Clinical Skills Task Group #5 Report

Chairs: K. Klym and R. Brown

TG#5 Clinical Skills

Co-Chairs: Rob Brown, Karen Klym

Assignment: The nature and complexity of the skills required of the

physician is wide-ranging. The skill set includes and is built upon

foundational skills such as communication, organization, and leadership. It

progresses to specific functions, such as history taking, physical

examination, emergency management and procedures. This TG will focus

on defining the scope of clinical skills, identifying the pedagogical

approaches to be used, identifying key principles for integration with

cognitive curriculum, connecting goals and objectives and evaluation and

outlining overall timing/structure of clinical skills instruction.

Keywords: clinical skills, communication skills, History taking, physical examination, conflict resolution, procedural skills, crisis resource management.

Task Group #5

Definition of Clinical Skill

Anything that a physician DOES

Simple complex

Blood glucose monitoring

Clinical Reasoning

Broad scope

Mapping to CanMeds or another framework not udnertaken

Our Process Summer 2011

Literature search for curriculum development

Collation of AFMC, AAMC, GMC, CUSEC lists into one

master list

Committee Meetings Sept-Oct 2011

Review Master list

Deleted clearly inappropriate skills

Combined similar individual skills into single skills

Combined single skills into larger skills as appropriate

AFMC document considered to me a minimum standard throughout

Process Part 2

Reorganized list to categories with similar properties

Interviewing and Record-keeping

Physical Exam

Procedural

Clinical Reasoning

Diagnostic Testing

Separation of Essential Clinical Presentations

Many “skills” from the master list were felt to represent ECP’s

Removed but recorded

Process Part 3

Describing incremental learning

Several taxonomies considered

Miller

Bloom

Dreyfus

AFMC

Modified AFMC taxonomy used

Maps directly to AFMC for procedural skills

4-point scale modified for non-procedural skills for consistency

Supplemented with RIME for interviewing and record-keeping

Performance Level

Expectation

Level 1: Describe the elements of the interview

Level 2: Perform with guidance

Level 3: Perform successfully independently in a

straightforward situation

Level 4: Perform successfully independently in a complex

environment/situation

Skill End of Med 2

Oral Case Presentation R- 4 I- 3

M- 2 E- 1

Interviewing and Record-keeping

Physical Exam

Level Expected Performance

Level 1: Describe the physical sign or maneuver but not elicit it.

Level 2: Perform the maneuver, and explain the rationale for the test. Elicit the physical sign.

Level 3: Perform the maneuver or recognize the physical sign and interpret the findings in terms of pathophysiology.

Level 4:

Perform the maneuver or recognize the physical sign and may know the evidence justifying the use of the test; interpret the findings and generate a differential diagnosis based on the findings.

Procedural

Level Expected Performance

Level 1: Describe the indications, contraindications, risks, common

complications and the process of the procedure

Level 2: Perform the procedure under supervision in a non-clinical

setting (e.g. simulated set-up)

Level 3: Perform the procedure in a stable patient under supervision in

a controlled clinical setting

Level 4: Perform the procedure in a stable patient without supervision

in a controlled clinical setting

Clinical Reasoning Level Expectation

Level 1: Describe the elements of the interview

Level 2: Perform with guidance

Level 3: Perform successfully independently in a

straightforward situation

Level 4: Perform successfully independently in a complex

environment/situation

Diagnostic Testing Level Expectation

Level 1: Describe the approach to interpretation

Level 2: Demonstrate an orgaized approach to interpretation of the test

Level 3: Identify and interpret the physiologic significance of abnormal findings

Level 4: Identify the key diagnostic findings for the test in all of the Essential Clinical presentations

General Principles for Reform

Spiral Curriculum

Deliberate Practice and Reflection

Utilize multiple learning experiences

Design good goals and objectives

Provide teacher development

Student engagement

Orientation

Ongoing curriculum development

Timing and Structure

Synchrony with knowledge curriculum

Ideal but not completely possible

Clinical Reasoning

Core of the organization for clinical skills

Reflection on fully developed cases through Med 1

Through second year introduce

Increasing complexity and information seeking in virtual cases

actual Hx Px into cases using structured and unstructured Pts

Progress through RIME levels in structured + unstructured CPA’s

Add in other skills as appropriate to support reasoning

Recommendation 1 Timing and structure

Attempt to coordinate skills sessions with the related

knowledge curriculum

Build an incremental clinical reasoning curriculum with the

other clinical skills interposed at appropriate points

Introduce complex skills in a spiral and developmental

course structure

Recommendation 2 Foster deliberate practice and reflection

Provide structured sessions in skills lab with guided reflection

Create print and web-based modules for procedural skills

and/or physical exam skills for self-study

Provide self-directed access to skills training models and

modules for reinforcing self-study

Utilize a log of ECP’s and clinical skills that incorporates

some degree of preceptor feedback and learner reflection

Recommendation 3 Multiple methodologies

Most skills should be taught in multiple ways over multiple

exposures, with gradual integration into more comprehensive

real or simulated patient care events

Recommendation 4 Introduce clinical exposures

Introduce actual patient exposures into training at multiple

levels with goals and objectives aimed at the level of the

trainee.

Recommendation 5 Teacher development

Create formal teacher development programs for

Deliberate practice and reflection

Provision of feedback

Goals and Objectives of sessions

Create and disseminate appropriate goals and objectives for

all sessions

Create a structure/approach for recognition and

development of teachers

Recommendation 6 Clerkship Sessions

Create specific sessions with structured patient encounters or

focused real patient sessions to reinforce communication, basic

interview and exam skills as well as advanced clinical reasoning

Recommendation 7 Student Orientation

Create web-based orientation material for

overall course structure

goals and objectives

general milestones for progress

principles guiding curriculum

Provide a specific session to inform students of orientation

material, emphasize principles of deliberate practice and

promote active participation

Recommendation 8 Continuous Improvement

Include a prospective plan for reassessment and improvement with

specific timelines using student and faculty feedback