Knowing is not enough; we must apply.

Willing is not enough; we must do.

Goethe
Clinical Skills Education
Considerations on…
Why, What & How?
Eugene C. Corbett, Jr., M.D., FACP
Brodie Professor of Medicine
Professor of Nursing
University of Virginia
Chair, AAMC Task Force on Clinical Skills Education
Agenda

 What is skill learning?

 Knowledge versus skills education
 Why the emphasis on skills education now?
 Does curricular emphasis make a difference?
 How?
 AAMC Task Force recommendations
 Some examples of clinical skills teaching
 Some closing tips for skills teaching
In skills education….

….the accent is upon learner doing!

….upon the application of knowledge and

understanding to an intellectual,
psychomotor or affective activity
What is skill learning?

Reflect on your own skill development…

Think of anyone (teacher, friend, family

member…) who has been most helpful to you
in developing a skill that you are good at.
What is the skill?
What did they do to help you learn to do that
skill?
General Principles of
Skills Teaching & Learning
 It has a clear and specific purpose
 It reinforces knowledge and understanding
 It must be demonstrated well
 An opportunity to try it out
 An opportunity to practice it
 Coaching (observation) and
 Useful evaluation and helpful feedback
 Emphasis upon self-directed initiative
 Guided by an explicit performance standard
 Guided by a high performance standard
 Confidence-building opportunity in direct patient care
Knowledge Acquisition vs
Skill Development
DOMAIN KNOWLEDGE SKILL

Teacher Role lecture mentor

Activity Center teacher learner

Learning anytime limited
Opportunity
Learning variable size discrete &
Increment well defined
Assessment & anytime as soon as possible
Feedback:
Setting almost anywhere clinical/simulated
Need for repetition: variable mandatory
Why the emphasis on skills education?

Patient care is an applied activity

Performance emphasis is increasing at all levels of our
professional activity
Medical school skills education has been slipping
We want better UME clinical performance outcomes
Competency-based Clinical
Performance Outcomes in
Medical Education & Practice
• LCME: Medical Education Objectives and
Documentation of Students’ Clinical Experience
• USMLE Clinical Skills Examination
• AAMC: Students Clinical Skills Education
• ACGME Postgraduate competencies
• IOM: Medical Error in the caring process
• JCAHO: Hospital Performance Measures
• 3rd Party Payers: Physician Pay-for-Performance
Abraham Flexner

“On the pedagogic side, modern medicine,

like all scientific teaching, is characterized
by activity. The student no longer merely
watches, listens, memorizes: he does. His
own activities in the laboratory and in the
clinic are the main factors in his instruction
and discipline. An education in medicine
nowadays involves both learning and
learning how; the student cannot effectively
know, unless he knows how.” (1910)
The Purpose of
Undergraduate Medical Education

…to provide for the development of the

knowledge, skills and values necessary
to undertake the life-long responsibilities
of a physician….
 UME Clinical Skills Education:
(It looks weak!)

• It is not explicit in the curriculum

• It is variable within a school
• It is not standardized across schools
• It is not explicitly developmental
over the 4 year curriculum
• It is only loosely connected to GME
expectations
Some AAMC Medical School Data:

1. Competency-based skill learning objectives 26%

2. Any formal skills curricula 52%
3. Skills curricula in clinical years 13%
4. Explicit list of skills to be learned 21%
5. Clinical skills education facility 59%
6. Standardized patients/assessment 65%
UVA CLINICAL SKILLS SURVEY
Student Self-estimate of Skill Performance
(2003)

 Hepatic size & consistency 77%

 Basic CPR 73%
 Suture a Laceration 72%
 Observe & interpret a Gallop 65%
 Interpret spirometry 62%
 Do a peak pulmonary flow 52%
 Work with a reluctant nurse 52%
 Phone: a swallowed penny 45%
 Jugular venous pulsation 38%
 Simple forearm cast 8%
 UVA Post-clerkship OSCE data
(2006)
Score Above the Median Score Below the Median
Skill

Critical Action Critical Action Critical Action Critical Action

Correct Incorrect Correct Incorrect

Detect an Arrhythmia (n=45) 17.8% 13.3% 20% 48.9%

Maintain Aseptic Technique 1.8% 46.4% 0% 51.8%

(n=110)

Measure Blood Pressure 35.3% 10.1% 28.6% 26.0%

(n=119)

Maintain 22.0% 0% 4.3% 73.7%

Confidentiality (n=118)

Perform an ECG (n=26) 3.8% 42.3% 0% 53.9%

Phone Triage an Infant with 26.1% 21.7% 0% 52.2%

Fever (n=23)

Communicate Through an 4.9% 21.9% 9.8% 63.4%

Interpreter (n=41)

Manage a Medical Error 26.1% 21.7% 2.2% 50.0%

(n=46)

Examine Child’s Ears (n=33) 30.3% 18.2% 0% 51.5%

Auscultate the Second Heart 30.3% 6.1% 9.1% 54.5%

Sound (n=33)
 A 4th Year Medical Student
(2006)

“While in medical school we are continually

encouraged to master a common body of
knowledge, we are not as expected to master
clinical skills. After reviewing my performance
on videotape, I realize that I also have to master
the skills of the patient encounter.”
Clinical Skills Education,
Curricular Emphasis…

 Does it make any difference in clinical

learner performance outcomes??
 Overall Score on 4th Year Clinical Skills
35 Assessment
30
Studen
25
ts
#

Old Curriculum
20

15

10

35

30

25
Studen

20
New Curriculum
ts
#

15

10

0
DUTCH CLINICAL SKILLS OUTCOMES
 AAMC Task Force on
Clinical Skills Education,
a key consensus issue:

How do we define basic clinical method?

What are the essential clinical

competencies for UME??

www.aamc.org/meded/clinicalskills/ 2005, 2008

 Medical Education:
begin with the end in mind…

Clinical Competency Domains

=
Medical Education Objectives
 12 Clinical Competency Domains
of Basic Clinical Method
AAMC 2005

#1-3. Three competencies that students bring to

medical school in varying degrees of
development
#4-8. The five elementary competencies
#9-11. The 3 clinical management competencies
#12. The most practical clinical competency
 Basic Clinical Method

The 3 competencies that students bring in

varying degrees of development to
medical school:

1. Professionalism
2. Patient engagement &
communication
3. Scientific knowledge & method
Basic Clinical Method

The 5 elementary competencies:

4. Clinical history-taking
5. Mental & physical examination
6. Clinical tests & imaging
7. Basic clinical procedures
8. Clinical information management
Basic Clinical Method

The 3 case management competencies:

9. Diagnosis & differential diagnosis
{defining the clinical problem}
10. Clinical Intervention
{caring for the clinical problem}
11. Clinical prognosis
{anticipating and planning for
future healthcare outcomes}
AAMC 2005

The final universal clinical competency:

12. The ability to provide the patient’s
care within the context of
the patient and their preferences,
family preferences,
economic, cultural,
ethical, legal,
healthsystem,
and societal preferences and constraints.
ACGME 1999

1. Professionalism
2. Interpersonal & communication skills
3. Medical knowledge
4. Patient care
5. System-based practice
6. Practice-based learning & improvement
ACGME for UME??

Patient Care
Professionalism
Interpersonal & communication skills
Medical knowledge
System-based practice
Practice-based learning & improvement
 How?

What are some examples of skills teaching?

Some practical tips
for clinical skills teaching…

 Keep in mind the 12 domains of basic clinical method

 Specifically speaking, there are many basic clinical
skills to teach and learn
 Choose to your strengths but add on some others
 Make it case-based if at all possible
 Please don’t worry about being too basic
 Know your learners and what they can do
 In the clinical setting, delegate clinical task doing
whenever you can
 Encourage others (including your residents) to do the
same
Some practical tips
for clinical skills teaching…

 Observe your learners more and give them

performance feedback whenever you can
 Set up your expectations explicitly ahead of time!
 Encourage your patients to help out!
 Encourage yourself and your colleagues to lecture
less and mentor more in the clinical setting
 Practice makes perfect at all levels
 Help set higher standards for clinical skills teaching
and learning
 Make it fun!
800 Baylor
700 Case
Chicago
600 Cornell
GW
500
Minnesota
400 Nebraska
Pittsburg
300
Tulane
200 U Mass
UNC
100
USC
0 Wisconsin
1972-73 1984-85 1995-96 Average
Organizing Clinical Skills Education
By the spectrum of clinical care:
 Emergency care
 Acute care

 Critical care

 Chronic care

 Palliative & terminal care

 Wellness & preventive care

 Population Care