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Promoting the Development of Clinical Skills throughout the Continuum of Medical Education University of North Carolina

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Title: Promoting the Development of Clinical Skills throughout the Continuum of Medical Education University of North Carolina


1
Promoting the Development of Clinical Skills
throughout the Continuum of Medical Education
University of North Carolina Chapel Hill
School of MedicineNovember 9, 2011
2
Ann C. Jobe, MD,MSNExecutive DirectorClinical
Skills Evaluation Collaboration (CSEC)
3
Clinical Skills in Practice
  • The physician-patient encounter is central to the
    identity of physicians in the US
  • Clinical skills of trainees and young physicians
    have been described as deficient since at least
    the 1970s
  • Good evidence supports the diagnostic and
    therapeutic value of the clinical encounter but
  • ..Technology, fragmented care, reimbursement,
    and practice culture affect the clinical
    encounter

Weiner,A. Nathonson M JAMA 1976
236852-855 Verghese, A et al Annals Int Med
2011155550-553
4
Clinical Skills in Practice
  • The clinical encounter is often buried in process
    measures, such as HEDIS or other guidelines
  • The ritual value of the clinical encounter is
    important, and must be balanced by its documented
    utility
  • The environment determines most of what and how
    trainees learn about the clinical examination

Weiner,A. Nathonson M JAMA 1976
236852-855 Verghese, A et al Annals Int Med
2011155550-553
5
COMMUNICATION
  • The essence of the patient-physician relationship
  • Includes communicating verbally, non-verbally, as
    well as actions and interactions during a
    physical examination

6
Communication
  • It is all about COMMUNICATING with patients and
    families and health professionals
  • It is all about improving communication to
    improve the quality and safety of health care

7
Why Assess Communication Skills?
  • Essential physician competency
  • (LCME, ACGME, ABMS, USMLE)
  • Clinical outcomes require effective communication
  • Public expectations need for more information
    and supportive interactions.
  • Quality measures now incorporate
    patient-centeredness

8
Patient-Centered Communication
  • Exploring the patients illness experience
  • Understanding the patient as a whole person
  • Picking up on patient cues
  • Involvement of the patient in problem definition
  • Involvement of the patient in decision-making
  • (now gt50 expect such involvement)
  • Finding common ground regarding management
  • Enhancing the doctor/patient relationship by
    being responsive to the patient

  • IOM,2001 Street,2008

9
Communication Skills
  • Prospective study of 80 medical outpatients with
    new or previously undiagnosed conditions
  • Internists asked to list their differential
    diagnoses and to estimate their confidence in
    each diagnostic possibility
  • after the history,
  • after the physical examination, and
  • after the laboratory investigation.

10
Communication Skills
  • In 61 of 80 cases (76), the leading diagnosis
    after taking the history agreed with the
    diagnosis accepted at the time the record was
    reviewed
  • The physical examination led to the diagnosis in
    10 patients (12)
  • The laboratory investigation led to the diagnosis
    in 9 patients (11)
  • These data support the concept that most
    diagnoses are made from the medical history

11
Communication Skills
  • Authors suggest that more time should be devoted
    to improving history-taking skills during
    clinical training.
  • Peterson MC, Holbrook JH, Hales D, Smith NL,
    Staker LV Contributions of the history, physical
    examination, and laboratory investigation in
    making medical diagnoses.
  • West J Med 1992 Feb 156163-165

12
Communication Skills
  • Numerous publications confirm that poor skills in
    patient communication are associated with
  • Lower levels of patient satisfaction
  • Higher rates of complaints
  • Increased risk of malpractice claims
  • Poorer health outcomes

13
  • High level skills in bedside medicine
    clinical skills
  • Ability to elicit a patients story/history
  • Correct use of evidence-based PE maneuvers in a
    focused manner based on history
  • Ability to synthesize information gathered
  • Ability to communicate and negotiate plans for
    management
  • are the cornerstone of patient safety and quality
    of care

14
Why Does It Matter?
  • Initiatives focused on improving clinical skills,
    especially communication through teaching and
    assessment - will be most successful in improving
    the quality and outcomes of care provided by
    health professionals

15
Comprehensive Program
  • Overarching Competencies and Objectives
  • Map for addressing teaching and assessing
    throughout the continuum of education
  • Course content
  • Assessment methodologies

16
AAMC Recommendations ForClinical Skills
Curricula For UndergraduateMedical
Education(2008)
  • Professionalism
  • The ability to understand the nature of, and
    demonstrate professional and ethical behavior in,
    the act of medical care.
  • Patient Engagement and Communication Skills
  • The ability to engage and communicate with a
    patient, develop a student-patient relationship,
    and communicate with others in the professional
    setting
  • Biomedical Knowledge Application Skills
  • The ability to apply scientific knowledge and
    method to clinical problem solving.

17
AAMC Recommendations ForClinical Skills
Curricula For UndergraduateMedical
Education(2008)
  • History Taking
  • The ability to take a clinical history, both
    focused and comprehensive.
  • Patient Examination
  • The ability to perform a mental and physical
    examination
  • Clinical Testing
  • The ability to select, justify and interpret
    selected clinical tests and imaging
  • Clinical Procedures
  • The ability to understand and perform a variety
    of basic clinical procedures

18
AAMC Recommendations ForClinical Skills
Curricula For UndergraduateMedical
Education(2008)
  • Diagnosis
  • The ability to diagnose and explain clinical
    problems in terms of pathogenesis, to develop
    basic differential diagnosis, andto learn and
    demonstrate clinical reasoning and problem
    identification.
  • Clinical Information Management
  • The ability to record, present, research,
    critique and manage clinical information
  • Clinical Intervention
  • The ability to understand and select clinical
    interventions in the natural history of disease,
    including basic preventive, curative and
    palliative strategies

19
AAMC Recommendations ForClinical Skills
Curricula For UndergraduateMedical
Education(2008)
  • Prognosis
  • The ability to understand and formulate a
    prognosis about the future events of an
    individuals health and illness basedupon an
    understanding of the patient, the natural history
    of disease, and upon known intervention
    alternatives.
  • Personalizing Clinical Care
  • The ability to provide clinical care within the
    practical context of a patients age, gender,
    personal preferences, family, healthliteracy,
    culture, religious perspective, and their
    economic circumstances

20
Core Competencies Assessment
  • Patient Care/Clinical Skills
  • Students must be able to provide care that is
    compassionate, appropriate, and effective for
    treating health problems and promoting health

21
Core Competencies Assessment
  • Interpersonal Communication Skills
  • Students must demonstrate interpersonal and
    communication skills that facilitate effective
    interactions with patients and their families and
    other health professionals

22
Developing a Comprehensive Program
  • Types of assessments
  • Examinees
  • Timing of assessments

23
  • Types of assessments
  • Formative
  • Designed to provide feedback to facilitate
    acquisition of new skills or improvement of
    performance
  • Part of continuous professional development
  • Part of performance and quality improvement

24
  • Types of assessments
  • Summative
  • High stakes
  • Associated with an important decision like
    graduation, licensure, certification or
    credentialing
  • Utilized to distinguish between those who are
    competent and those who are not

25
  • Types of assessments
  • Snapshot
  • One time assessment
  • Longitudinal
  • Repeated over various periods of time

26
  • Timing of assessments
  • At planned intervals for promotion decisions
  • Ongoing for continuous professional development
    and/or performance improvement
  • One-time snapshot for initial licensure
  • Repeat assessment for license renewal
  • For credentialing or granting privileges
  • Review for re-entry into practice

27
Program Elements
  • Depend on PURPOSE of the assessment
  • and
  • LEVEL of the examinee

28
Assessing Skills and Performance
  • What is included in an assessment of skills and
    performance?
  • What are some of the assessment methods and how
    are they assembled?
  • How do the methods perform against the criteria
    for good assessment?

29
Millers Pyramid for Assessing Clinical Competence
Action
Performance
Competence
Knowledge
30
Kirkpatrick Criteria
  • Results
  • Change in organizational practice
  • Benefits to patients/clients
  • Behavior
  • Transfer learning to workplace
  • Learners apply new knowledge and skills
  • Learning
  • Change attitudes/perceptions
  • Change knowledge/skills
  • Reaction
  • Customer satisfaction related to participation in
    educational activities

31
Simulation
  • Simulation
  • Real patients are replaced with realistic but
    artificial experiences
  • Trainee interacts with the re-creations
  • Judgments are made about their performance

32
Simulation
  • Methods can be divided according to how faithful
    they are to reality
  • Intermediate fidelity
  • Task specific models
  • Instructor driven models
  • High fidelity
  • Virtual reality
  • Standardized patients (SPs)?

33
Method Task Specific Models
  • Designed around a specific task
  • Venipuncture model
  • Animal cadavers
  • Usually not automated
  • Relatively inexpensive

34
Method Instructor Driven Models
  • Physical representation
  • Responses driven by an instructor
  • Little feedback
  • Moderate cost

35
Method Virtual Reality Simulators
  • Simple physical representation
  • Sensing device that informs computer of user
    actions
  • Computer models realistic reactions
  • 3D imaging
  • Haptics

36
Method Standardized Patients
  • Individuals trained to portray a patient
  • Scripted and standardized
  • USMLE Step 2 CS example
  • Integrated Clinical Encounter
  • Data gathering
  • SP completing checklists
  • Written communication
  • Doctor rating a patient note
  • Communication Interpersonal skills
  • SP Rating
  • Spoken English
  • SP Rating

37
Ideal Assessment of Communication Skills
  • Evidence-based construct
  • Assessment instrument consists of observable
    behaviors
  • Realistic stimuli
  • SPs trained to use instrument reliably
  • Appropriate scoring decisions

38
Putting it Together Objective Structured
Clinical Examination (OSCE)?
  • Multiple stations
  • Each focused on a specific aspect of competence
  • Stations might include
  • Manikins
  • SPs
  • ECG or X-ray interpretation
  • Heart sounds
  • Animal cadavers
  • Anastomosis
  • Laparoscopic vessel ligation
  • Simulators
  • In a way the OSCE is not an examination method
    rather it is an examination format or framework
    into which many different types of test methods
    can be incorporated
  • Ian Hart, 2001

39
Putting it Together OSCE
  • Stations are usually short 10-15 minutes
  • Test is composed of 8-25 stations
  • Round-robin format
  • At a bell, examinees rotate to next station
  • Can accommodate as many examinees as stations
  • Total score is calculated across all stations

40
Work-based Methods
  • Work-based assessment
  • Real patient encounters
  • Trainees are observed
  • Judgments are made about their performance
  • When your work speaks for itself, don't
    interrupt.
  • Henry Kaiser

41
Work-based Assessment
  • Foundation Programme (in the UK)
  • Two-year program
  • Bridge between medical school and advanced
    training
  • Series of clinical placements
  • Assessment Purpose
  • Determine fitness to progress to the next level
  • Identify trainees in difficulty
  • Provide feedback
  • Establish accountability
  • Three methods
  • Mini-Clinical Evaluation Exercise (mCEX)
  • Directly Observed Procedures (DOPs)?
  • Case-Based Discussion (CbD)?

42
Mini-Clinical Evaluation Exercise (mCEX)
  • Process
  • List of patient problems
  • Trainee picks a patient
  • Assessor observes the encounter
  • Focused clinical task
  • Assessor rates
  • Hx, PE, Communication, Clinical Judgment,
    Professionalism, Organization/Efficiency
  • Assessor provides feedback
  • Takes 15-20 minutes

43
Directly Observed Procedures (DOPs)?
  • Process
  • List of procedures
  • Trainee picks a patient
  • Assessor observes the encounter
  • Procedure
  • Assessor rates
  • Preparation, Sedation, Asepsis, Technical skill,
    etc.
  • Assessor provides feedback
  • Takes 15-20 minutes

44
Case-Based Discussion (CbD)?
  • Process
  • List of patient problems
  • Trainee picks 2 case records
  • Assessor selects one
  • Discussion centered on the trainees notes
  • Assessor rates
  • Diagnosis, Treatment, Planning, Professionalism,
    etc.
  • Assessor provides feedback
  • Takes 15-20 minutes

45
Putting it Together Work-based Assessment
  • An OSCE on the hoof
  • Multiple encounters are needed
  • Captured as feasible during clinical training
  • Multiple examiners are needed
  • Encounters can be made to conform loosely to a
    problem list
  • Ongoing, longitudinal assessments

46
Criteria for Judging an Assessment
  • How do simulation and work-based assessment
    perform against the criteria?
  • Validity
  • Reliability
  • Equivalence
  • Educational effect
  • Opportunity for feedback
  • Feasibility

47
Validity
  • What is validity?
  • Degree to which the inferences based on scores
    are correct
  • Does the test measure what it is supposed to
    measure?
  • Simulation
  • Good content coverage
  • Rare conditions
  • Errors cause no harm
  • Good fidelity
  • Work-based methods
  • Excellent content coverage
  • Includes difficult to simulate conditions
  • High fidelity

48
Reliability
  • What is reliability?
  • If an assessment process is repeated with the
    same trainees, they should get the same scores
  • Physician performance varies considerably from
    patient to patient
  • The trainee must be observed with several
    patients
  • Assessors differ in stringency
  • The trainee must be evaluated by different
    examiners

49
Equivalence
  • What is equivalence?
  • To compare examinees they must have taken
    assessments that are equal in difficulty
  • Fairness
  • Comparable meaning
  • Simulation
  • Different examinees can be given the same items
  • Security
  • Statistical techniques help with different
    versions
  • Work-based methods
  • Equivalence is a problem that can be mitigated
    but not eliminated

50
Educational Effect
  • Students respect what you inspect.
  • Both simulation and work-based methods signal the
    importance of working with patients
  • Drives learning

51
Opportunity for Feedback
  • Feedback is critical to learning
  • General education (Hattie, 1999)?
  • Meta-analysis of 12 meta-analyses
  • Feedback is among the largest influences on
    achievement
  • Medical education (Veloski et al., 2006)?
  • Feedback alone is effective in 71 of studies
  • Simulation
  • Amount of feedback varies by method
  • Depends on deployment
  • Lower for instructor driven methods
  • Higher for model driven methods
  • Work-based methods
  • Trainees rarely observed
  • Provides an excellent opportunity for feedback
    following observation

52
Feasibility
  • There are significant resource constraints in
    most educational programs
  • Simulation
  • Purchase, maintenance, logistics
  • Case development
  • SP/Observer training
  • Work-based methods
  • Faculty development
  • Logistics

53
Summary Assessment of Skills and Performance
  • Trainees must show how
  • Simulation
  • Can produce equivalent scores
  • Work-based methods
  • Cover more patient problems
  • Can be more feasible
  • Both methods
  • Require multiple patients and examiners
  • Have positive educational effects
  • Provide opportunities for feedback

54
Finding Opportunities
  • Seeking out the best practices already in place
    across the organization
  • Disseminating and seeding what is working to
    other areas
  • Finding ways to maximize synergy of work already
    in place

55
Opportunities Along the Continuum
  • Assessment of team member performance

56
Opportunities Along the Continuum
  • Assessment of outcomes of a teams performance

57
Opportunities Along the Continuum
  • Assessment of individual team members using
    standardized team members

58
Opportunities Along the Continuum
  • Assessment of teams composed of members of
    several health professions

59
Opportunities Along the Continuum
  • Standardized Patient assessments/ OSCEs
    simulations for
  • Incoming residents
  • Residents moving into supervisory roles
  • Residents at completion of residency
  • New medical staff credentialing review and
    privileging
  • Individuals who are re-entering practice

60
Opportunities Along the Continuum
  • Secret Shoppers -standardized patients in
    clinical settings assessing clinical skills of
  • Residents
  • Faculty
  • New medical staff credentialing review and
    privileging
  • Individuals upon re-entry into practice

61
Most Important Consideration
  • A Comprehensive Program based on
  • Well defined Purpose and Goals
  • Overarching Competencies and Objectives
  • A detailed Map that covers the timing and
    methodologies of assessments across the continuum
  • Focused efforts on gaps in teaching and
    assessment
  • A well thought out evaluation of the program
  • Providing data and evidence supporting the
    benefit to patients and improvement in care

62
Why Does It Matter?
  • Initiatives focused on improving clinical skills,
    especially communication through teaching and
    assessment - will be most successful in improving
    the quality and outcomes of care provided by
    health professionals

63
THANK YOU
  • Let us continue on the journey together
    improving how we care for our patients
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