Procedural and technical skills are among the clinical skills required for the practice of medicine, regardless of specialty. Although internal medicine is more cognitively, and less procedurally, oriented than are many specialties, internists perform, on average, 16 procedures in their practices.1 2 3
Residents are expected to perform a number of procedures early in their training and with variable levels of supervision. However, several studies have raised doubts about residents’ preparedness for these duties. A survey of internal medicine program directors found a low level of confidence in their trainees’ ability to perform a variety of procedural skills.4 5 6 7
Although medical students acquire experience performing procedures during their third-year clerkships, which skills they should acquire remains unclear. A survey published in 1991 outlined ten procedures that a majority of clerkship directors thought medical students should learn during their internal medicine clerkship.8 9 10–12
Residency training and medical practice are rapidly changing, and we were concerned that attitudes about students’ learning procedural skills may have changed since prior assessments. Clerkship directors have a valuable perspective of what medical students need to learn, and they are charged with evaluating what students have learned in their clerkship experiences. We sought the opinions of the CDIM members regarding which procedural skills they thought medical students should learn and do learn during their clerkships. We hypothesized that the clerkship directors’ opinions might be affected by their clinical duties, career experiences, or clerkship structure, so data were collected on these subjects as well. CDIM members include researchers and clinicians, generalists and specialists, hospitalists, and ambulatory physicians. We thought that those clerkship directors with more clinical duties, especially inpatient, and those with longer inpatient clerkships might have higher procedural expectations for students
Method
The 2002 CDIM membership survey covered four themes dealing with medical student education. The survey also contains yearly updates on clerkship characteristics and clerkship directors’ demographics. The membership represents the internal medicine clerkship directors at 123 U.S. and Canadian medical schools. The survey had been prepared by the CDIM Publications Committee and approved by the CDIM Council. The content was based on review of earlier work and procedures identified by the committee. Responses were kept confidential.
The complete survey questionnaire consisted of 79 items. The first section of the questionnaire asked about demographics. Those of interest for this analysis were age, year of medical school graduation, gender, full-time (versus part-time) status, academic rank (instructor, assistant professor, associate professor or professor), percentage of time spent on the internal medicine clerkship, and the amount of time spent in clinical activities. The questions were multiple choice, fill in the blanks, or answered using a five-point Likert scale. The next section dealt with clerkship characteristics. The items included clerkship length, ambulatory components, and participation of other departments in the clerkship. The question formats were similar to those in the first section.
The central part of the questionnaire consisted of eight items dealing with teaching procedural skills. The first item asked participants to indicate whether they thought medical students should be taught and actually do learn 20 technical and procedural skills during their third or fourth years of medical school. The skills listed were spirometry interpretation, chest x-ray interpretation, evaluating peripheral blood smears, electrocardiogram interpretation, reading gram stains, urinalysis, performing blood cultures, throat cultures, phlebotomy, inserting venous catheters, obtaining arterial blood samples, performing lumbar punctures, nasogastric tube insertion, thoracentesis, paracentesis, cardioversion, urethral catheter insertion, obtaining Pap smears, purified protein derivative (PPD) placement, and performing cardiopulmonary resuscitation.
The remaining seven items asked about instructional techniques and assuring students’ competency in performing procedures. First, participants were asked whether they offered any instruction in procedures. If they answered yes, they were asked if the instruction consisted of lectures, texts, workshops, computer-based instruction, handouts, or other forms. The next item asked if the participants assessed competency at procedures. If they did, they were asked whether competency was assessed by a clinical skills examination, faculty or resident evaluations, a written examination, a standardized patient examination, or some other method. The next two items dealt with whether log books were used to document procedures which students either performed or observed. Finally, we asked if the clerkship directors desired curricular materials on procedures from CDIM.
CDIM members had the choice of completing either a mailed paper questionnaire or an electronic version on CDIM's Web site. Each member received an e-mail notification and a paper copy of the questionnaire. Approximately 60% chose the paper format, while 40% chose the electronic format. Questionnaires were coded to enable tracking of nonrespondents, but codes were separated from completed questionnaires. Nonrespondents were given up to three e-mail or telephone reminders over the ensuing four months. CDIM staff collected and entered the questionnaire data.
The analysis was performed at the University of Pittsburgh. Comparisons between dichotomous variables were performed using chi square. Comparisons between continuous variables were performed with t -tests, analysis of variance, or the Wilcoxon rank sum test, where appropriate. To adjust for demographics and clerkship characteristics, we performed a multivariate analysis using forward, stepwise linear regression with the number of procedures students should and actually learn as dependent variables. All analysis was performed on JMP software (SAS Institute, Cary, North Carolina).
Results
The questionnaires were completed by 89 clerkship directors (72%). Their demographic data are shown in Table 1 . Of note, most of the respondents were full-time faculty with a mean interval of 20 years since medical school graduation. They represented a mixture of academic ranks and generally described themselves as clinician educators. They maintained significant clinical activity, with 3.4 half-days of outpatient clinic weekly and 8.8 weeks of service yearly. They spent more than a quarter of their time on the internal medicine clerkship and had been clerkship directors for over six years. The mean clerkship length was ten weeks, 74 clerkships included ambulatory components, and 31 respondents participated in interdisciplinary clerkships.
Table 1: Demographic Characteristics of 89 U.S. and Canadian Internal Medicine Clerkship Directors Who Responded to a Questionnaire on Teaching Procedural and Interpretive Skills to Medical Students, 2002
The majority of respondents thought students should learn 17 of the 20 procedural skills (see Table 2 ). Over 80% thought that students need to learn to interpret chest x-rays, perform phlebotomy, interpret electrocardiograms, perform throat cultures, obtain blood cultures, perform urinalysis, and perform Pap smears during their junior clerkships. The mean number of procedures respondents thought students should be taught was 15 (standard deviation [SD] = 3) with a median of 16. Of the procedures we listed, only thoracentesis, paracentesis, and cardioversion were thought by a majority of respondents to be inappropriate for third year students to learn. In a multivariate analysis, the expectations regarding students’ learning procedural skills were unaffected by controlling for respondents’ demographics, clerkship characteristics, or the teaching variables.
Table 2: Responses of 89 U.S. and Canadian Internal Medicine Clerkship Directors to Questions about Whether Medical Students Should Be Taught and Do Learn Interpretive and Procedural Skills, 2002
The responses to “should teach” and “do learn” items were highly correlated (r = .67). However, the mean number of procedures that respondents thought their students actually learn was only 12 (SD = 4). The majority thought that students do not learn pulmonary function testing, peripheral blood smears, gram stains, lumbar puncture, thoracentesis, paracentesis, cardioversion, and urethral catheter insertion, even though they thought their students should learn them. For PPD, gram stain, urinalysis, throat cultures, and peripheral blood smears, the gap between “should teach” and “do learn” was more than 20%.
Few respondents thought the listed skills should be taught during the fourth year of medical school. However, when respondents who thought thoracentesis, paracentesis, and cardioversion should be learned in the third year are combined with those who felt these skills should be learned in the fourth year, they become a majority who thought the skills should be learned during medical school.
About half (44%) had some type of formal instruction in procedural skills, and they incorporated a variety of teaching techniques, including workshops (no. = 37), lectures (no. = 16), handouts (no. = 11), computer-based instruction (no. = 7), texts (no. = 5), and other forms of instruction (no. = 7). Several of the respondents used multiple instructional methods. Despite these existing curricula, most clerkship directors (85%) would have welcomed receiving curricular materials on teaching procedural skills from a national organization, such as CDIM.
Forty-six respondents (52%) required students to keep logs of procedures they performed, and 39 tested students’ competency in performing procedures. The testing methods included instructors’ evaluations (no. = 26), a written examination (no. = 16), an objective structured clinical examination (OSCE) (no. = 15), and a clinical skills examination (no. = 13).
Discussion
This study demonstrates a consensus among internal medicine clerkship directors that medical students should learn a variety of procedural and interpretive skills. Over half of the respondents thought the students should learn each of the procedures about which we asked, except for three invasive procedures. On average, each respondent thought 15 of the skills were appropriate for students to learn. Adjusting for respondents’ demographics and clerkship characteristics did not affect the findings. We thought that clerkships with more clinical, especially inpatient, duties might have higher expectations for students’ mastering procedural skills. Similarly, we thought longer clerkships, ones with greater inpatient components, or ones involving other disciplines (such as surgery) might have greater expectations. However, none of these factors affected the respondents’ opinions.
Thirteen of the 20 skills in our questionnaire appeared on a prior CDIM questionnaire. For none was the difference between those respondents’ and the current respondents’ opinions more than 20%, and for only three was the difference more than 10%.8 9
Some responding clerkship directors doubted whether students do learn the skills, and there may be several reasons for failure to learn them. Some sites may lack a sufficient patient base, and some may have logistical complications, such as delegating procedures to nonphysicians. Some academic attending physicians seldom perform these procedures and may feel inadequate as teachers.13 10,11
The respondents described using several instructional methods, and we did not attempt to establish the methods’ effectiveness. Successful approaches usually involve workshops supplemented by didactic sessions or Web-based materials. The authors of these various studies describe using models, cadavers, standardized patients, pathologic specimens, and animals for teaching, while instructors may be faculty, residents, or lab technicians.14–18
About half our respondents reported using logs and nearly as many assessed competency. Logs have the advantages of convenience and their use is associated with increased student exposures.19 20
Our study had some strengths and weaknesses that deserve mentioning. It represents a sample of internists actively involved with U.S. and Canadian medical students and had a good response rate. However, CDIM members offer an internal medicine perspective that may differ from the perspectives of clerkship directors in other specialties. Furthermore, respondents’ opinions may vary from those of other faculty members or nonfaculty practitioners. Medical students may disagree with clerkship directors about the skills with which they do acquire competence. As in any cross-sectional study, the responses represent a single point in time. Finally, the questionnaire's length limitations did not allow us to attempt to establish a hierarchy or a ranking of which procedures were felt to be most vital for students to learn.
In summary, this study demonstrates a consensus among internal medicine clerkship directors that procedural and interpretive skills should be taught to medical students. However, discrepancies exist between what students should and actually do learn. These findings may help prioritize teaching efforts and may stimulate the development of curricular materials, which many clerkship directors indicate they would welcome.
The views expressed in this paper are solely those of the authors and do not necessarily reflect the official views of the U.S. Department of Defense, the United States Air Force, or other federal agencies. The authors would like to thank the CDIM staff for collecting the data and Sylvia Ford for preparing the manuscript.
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