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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 Medicine November 9, 2011
2
Ann C. Jobe, MD,MSN Executive Director Clinical
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 For Clinical Skills
Curricula For Undergraduate Medical
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 For Clinical Skills
Curricula For Undergraduate Medical
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 For Clinical Skills
Curricula For Undergraduate Medical
Education(2008)
  • Diagnosis
  • The ability to diagnose and explain clinical
    problems in terms of pathogenesis, to develop
    basic differential diagnosis, and to 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 For Clinical Skills
Curricula For Undergraduate Medical
Education(2008)
  • Prognosis
  • The ability to understand and formulate a
    prognosis about the future events of an
    individuals health and illness based upon 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, health literacy,
    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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