Making the Case for Teaching and Assessing Clinical Skills University of North Carolina – Chapel Hill School of Medicine November 10, 2011.

Making the Case for Teaching and Assessing Clinical Skills University of North Carolina – Chapel Hill School of Medicine November 10, 2011

Ann C. Jobe, MD, MSN Executive Director Clinical Skills Evaluation Collaboration (CSEC)

A Little Context and Perspective

United States Medical Licensing Examination (USMLE)
The USMLE is a single licensure pathway for all individuals (graduates of US and international medical schools) wanting to practice medicine in the United States Implemented in early 1990’s

The USMLE is sponsored by the Federation of State Medical Boards of the United States, Inc. (FSMB), and the National Board of Medical Examiners® (NBME®)

A Look Back in Time Prior to late 1960’s – state boards made up their own exams – different exams in each state Late 1960’s - the Federation Licensing Examination (FLEX) – a single examination (Components 1 and 2), used by all states, was developed by NBME for the Federation of State Medical Boards (FSMB).

A Look Back in Time Educational Commission for Foreign Medical Graduates (ECFMG) – from 1984 to 1993 had a separate examination, developed by NBME, for international graduates – Foreign Medical Graduate Examination in the Medical Sciences (FMGEMS)

A Look Back in Time Prior to the early 1990’s, there were three separate licensing examinations in the US: FLEX – Components 1 and 2 NBME – Parts 1, 2, and 3 FMGEMS

A Look Back in Time USMLE - introduced in early 1990’s
Single examination pathway for initial medical license (graduates of US and international medical schools) A national standardized series of exams to assure minimal competency

Each of the three Steps of the USMLE complements the others No Step can stand alone in the assessment of readiness for medical licensure.

Step 1 understanding and application of important concepts of the foundational sciences essential for the practice of medicine Multiple choice exam; computer-based delivery Step 2 application of medical knowledge, skills, and understanding of clinical science essential for the provision of patient care under supervision Clinical Knowledge (CK) Clinical Skills (CS)

Step 2CS Standardized patients used to assess an examinee’s ability to gather information from patients, perform physical examinations, communicate their findings to patients and colleagues

Step 3 application of medical knowledge and understanding of biomedical and clinical science essential for the unsupervised practice of medicine Multiple choice exam and computerized case simulations (CCS); computer-based delivery

Life Cycle of a Physician in the United States
American Board of Medical Specialties (ABMS) Specialty Boards Board Certification Exams Recertification q 7-10 yrs NRMP Match Medical School Maintenance of Certification (MOC) Postgraduate Training 3-7 yrs Fellowship Practice Year 1 Year 2 Year 3 Year 4 Maintenance of Licensure (MOL) Step 1 Step 2 CK Step 2 CS Step 3 Licensure Relicensure q 1-3 yrs United States Medical Licensing Examination (USMLE) State Licensing Authorities

Miller’s Pyramid Action Performance Competence Knowledge DOES
SHOWS HOW KNOWS HOW KNOWS

Kirkpatrick Criteria Results Behavior Learning Reaction
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

COMPETENCY “Core Competencies” Patient Care Knowledge
Accreditation Council for Graduate Medical Education (ACGME) American Board of Medical Specialties (ABMS) Patient Care Knowledge Communication and Interpersonal Skills Professionalism Systems-Based Practice Practice-Based Learning and Improvement

Correlations among Step scores
Step l Step 2 CK Step 2 CS ~.65 ----- Step 2 CS Data-gathering Communication/IP skills Spoken English proficiency Patient note .19 .09 .20 .26 .16 .13 .30 Step 3 ~.50 ~.70 N/A References: Step l and Step 2: Andriole, Pangaro, Harik; Step 2CS: Harik , Step 3: Andriole, Markert,

The Improvement of Assessment
National Board of Medical Examiners (NBME) First examinations in 1916 were voluntary: “weeklong extravaganzas” (essay, laboratory, oral, practical and bedside components) 1922 – 1950: Basic biomedical sciences - essay questions; fundamentals of clinical medicine - essay questions; observed patient encounters and an oral examination

National Board of Medical Examiners (NBME) 1950’s: Essay questions replaced with “selected-response” questions (MCQs); Studies of the bedside oral examination demonstrated that the scores provided more information about the examiner than the examinee. Due to this psychometric unreliability, it was eliminated in 1964

National Board of Medical Examiners (NBME) 1960’s: number of test formats tried for final clinical examination motion pictures of clinical encounters projected to examinees, who answered MCQs based on encounters Multi-step, latent-image management problems 1980’s: all parts of examinations were MCQs

A Look Back in Time Public concerns that “physicians don’t listen to patients” State Medical Boards – most frequent complaints related to communication Increase in medical liability suits – estimated that a clinician’s communication style and attitude were major factors in nearly 75% of these suits

A Look Back in Time Only some medical schools had formal courses to teach communication/clinical skills More than 60% of graduating medical students replied on the AAMC Graduation Survey that they had never been observed doing a complete history and physical

National Board of Medical Examiners (NBME)
To protect the health of the public through state of the art assessment of health professionals. While centered on assessment of physicians, this mission encompasses the spectrum of health professionals along the continuum of education, training and practice and includes research in evaluation as well as development of assessment instruments.

National Board of Medical Examiners (NBME)
Large scale development efforts, partnering with medical schools in pilots, to assess medical students’ clinical skills Utilized Standardized Patients (SPs)

Educational Commission for Foreign Medical Graduates (ECFMG)
The ECFMG promotes quality health care for the public by certifying international medical graduates for entry into U.S. graduate medical education, and by participating in the evaluation and certification of other physicians and health care professionals.

Educational Commission for Foreign Medical Graduates (ECFMG)
Large scale development efforts to provide an assessment of International Medical Graduates’ clinical skills Implemented the Clinical Skills Assessment (CSA) in 1998 CSA – a national standardized assessment, using Standardized Patients (SPs), required for International Medical Graduates who wanted to enter the U.S.

Clinical Skills Evaluation Collaboration CSEC
A Collaborative Partnership, established in 2003, between the Educational Commission for Foreign Medical Graduates (ECFMG) and the National Board of Medical Examiners (NBME)

History of CSEC 1998 June 2001 May 2003 June 2004
Clinical Skills Assessment (CSA) June 2001 Discussions regarding collaboration initiated May 2003 CSEC Collaboration Agreement signed June 2004 1st administration of USMLE Step 2 Clinical Skills (CS)

Reaction to Step 2 CS State medical boards and the USMLE Composite Committee felt strongly that a national standardized assessment of clinical skills, overseen by an external body, was needed to validate the competency of medical school graduates and to protect the public

Reaction to Step 2 CS Large percentage of US medical schools, medical students and the American Medical Association (AMA) opposed the exam – stating that the medical schools should assess this and that the schools were doing this Concern about expense (dollars and time) for students

COMMUNICATION The essence of the patient-physician relationship
Includes communicating verbally, non-verbally, as well as actions and interactions during a physical examination

COMMUNICATION Effective communication is a cornerstone of patient safety

Communication breakdown, whether between care providers or between care providers and their patients, is the primary root cause of the nearly 3,000 sentinel events – unexpected deaths and catastrophic injuries – that have been reported to The Joint Commission “What Did the Doctor Say?”: Improving Health Literacy to Protect Patient Safety The Joint Commission, 2007

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

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

Communication – “It’s About Time”
“Science and technology have advanced enormously over the last decades but ultimately the best medical care requires deep knowledge of science as well as the skills to communicate effectively with patients.

“If the medical profession wishes to maintain or perhaps regain trust and respect from the public, it must meet patients’ needs with a renewed commitment to excellence in the communication skills of physicians. It is time to make this commitment.” Levinson W, Pizzo PA Patient-Physician Communication – It’s About Time. JAMA, May 4, 2011; 305(17):

“ABMS should incorporate assessment of communication into certification and maintenance of certification.” “Better assessment tools are needed to allow trainees and practicing physicians to measure their skills on basic and more advanced communication skills, such as disclosing medical errors and discussing patients’ end of life care wishes.” Levinson and Pizzo

Honoring Our Contract with Society
All health professions, to fulfill our obligation to our patients: Need to renew our commitment to excellence in communication skills Need to include results of assessments of communication skills into licensure and certification decisions

Why Does It Matter? Initiatives focused on improving communication – through teaching and assessment - will be most successful in improving the quality and outcomes of care provided by health professionals

CSEC Today 244,571 examinees (through 10-31-2011)
2,934,852 Standardized Patient encounters 53% (130,160) USMGs 47% (114,411) IMGs

USMLE Step 2 Clinical Skills
Mastery of clinical and communication skills, as well as cognitive skills, by individuals seeking medical licensure is important to the protection of the public. (from USMLE Bulletin of Information)

CSEC Centers Atlanta Chicago Houston Los Angeles Philadelphia

ATLANTA, GEORGIA

CHICAGO, ILLINOIS Chicago

HOUSTON, TEXAS Houston

LOS ANGELES, CALIFORNIA

PHILADELPHIA, PENNSYLVANIA

Step 2 CS Examinees About 2,000 to 3,000 examinees each month
About examinees per month at each Center

Step 2 CS Scheduling Centers run 5-6 days a week
Minimum at each center is 2 “sessions” per day A “session” = 12 examinees AM1 Session & AM2 Session Several centers also run in the evening - one PM Session

CSEC Centers “Full time” (12-15) “Part time as needed” Center Manager
Assistant Center Manager SP Operations Specialist (SPOS) SP Trainers (6) Facilities/Office Coordinator End User Support Staff (IT/AV) Chief Proctor/Proctors Control Room Operators “Part time as needed” Standardized Patients Medical Advisor Receptionist

Step 2 CS Examinees YEAR TOTAL USMGs IMGs 2010 33,951 19,485 14,880
2009 34,837 18,983 15,854 2008 35,224 17,711 17,513 2007 33,832 16,121 2006 32,843 17,473 15,132 2005 31,939 17,671 14,268 2004 6,501 8,379

Step 2 CS Fees USMG IMG (increase of $145(15%) over 7 year period)
: $975 2007: $1,005 2008: $1,025 2009: $1,055 2010: $1,075 2011: $1,120 IMG (increase of $155 (13%) over 7 year period) : $1,200 2010: $1,295 2011: $1,355

USMLE Step 2 Clinical Skills
The cases cover common and important situations that a physician is likely to encounter in clinics, doctors’ offices, emergency departments, and hospital settings in the United States.

The cases that make up each administration of the Step 2 CS examination are based upon an examination blueprint. The sample of cases selected for each examination reflects a balance of cases that is fair and equitable across all examinees. On any examination day, the set of cases will differ from the combination presented the day before or the following day, but each set of cases has a comparable degree of difficulty.

Presentation Categories
Case Content Cardiovascular Respiratory Gastrointestinal Musculoskeletal Constitutional Neurological Psychiatric Genitourinary Women’s health Case Acuity Acute Subacute/Chronic Form Patient age Age less than 18 Age 18 – 44 Age 45 – 64 Age 65 + This is a sample test blueprint made up according to a number of factors, including case content, acuity, age and gender of the patient. CV – chest pain (stable angina, acute angina), leg pain (claudication), palpitations (tachycardia), lightheadedness (atrial fibrillation) Constitutional – sleeping problems, fatigue, thirst (diabetes) Low mood, sleeping problems, fatigue (thyroid disorder) Gastrointestinal – Rectal bleeding (hemmorhoids, cancer) Stomach pain (ulcer, cancer, celiac sprue) Genitourinary Blood in urine (kidney stones, STD, cancer) Urinary frequency (overactive bladder, infection, cancer) Psychiatric Eating disorder Anorexia(not eating) could be attributable to a psychiatric, consitutional, or other cause. Palpitations attibutable to anxiety disorder Patient Gender Male Female

Other Case Formats Although there are no young children presenting as patients, there may be cases in which an examinee encounters - either in the examination room or via the telephone - a parent or caregiver of a child or other individual (e.g., an elderly patient).

The examination lasts approximately 8 hours. Two breaks are provided:
Each Step 2 CS “session” includes 12 encounters of twenty-five minutes each. 15 minutes with patient 10 minutes for patient note The examination lasts approximately 8 hours. Two breaks are provided: 1st break is 30 minutes long (lunch) 2nd break is 15 minutes long (snack).

Registration Room

Orientation Room

Exam Room

Step 2 CS Components Communication and Interpersonal Skills (CIS)
Spoken English Proficiency (SEP) Integrated Clinical Encounter (ICE) Data gathering (DG) History & PE Patient note (PN)

Step 2 CS Components USMLE Step 2 CS is a Pass/Fail examination
Each of the three subcomponents (CIS, SEP, ICE) must be passed in a single administration in order to achieve a passing performance on Step 2 CS

Assessment of Communication and Interpersonal Skills (CIS)
CIS performance is assessed by the standardized patients a global rating of these skills using a series of generic rating scales same CIS scale for all 12 encounters 3 sub-components: Information gathering (questioning skills) Information sharing Professional manner and rapport

Questioning skills/ Information Gathering - examples include: use of open-ended questions, transitional statements, facilitating remarks avoidance of leading or multiple questions, repeat questions - unless for clarification, medical terms/jargon unless immediately defined, interruptions when the patient is talking accurately summarizing information from the patient

Information-sharing skills - examples include: acknowledging patient issues/concerns and clearly responding with information avoidance of medical terms/jargon unless immediately defined clearly providing counseling when appropriate closure, including statements about what happens next

Professional manner and rapport - examples include: asking about expectations, feelings, and concerns of the patient support systems and impact of illness, with attempts to explore these areas showing consideration for patient comfort during the physical examination attention to cleanliness through hand washing or use of gloves

Professional manner and rapport - examples include: providing opportunity for the patient to express feelings and/or concerns encouraging additional questions or discussion making empathetic remarks concerning patient issues/concerns patient feel comfortable and respected during the encounter

Assessment of Spoken English Proficiency (SEP)
SEP performance is assessed by the standardized patients using rating scales; same scale for all 12 encounters based upon frequency of pronunciation or word choice errors that affect comprehension amount of listener effort required to understand the examinee's questions and responses clarity of spoken English communication within the context of the doctor-patient encounter (e.g., pronunciation, word choice, and minimizing the need to repeat questions or statements)

Scoring of the Step 2 Clinical Skills Subcomponents
The ICE subcomponent includes assessment of: Data gathering (DG) - patient information collected by history taking and physical examination Documentation (PN) - completion of a patient note summarizing the findings of the patient encounter, diagnostic impression, and initial patient work-up

Data gathering (DG) performance is assessed by the standardized patients using checklists developed by committees of clinicians and medical school clinical faculty checklists comprise the essential history and physical examination elements for each specific clinical encounter

The patient note is rated/scored by trained physician raters The patient note (PN) consists of three areas Medical History and Physical Examination Differential Diagnosis (list up to 5) Diagnostic Workup

Scored holistically Relevant and correct information Congruency/consistency with specific case –based scoring guidelines Integration/synthesis of information Organization, coherence, cohesiveness, flow, legibility

Performance on Step 2 CS Failure rate for USMGs Failure rate for IMGs
: 4% : 2% : 3% : 3% : 3% : 3% Failure rate for IMGs : 17% US Citizens: 11% Foreign Citizens: 18% : 15% : 23% : 28% : 27% : 24%

Performance on Step 2 CS Passing rate for USMGs (first takers)
: CIS >99%; SEP >99%; ICE 98% : CIS 99%; SEP 100%; ICE 97% : CIS 99%; SEP >99%; ICE 98% : CIS 99%; SEP >99%; ICE 98% : CIS 99%; SEP >99%; ICE 98%

Performance on Step 2 CS Passing rate for IMGs (first takers)
: CIS 93%; SEP 98%; ICE 89% : CIS 87%; SEP 99%; ICE 85% : CIS 81%; SEP 92%; ICE 86% : CIS 84%; SEP 94%; ICE 84% : CIS 87%; SEP 95%; ICE 85%

Standardized Patients in Step 2 CS
Why use SPs - Less expensive than physicians More available than real patients or physicians Can be trained to be standardized

Can Simulate Some Physical Findings
Breathing difficulties Acute abdomen Joint and back pain Hearing loss Neurological findings Petechiae, bruising Includes SOB and pneumothorax Neuro includes loss of sensation, change in gait or vision

SPs Are Realistic Physicians are unable to distinguish between SPs and real patients. Physicians demonstrate similar actions with SPs as with real patients. One study sent unannounced SPs into physician’s offices, and they were unable to detect these patients. Another study looked at how physicians interacted with SPs and found they performed in a similar manner with respect to history taking and physical exam with real patients in the clinical setting.

SPs Are Accurate SPs are more than 90% accurate in portraying case details SPs more accurate than physicians Multiple SPs have little effect on examination reliability Elliot, DL and Hickam DH (1987). Evaluation of physical examination skills: reliability of faculty observers and patient instructors. JAMA 258(23), On average, SPs are more than 90% accurate in portraying the details of the case they are trained to represent. One study showed that with limited training, laypersons can reliably evaluate 83% of the same clinical skills that were evaluated by faculty physicians. With more training, SPs can approach being 100% accurate. Some skills are easier to experience than to observe; for example, abdominal palpation (how deep, how much pressure). Still other studies have shown that several SPs portraying the same case have little impact on the reliability of the exam. Elliot, DL and Hickam DH (1987). Evaluation of physical examination skills: reliability of faculty observers and patient instructors. JAMA 258(23),

Exam Room

SP Accuracy Live reviews and video reviews of SPs (portrayal of case and rating of examinee) Categories: No error(s) or with minor error(s) not impacting scoring More significant error(s) - required remediation Substantial error possibly impacting scoring – removed from the exam

SP Accuracy 96.9% - no error or minor error
3% - more significant error 0.06% - substantial error

Improving Quality and Safety in Health Care
Solving the Puzzle Improving Quality and Safety in Health Care

What makes me happy about this exam
Assuring that patients are protected by increasing the levels of quality and safety in delivery of health care Consequential or Educational validity – impact on teaching in medical schools

Consequential or Educational Validity Impact on Curriculum
Almost all medical schools have clinical skills centers – or share a center Most schools utilize standardized patients for teaching and assessment

Consequential or Educational Validity Impact on Curriculum
Most schools have separate clinical skills, “doctoring” or “introduction to clinical medicine” courses – many have longitudinal content and teaching in clinical skills Most schools have several assessments of clinical skills using SPs across the curriculum – formative and summative

Medical School Requirements for Class of 2011
129 medical schools Record a passing score to graduate 79 schools = 11,299 (61%) Record a score to graduate 47 schools = 6,845 (37%) No requirement 3 schools = 309 (2%) updated

Reliability Dependability of assessment scores – consistency and reproducibility Similar to a signal-to-noise ratio where the “signal” is good information and “noise” is measurement error Reliability in range is acceptable for performance assessments

Internal Structure Reliability – the reproducibility of the data or scores on the assessment USMLE Step 1 (2009) Step 2 CK (2008) .91 Step 2 CS ( ) ICE CIS SEP Step 3 (2009)

Outcomes Research Does an examination/assessment predict the quality of care delivered by physicians in future practice? How does performance on an assessment link to desired outcomes? Medical Council of Canada (MCC) exams Qualifying examinations: QE1 (medical knowledge) and QE2 (clinical skills) 2 recent studies – published in 2007 and 2009

Outcomes Research Tamblyn R, et al. JAMA 2007; 298 (9): 993-1001.
“Scores achieved in patient-physician communication and clinical decision making on a national licensing examination predicted complaints to medical regulatory authorities.”

Outcomes Research Wenghofer E, et al. Medical Education 2009; 43: “Doctor scores on qualifying examinations are significant predictors of quality-of-care problems based on regulatory, practice-based peer assessment.”

What keeps me awake at night
“Physician by Number” - JAMA “Piece of My Mind” – July 8, 2009 “Kaplanization” of the exam Challenge to simulate physical findings “Binge and Purge” phenomenon Feedback to examinees

“Performing” – “On Stage”
“I go through the motions for practice, but I lack the ability to discern subtle differences in my findings. It’s a performance: a didactic routine with precise directions to guide the end result – reminiscent of the paint-by-number kits I loved as a child.”

Acronym approach On Old Olympic Terraced Tops…. ADCAVAMDIMSL

PAM HUGS FOSS SIQORAA

SIQORAA for setting intensity quality onset radiation Aleviating fact and aggravat fact PAM for previouis episodes , Allergy, medication HUGS .illness, for hospitalisation, surgery, system illness FOSS for family med hist, Obg/gyn, sexual activity and then sleep patterns and life habits like cig alcohol.. This is an entry from a website discussion forum on USMLE Step 2 CS

Rote and perfunctory performance
Test taking strategies to “get points”

Lack of Physical Findings
Examinees are aware of this Examinees tend to “short-cut” PE maneuvers Is this contributing to the decline in clinical skills, especially PE

Physical Examination Current Step 2 CS assesses an examinee’s ability to do physical examination maneuvers correctly BUT does not effectively assess the ability of an examinee to discern physical findings

How Best to Assess Can an individual truly distinguish normal from abnormal physical findings How well does an individual synthesize and integrate all the information gathered from a patient

Teaching to the Exam This is a “High stakes” exam – required for residency and licensure Like any important activity – Step 2 CS (and other USMLE exams and certification exams) have engendered “secondary businesses” – that are money makers……

What is Measured is Important
What methods of “teaching to the test” result in acquisition of the best evidence-based clinical skills Do individuals who take review courses acquire the “gold standard” clinical skills or “test taking strategies” How do we insure that physicians maintain the clinical skills that are important across a professional lifetime

“Binge and Purge” Should there be more or additional “high stakes” assessments of clinical skills During residency For certification For maintenance of licensure and certification

Feedback “Immediate feedback is effective, delayed feedback is less so.” Duffy, Holmboe Step 2 CS feedback is: Not specific enough Delayed Is this another way that leads to loss of the “best” skills or retention of poor skills?

Role Modeling vs Feedback
“Do as I say, not as I do” The impact of the “hidden curriculum” and role models

Challenges and Opportunities Ahead for CSEC

“Even if you’re on the right track, you’ll get run over if you just sit there.”
Will Rogers

May - July 2011 As of July 2011 – all patient notes are typed – no longer may choose to write or type the notes Increased realism in portrayals of SP cases – designed to enhance the stimulus for assessment of examinee’s communication skills

Launch 2004 Doctor: I think you may have cancer. SP: OK Present Doctor: I think you may have cancer. SP: I wasn’t expecting to hear that. That is very upsetting. 2012 Implementation Doctor: I think you may have cancer. SP: I wasn’t expecting to hear that. That is very upsetting. OR SP: I looked it up online and was shocked that cancer might be possible, but I also saw some other possibilities. I wrote them down and would like your opinion.

Six Function Model Communication Skills Competency
June 2012 Six Function Model Communication Skills Competency 1. Fostering the Relationship 2. Gathering Information 3. Providing Information 4. Helping the Patient with Making Decisions Basic Advanced 5. Supporting Emotions 6. Helping Patients with Behavior Change

Six Function Model Communication Skills Competency
1. Fostering the Relationship 2. Gathering Information 3. Providing Information 4. Helping the Patient with Making Decisions Supporting Emotions 6. Helping Patients with Behavior Change Add reference and cleanup H. de Haes and J. Bensing, 2009

Assessment Construct Comparison of Original and
Enhanced Construct for Step 2CS CIS Original Construct Enhanced Construct Professional Manner and Rapport Fostering the Relationship Supporting Emotions: Basic Information Gathering Gathering Information Information Sharing Providing Information Making Decisions: Basic

Functions Sub-Functions 1. Fostering the Relationship Express interest in the patient Treat the patient with respect Listened and paid attention to the patient 2. Gathering Information Give the patient a chance to tell his/her story Explore the patient’s reaction to illness/problem 3. Providing Information Provide information related to the working diagnosis Provide information on next steps 4a. Making Decisions: Basic Get the patient’s perspective on diagnosis and next steps Finalize plans for next steps 4b. Making Decisions: Advanced Sub-functions yet to be determined from video review 5a. Supporting Emotions: Basic Facilitate expression of implied or stated emotion 5b. Supporting Emotions: Advanced Sub-functions yet to be determined from video review 6. Helping Patients With Behavior Change

New Patient Note Format
June 2012 New Patient Note Format Assess “Data Interpretation” 1-3 Differential Diagnoses Pertinent “positive” and “negative” History and PE findings that support diagnosis or diagnoses List of plans for next steps in work-up to confirm or rule-out diagnosis or diagnoses

June 2012

Enhanced/Challenging Communication Skills
Counseling patients about behavioral change Delivering bad news Disclosing an error - apology Negotiating a treatment plan that takes into consideration patient values and preferences

Enhanced/Challenging Communication Skills
Starting a medication - assessing level of health literacy – “teach back” Advanced directives Medication reconciliation Functional status assessment

Communicating with more than one person in the room
Elderly patient with adult child Translator for patient that cannot speak or understand English Family conference

Communicating with other Health Professionals
Consultation with a physician, pharmacist, physician assistant, nurse Referral to a specialist “Hand-offs” Shift changes Hospital discharge

Team Assessment Standardized team members – nurse, physician, physician assistant, social worker, physical therapist, pharmacist, occupational therapist…..

Improving Quality and Safety in Health Care
Solving the Puzzle Improving Quality and Safety in Health Care

What is Measured is Important
Individual and organizational behavior and focus changes in the lens of high stakes examinations Measurement of pure knowledge is not sufficient to determine if an individual can do something or apply knowledge Longitudinal/repeated assessments are the best way to sustain behavior change

CSEC Vision Statement CSEC will be a significant contributor to a system in which patients throughout the world receive safe, high-quality, patient-centered health care services delivered by health care professionals who are highly competent in clinical and interpersonal skills

Take Home Message 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

Take Home Message Effective communication is a cornerstone of patient safety and quality of care Initiatives focused on improving communication – through teaching and assessment - will be most successful in improving the quality and outcomes of care provided by health professionals

The Impact of the Prevailing Culture
“Do as I say, not as I do” The impact of the “hidden curriculum” and role models

Culture – Like an Iceberg
What is seen What is unseen

Curriculum Seen Unseen Formal curriculum – what students are taught
Informal (Hidden) curriculum – what students experience as expressions of professional values

Cultures can be invisible to those living in them
Question to fish – What is it like living in water? Answer – What is water?

An Opportunity to Move to a New Excellence
Make the hidden visible Match the informal with the formal curriculum How can I model what I wish to see?

The Impact of the Prevailing Culture
The best approach to insure the development and maintenance of a high level of “bedside/clinical skills” is to insure that everyone in the organization supports and role models “best practices” in clinical skills

Commitment to Excellence in Clinical Skills
One “Champion” or even better a few “Champions” Or even better – an Academy of Educators committed to role modeling the best of clinical skills

Why Does It Matter? Initiatives focused on improving communication – through teaching and assessment - will be most successful in improving the quality and outcomes of care provided by health professionals

Change “They always say time changes things, but you actually have to change them yourself.” Andy Warhol

Final words “Whether you think you can, or think you can’t, you are right.” Henry Ford

THANK YOU Let us continue on the journey together – improving how we care for our patients

Making the Case for Teaching and Assessing Clinical Skills University of North Carolina – Chapel Hill School of Medicine November 10, 2011.

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Making the Case for Teaching and Assessing Clinical Skills University of North Carolina – Chapel Hill School of Medicine November 10, 2011.

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