Transcript Promoting the Development of Clinical Skills through the Continuum

Promoting the Development of Clinical Skills
throughout the Continuum of Medical Education
University of North Carolina – Chapel Hill School of Medicine
November 9, 2011
Ann C. Jobe, MD,MSN
Executive Director
Clinical Skills Evaluation Collaboration (CSEC)
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 1970’s
• 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; 236:852-855
Verghese, A et al; Annals Int Med 2011;155:550-553
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; 236:852-855
Verghese, A et al; Annals Int Med 2011;155:550-553
COMMUNICATION
• The essence of the
patient-physician
relationship
• Includes
communicating
verbally, non-verbally,
as well as actions and
interactions during a
physical examination
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
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
Patient-Centered Communication
• Exploring the patient’s 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 >50% expect such involvement)
• Finding common ground regarding management
• Enhancing the doctor/patient relationship by
being responsive to the patient
IOM,2001; Street,2008
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.
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
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; 156:163-165
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
High level skills in “bedside
medicine” – “clinical skills”
• Ability to elicit a patient’s
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
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
Comprehensive Program
• Overarching Competencies
and Objectives
• Map for addressing
teaching and assessing
throughout the continuum of
education
• Course content
• Assessment methodologies
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.
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
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
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 individual’s 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
patient’s age, gender, personal preferences, family, health
literacy, culture, religious perspective, and their economic
circumstances
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
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
Developing a Comprehensive
Program
• Types of assessments
• Examinees
• Timing of assessments
• 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
• 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
• Types of assessments
• “Snapshot”
• One time assessment
• Longitudinal
• Repeated over various periods of time
• 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
Program Elements
• Depend on
PURPOSE of the
assessment
and
• LEVEL of the
examinee
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?
Miller’s Pyramid for Assessing
Clinical Competence
Does
Shows How
Knows How
Knows
Action
Performance
Competence
Knowledge
Kirkpatrick Criteria
4. Results
Change in organizational practice
Benefits to patients/clients
3. Behavior
Transfer learning to workplace
Learners apply new knowledge and skills
2. Learning
Change attitudes/perceptions
Change knowledge/skills
1. Reaction
Customer satisfaction related to participation in
educational activities
Simulation
• Simulation
• Real patients are
replaced with realistic
but artificial experiences
• Trainee interacts with
the re-creations
• Judgments are made
about their performance
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)
Method: Task Specific Models
• Designed around a
specific task
• Venipuncture model
• Animal cadavers
• Usually not automated
• Relatively inexpensive
Method: Instructor Driven
Models
• Physical representation
• Responses driven by
an instructor
• Little feedback
• Moderate cost
Method: Virtual Reality
Simulators
• Simple physical
representation
• Sensing device that
informs computer of user
actions
• Computer models realistic
reactions
• 3D imaging
• Haptics
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
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
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
“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”
• Anastomosis
• Laparoscopic vessel ligation
• Simulators
Ian Hart, 2001
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
Work-based Methods
• Work-based assessment
• Real patient encounters
“When your work
speaks for itself,
don't interrupt.”
• Trainees are observed
Henry Kaiser
• Judgments are made
about their performance
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)
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
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
Case-Based Discussion
(CbD)
• Process
• List of patient problems
• Trainee picks 2 case
records
• Assessor selects one
• Discussion centered on the
trainee’s notes
• Assessor rates:
• Diagnosis, Treatment,
Planning, Professionalism, etc.
• Assessor provides feedback
• Takes 15-20 minutes
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
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
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
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
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
Educational Effect
“Students respect what
you inspect.”
• Both simulation and
work-based methods
signal the importance of
working with patients
• Drives learning
Opportunity for
Feedback
• Feedback is critical to learning
• General education (Hattie,
1999)
• Meta-analysis of 12 metaanalyses
• 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
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
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
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
Opportunities Along the
Continuum
• Assessment of
team member
performance
Opportunities Along the
Continuum
• Assessment of
outcomes of a
team’s
performance
Opportunities Along the
Continuum
• Assessment of
individual team
members – using
“standardized team
members”
Opportunities Along the
Continuum
• Assessment of
teams composed
of members of
several health
professions
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 reentering practice
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
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
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
THANK YOU
Let us continue on
the journey
together –
improving how we
care for our
patients