What You See is What You Get: Conducting Direct Clinical Observations

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What You See is What You Get Conducting Direct
Clinical Observations

• John Encandela, PhD
• Lyuba Konopasek, MD
• Deepa Rao, MEd
• April 29, 2008 Weill Cornell April 30, 2008
  Columbia UMC

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This Workshop

• Objectives
• Identify key components of direct clinical
  observations.
• Identify areas of competencies assessed with
  direct observations.
• Identify various direct observation tools.
• Identify which tool would be appropriate for
  participants program and needs.
• Develop a plan for next steps in implementing a
  clinical observation assessment in participants
  program.

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What are Direct Clinical Observations

• Observation of resident/patient with observer in
  the room
• Assessment of clinical skills and behaviors
• Time efficient snapshot
• 10-25 minute time commitment from learner and
  observer
• Immediate formative feedback
• Limited feedback points given outside of
  patient room

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Why Direct Clinical Observation?

• 1995 AAMC noted shortcomings in teaching and
  evaluation of clinical skills.

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Why Direct Clinical Observation?
You can observe a lot just by watching.
--Yogi Berra
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Why Direct Clinical Observation?
Direct observation is best way of ensuring that
clinical competence exits.
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Why Direct Clinical Observation?

• Short observations and feedback provide
  effective teaching experience (not only
  evaluation).

Unconscious Competence
Conscious Competence
Conscious Incompetence
Unconscious Incompetence
Howells Stages of Competence
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Determining Goals of Implementing Direct Clinical
Observation

• Formative only
• To help residents improve performance in skill
  areas
• Summative only
• BUT, summative assessment was not original
  purpose of DCO different from OSCE
• Formative and summative

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What is Observed and Assessed?

• Interviewing/Communication/Counseling
• ISC, PC
• Humanistic Qualities/Professionalism
• Prof
• Physical Examination Skills
• PC, ISC, Prof
• Diagnosis Skills/Clinical Judgment
• MK
• Organization/Overall Clinical Competence
• Prof, PBLI
• 
  

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Examples of Existing Tools

• Structured Clinical Observations (SCO)
• Mini CEX

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SCO

• Communication skills
• Observer should pay attention to
• Content (What learner asks/tells?)
• Process (How learner asks/tells?)
• Physical exam
• Diagnosis
• Observer must diagnose the patient and the
  learner

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Implementing SCO

• Well in advance
• Introduce Learners to form before you conduct
  observations
• Beginning rotation
• At orientation
• Just before observation
• Negotiate which part of the encounter to observe
  with student
• Prepare patient

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Implementing SCO

• At time of observation
• Unobtrusively enter the room or ask learner to
  call for you when ready
• Observe the encounter10-15 minutes
• Focus observation using areas in checklist
• Write verbatim phrases for feedback
• Exit and allow learner to complete encounter
• Give feedback on 2-3 points5 minutes
• Give the learner copy of the completed checklist

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Implementing SCO

• Example Data gathering skills
• Opening/closing interview
• Data collection (open-ended questions, logical
  sequencing of questions)
• Relationship (listens, legitimizes patients
  feelings/concerns)
• Personal Manner (eye contact, body language)

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PRACTICE Data Gathering Skills
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Feedback

• Essential to learning with SCO
• Differs from reinforcement and evaluation

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Feedback

• Reinforcement ExplanationFeedback
• Based on observation
• Behavior based and focused on issues the learner
  can control
• Be specific
• Regulated in timing and quantity
• Timing - immediate
• Quantity- limited, not overwhelming

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Mini CEX

• Medical Interviewing Skills
• Physical Examination Skills
• Humanistic Qualities/Professionalism
• Clinical Judgment
• Counseling Skills
• Organization/Efficiency
• Overall Clinical Competence

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Implementing the Mini CEX

• Well in advance
• Introduce Learners to form before you conduct
  observations
• Beginning rotation
• At orientation
• Just before observation
• Negotiate which part of the encounter to observe
  with studentnot all areas of Mini CEX need to be
  observed in one sitting
• Prepare patient

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Implementing the Mini CEX

• At time of observation
• Unobtrusively enter the room or ask learner to
  call for you when ready
• Observe the encounter10-15 minutes
• Focus observation using areas in form
• Write verbatim phrases for feedback
• Exit and allow learner to complete encounter
• Give feedback on 2-3 points5 minutes
• Give the learner copy of the completed form

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PRACTICE Diagnosis Skills