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Clinical Skills

Overview

The Clinical Skills Program is a series of courses in the preclinical curriculum that is designed to equip students with the skills needed to benefit optimally from their clinical training in the clerkships. The program consists of five semester courses that include the following components: Doctor Patient Relationship (DPR), Interactional Skills (IAS), basic physical exam, clinical encounters across the life span, specialty area exams, oral case presentation and the written record. Students earn 9 credit hours in this sequence of courses which spans the first two years of medical school. They must successfully complete all components to progress to the clinical clerkships; the courses are all graded pass/fail.

Objectives

In the Clinical Skills Program, students will:

  1. recognize the many facets of the doctor patient relationship and be able to apply a biopsychosocial model to issues of health and medicine.
  2. master skills of basic interviewing and demonstrate competence in some advanced interviewing skills.
  3. master basic skills in physical examination and be able to perform and interpret a focused examination of the cardiovascular, pulmonary, musculoskeletal and neurologic systems as well as the breast and the genitalia examination of men and women.
  4. document historical and physical examination findings according to accepted formats including a complete written data base, problem list and a focused S.O.A.P. note.
  5. make sense out of the patient’s story and physical findings and begin to generate differential diagnoses appropriate to the level of training.
  6. exhibit professional behaviors including demonstration of respect for patients, colleagues, faculty and others in all settings.

Doctor Patient Relationship

This course introduces students to the doctor patient relationship through the study of related literature. Students read selected short stories, essays and poetry which depict the relationship from a variety of points of view; that of the patient, the doctor, family members, other health professionals and a medical student. The readings are discussed in small groups consisting of six students and a faculty preceptor. Each student completes a final project in which depicts his or her idea of the doctor patient relationship through a creative endeavor. Media for the final project include collages, short stories, poetry, videos, songs, and others. Small group sessions and assignments are augmented by a series of large group experiences in which panels of individuals, i.e., health care professionals, patients, family members of patients, and others discuss their experiences as doctors or patients.

Interactional Skills

The Interactional Skills course begins in the first semester after DPR. Students focus on basic interviewing skills in the first two semesters and begin to work on more advanced skills in summer semester of first year. Didactic material is introduced in large group sessions; most of the learning occurs in small groups consisting of six students and one faculty preceptor. Students practice interviewing with simulated patients. These interviews are recorded on video and reviewed in small group sessions. Each student completes three interviews during the semester and participates in the review of fifteen other interviews done by classmates.

Students have the opportunity to practice basic interviewing skills in a real clinical environment in second semester of the clinical skills curriculum. As part of the course on physical examination, students have four scheduled visits with patients in a community hospital. During these encounters, students interview the patient as well as practice components of the physical examination.

In the third semester, summer of year one, more advanced interactional skills are introduced and practiced. Students have an encounter with a young child (age 2 to 5 years), they interview an adolescent and a well elderly person. An interview about a sexual concern is accomplished using standardized patients. This interview is videotaped and reviewed in small group much like the earlier basic interviews.

In semesters four and five, students continue to build on their interactional skills as they encounter real patients in hospital visits and in laboratory sessions with individuals with specific diseases. The challenge of maintaining a patient centered approach while pursuing a medical diagnosis is articulated and transitions between the patient’s agenda and the doctor’s agenda are emphasized. After practicing these skills in clinical settings, students conduct an interview with a simulated patient who has a specific health complaint. This interview is video taped and reviewed in small group following the same format as the basic interviewing course.

At the close of the last semester of the program, students have another exercise in which they practice and demonstrate advanced skills in interviewing. This is the Comprehensive History and Physical exercise in which students meet with a simulated patient who has come to the student doctor for a comprehensive annual examination. The student’s task is to gather a complete data base through interview and physical examination. A patient centered approach is to be maintained throughout the encounter and the student is to utilize basic and advanced interviewing skills. The interview portion of the encounter is video taped and selected segments are reviewed with a preceptor.

Physical Examination

Skills of physical examination are introduced in second semester. A series of lectures are offered and readings are assigned from a text on physical diagnosis, but the majority of the teaching and learning occurs in small groups. Students meet in groups of 15 for two hours every other week to practice portions of the physical exam. They work in pairs, practicing on one another. On alternate weeks, students go to a hospital to practice their skills with a real patient. At the end of the semester, each student must complete a full physical examination from memory.

More advanced physical examination skills are introduced in the third semester as students examine a young child and a newborn. Both of these examinations require some flexibility in the sequence and content of the examination as the examiner must adapt to the child’s age, temperament and ability to cooperate. Age specific techniques are taught. As before, didactic material is introduced in large group format (lecture) and the students practice in small groups with physician preceptors and real children. The newborn exam is taught in the nursery of a community hospital.

Focused physical examination skills are introduced in semesters four and five as the students study the basic sciences in Problem Based Learning courses which are organized around organ systems (domains). Students learn the following examinations in depth: cardiovascular, pulmonary, breast, pelvic, male genitalia, abdomen, musculoskeletal and nervous system. The timing of each special area examination is coordinated to match the curriculum in the basic science domains. For example, students have two hours of lecture regarding the advanced examination of the cardiovascular system and a four hour laboratory session with patients with heart lesions as part of the clinical skills course while they are learning about the pathophysiology of the cardiovascular system in PBL. Cardiovascular and pulmonary exams are taught using individuals with physical findings of diseases of these systems. Breast, pelvic, male genitalia and abdomen are taught using patient models. Students practice the musculoskeletal and neurologic examination on classmates.

Written Record and Oral Case Presentation

Students begin to learn to document their findings according to accepted formats in the second semester when they visit patients in the hospital. They are required to write a short note including the chief complaint and parts of the history of present illness. In semester four, they are introduced to the full written record through a series of lectures and written materials. During semesters four and five, students write four complete written records and seven progress notes. A written assessment including a differential diagnosis is required for each of these assignments to encourage the development of analytical skills and medical thinking.

Oral case presentation skills are formally introduced in semester four (fall of Block 2). Students practice these skills with clinical preceptors during hospital visits.

Integration of Skills

Students are encouraged to integrate their skills as they encounter patients throughout the clinical skills program. A series of experiences have been developed which stress integration of skills and offer faculty an opportunity to assess student performance. These exercises, Performance Based Assessments, occur in semesters four and five (year 2) and are coordinated with the basic science Problem Based Learning domains. Students are presented with a clinical unknown and are asked to solve a diagnostic dilemma, drawing on their skills in interviewing, physical examination, and interpretation of ancillary data (i.e., chest x ray, pulmonary function tests). They report their findings and their interpretation of the information according to appropriate written format. A short essay question ties the pathophysiology underlying the disease to a sign or symptom of the case. There are currently three Performance Based Assessments in year two (Cardiac, Pulmonary and Neuro).

Evaluation

Evaluation of student performance in Clinical Skills includes: small group and scheduled experience attendance, small group participation, professional behavior, written content exams, written record assignments, interviewing skills, and physical examination skills. All courses within the sequence are graded pass/fail.