the E-00 cohort with the combined E-01 and E-02 cohort.
As noted in Tables 1 and Table 2, statistically significant improvement in students’ self-reported comfort levels were found for the following skills: obtaining a history of present illness, performing a complete physical exam, specific exam maneuvers chosen to represent the head and neck, cardiovascular, pulmonary, and abdominal exam, oral case presentations, discussing patients with attending physicians, using medical equipment and working in the patient care setting.
Our study focuses on students’ comfort level in a variety of different areas, rather than on the competencies of third year medical students during their core clinical rotations. Additional studies addressing competencies in these skills are currently taking place at the UWSOM. However, based on our results, we feel that exposure to the College system and revised ICM II course has an overall positive impact on students’ perspectives regarding their comfort with clinical skills and may help to alleviate some of the anxiety that third year students experience when beginning clinical rotations. Those third year students involved in the College system reported a statistically significant (p < .05) greater comfort level in half of the measured areas, and in at least one area in each of the general categories (history taking, physical examination, communication, and patient care). No specific area showed a statistically significant decline.
We decided to question students regarding comfort levels with specific physical examination maneuvers rather than with a certain part of the physical exam in the abstract. Our thinking was that the student would be able to provide a more accurate self-assessment when considering a concrete maneuver, which could serve as a proxy measure. In choosing which specific “benchmark” physical examination techniques to represent a particular body or organ system, we attempted to filter out those techniques that may have been learned during the first year of medical school (e.g., auscultation of normal heart sounds), as well as those techniques that tend to be part of a more advanced physical examination (e.g., eliciting a Murphy’s sign during an abdominal examination). Those techniques that are represented in the survey were specifically chosen because they are considered to be “benchmark” requirements for successful completion of the revised ICM II course. However, considering the broad range of maneuvers that are part of a complete physical examination, it becomes recognizably difficult to choose the perfect representative maneuver for each system.
Several areas did not show an improvement between the cohorts. Certain survey questions, such as those focused on perceived comfort level in obtaining a complete social history and review of systems, are not primary focuses of the ICM II course, but rather the focus of the introduction to clinical medicine I course (ICM I) taught during the first year of medical school. In addition, the teaching of the female breast exam and the male prostate exam occurs in the ICM I course and have not yet been the focus of change in the revised ICM II format. However, we note that the continued discomfort that students’ experience with the prostate exam highlights our need for added focus on teaching this important clinical skill. Other areas that failed to show improvement include the maneuvers for the neurological and musculoskeletal exam, and these results will also help to tailor future teaching efforts.
Several other questions did not show a statistically significant improvement, largely because students were already relatively comfortable with these areas. Only a few students in either cohort felt uncomfortable discussing patients with peers or with patient interaction. Comfort with formulating a differential diagnosis (p = .081) and comfort with patient interaction (p = .13) showed improvement but did not meet the criteria for statistical significance. For patient interaction, part of the lack of statistical significance likely resulted from the relatively high comfort level in both groups as noted above. However, these questions also represent two areas, clinical reasoning and communication skills, that lacked specific curricula during the time studied. We have subsequently developed and implemented curricula for clinical reasoning and communication and will be interested to see if comfort levels in these areas continue to improve.
Our study has a number of limitations. This is a single institutional study limited to the Colleges curriculum at the UWSOM. Moreover, since we investigated a curriculum-wide change, the subjects were not randomized and therefore a historical cohort was used as a control population. Due to the time required for study design and human subjects approval, our survey was administered approximately eight months after the initiation of third year clinical rotations. This required medical students to reflect back on perceptions they had during their first two rotations of third year, approximately 5–8 months prior to survey administration. However, even with the timing delay, we believe that our study was worth pursuing, given the opportunity to take advantage of a transition in the medical school curriculum. We made efforts to avoid recall bias by retaining the same timing of survey administration for all three groups. Our initial concern was that the delay would tend to underestimate differences between the cohorts. As time elapsed between the different second year exposures, any differences may become increasingly mitigated by the common third year experience. If such a ‘regression towards the mean’ did occur, it would tend to reduce rather than amplify any differences between cohorts, in which case our observed findings would be overly conservative.
Despite some of the limitations noted above, our results are encouraging that a College-based approach and expanded clinical experience during the second year of medical school help to increase students’ comfort level at the beginning of their third year.
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