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From Academic Leadership Empirical Research
Comparisons of OSCE scores for each of the ACT Pilot Program sessions between ACT Program participants and non-ACT participants are depicted in Table 2. Crude comparisons (unadjusted) suggested significant differences between the two groups in the geriatric skills modules. However, aggregate crude performance scores indicated no significant difference in OSCE scores between the two groups (p = 0.12). After adjustments for potential confounders, no significant differences were observed in OSCE scores for any of the modules between the two groups.
Table 3 provides summary comparisons of National Board of Medical Examiners Subject Shelf examination scores and USMLE Step I scores for SUNY Stony Brook students from the class of 2005, the year preceding the ACT Pilot program and the class of 2006 who participated in the ACT Pilot program. Since system restrictions at SUNY Stony Brook did not make randomization feasible among the study population, Step I scores between the groups were used as surrogate indicators to assess comparability between the two groups in their basic science knowledge. NBME subject examination scores were used as a surrogate of their clinical knowledge and problem solving abilities. There were no significant differences in Step I scores among students who attended SUNY Stony Brook versus those who engaged in clerkship rotations at other affiliate clinic locations in either year. For the Internal Medicine and Pediatrics board examinations, the class without the ACT program had significantly higher scores among those students who attended SUNY Stony Brook (p=0.03 and p=0.04, respectively). Interestingly, after the ACT program, there were no differences in the shelf exam scores between ACT Program participants and non-ACT participants even in Internal Medicine or Pediatrics.
Table 4 details the results of supplemental stratified outcomes for selected ACT Program modules. In the pulmonary module, history and physical score did not appear to be associated with total management score (p= 0.18). The crude analysis for the geriatric module specific to performance of the “get up and go test”, total scores in the MMSE and the SP score in the child abuse case were statistically significant (p=.003, 0.05, and 0.02, respectively), however the confidence interval was very wide, suggesting a high degree of imprecision. Not surprisingly, after adjustments for covariates, no statistically significant differences between the groups were observed for this assessment. Additionally, for the Obstetrics module, there was a highly significant difference in the delivery performance skills of the ACT group compared to the control group, even after adjusting for confounding variables (p=0.02), while no differences were found in the problem solving score between the two groups.
Secondary Findings of the ACT Pilot Program In addition to the ACT Pilot Program’s primary results, two unexpected secondary findings provided valuable insights that served as the basis for proposed changes in SUNY Stony Brook’s medical school policy and curriculum. Both of these secondary findings had strong implications for teaching clinical diagnostic reasoning skills. Our first unexpected finding was that although our Master Clinical Instructors had prepared to teach our medical students “advanced” clinical reasoning skills, their repeated empirical observations soon revealed that most of the students were unable to adequately demonstrate “basic” clinical reasoning; that is, students were ill prepared to differentiate diagnoses during simulated as well as live patient encounters. Although faculty observations at SUNY Stony Brook were similar to other reports in the literature (Elnicki et al., 2003; Groves et al., 2003; Poncelet and O’Brien, 2008), this finding was met with general surprise across our faculty, irrespective of clinical specialty area. The clear disconnect between the expectations of Master Clinical Instructors regarding the third and fourth year medical students’ proficiency levels in clinical reasoning and the students’ actual competency levels was another significant finding of the ACT study. The general expectation among the faculty was that students had acquired basic clinical reasoning by the completion of their third year, a presumptive belief given observed student performances. Although our faculty were surprised by the extent of disparity between their perceptions and actual medical student ability, this finding also has been reported by past researchers (Prince et al., 2000; Makoul, 2000; Radcliffe and Lester, 2003; Chumley et al., 2005; Prince et al., 2005; Bowen, 2006; Whipple et al., 2006; O’Brien et al., 2007). These secondary findings heightened concerns about the lack of sufficient emphasis on teaching introductory clinical reasoning skills earlier in the medical education curriculum. The medical faculty began exploring various factors that could have contributed to inadequate understanding of diagnostic pathways and differential clinical reasoning among third and fourth year medical students. By consensus, it was acknowledged that a lack of structured curricular emphasis on clinical reasoning was likely to be the leading contributor to the observed inadequacies. As described in detail elsewhere (Schiavone and Chandran, forthcoming), to address this shortcoming, efforts are presently underway to modify the medical curriculum at SUNY Stony Brook to further enhance clinical reasoning instruction. CONCLUSIONS Insightful Lessons Learned One of the objectives of undergraduate medical curricula is to provide students with the knowledge, skill and attitudes required for entering specialty training. The goal is that tomorrow’s physicians master the elementary skills that are vitally important for daily clinical work. However, how best to achieve this goal remains unclear. Skills in teaching and communicating have become increasingly recognized as important competencies for medical trainees (Makoul, 2001; Fisher et al., 2007; Accreditation Council for Graduate Medical Education, 2008). Despite this recognition, past studies have shown that there are often insufficient opportunities in medical school curricula to adequately discuss attitudes, strategies, and skills for dealing with many difficult situations that arise during patient encounters (Shapiro et al., 2006; Wu et al., 2006). In fact, many undergraduate medical students feel unprepared to begin clerkships and find the conversion to clinical learning particularly stressful (Radcliffe and Lester, 2003; Seabrook, 2004; Sanders et al., 2004; Chumley et al., 2005; Wu et al., 2006;). In response, academic medical institutions have employed a variety of strategies to improve the physical diagnostic skills and critical clinical reasoning aptitudes of their students (Elnicki et al., 2003; Fagan et al., 2003; Eva et al., 2007). Nevertheless, there is little data on the content of curricula designed to enhance the diagnostic reasoning skills of medical students, challenges and opportunities for strategic program implementation within the confines of natural settings (i.e., academic medical institutions), and the impact of such programs. Although a demonstration program, the results of the ACT project provide some promise that modest effects on improving the clinical reasoning performance of medical students can be achieved. However, due to several implementation and methodological limitations, significant differences in overall performance scores between ACT participants and non-ACT participants were not attained. These limitations alluded to important lessons with relevance to teaching and learning in academic medicine which merit further discussion. Programmatic Challenges for Enhancing Clinical Reasoning Skills of Medical Students In carrying out the ACT Pilot Program, several implementation and methodological challenges were encountered by the authors. The main program implementation challenges were: (a) motivating the medical school faculty to become engaged as Master Clinical Instructors given conflicting priorities; and (b) standardizing evaluator assessments of clinical reasoning skills across modules per clinic site. The salient lessons gained were that faculty were most responsive to becoming motivated to design ACT training modules when modest monetary incentives were offered to them. It is common knowledge that faculty in academic institutions rarely receive incentives or sufficient recognition for their teaching excellence. In fact, it has been shown that teaching and changing curricula are perceived by faculty as requiring more time for education and less time for those areas that contribute to academic recognition and financial rewards (Gruppen et al., 2003). Thus, after an initially poor response rate to faculty solicitation encouraging their involvement in the ACT Program, it became evident that such requests, albeit from the leadership at SUNY Stony Brook’s School of Medicine, were inadequate means to securing faculty engagement. Hence, an important lesson is that program budgets need to account for such expenses to increase the likelihood of success during the implementation phase. Another key take-away lesson was that system limitations negatively impacted the feasibility of ensuring standardization in skills assessments by evaluators across clinical modules. The ACT sessions were created and implemented by different faculty for the various clerkships creating some inherent variability in student training. The lack of significant programmatic impact between the two study groups could be attributed, in part, to this limitation given performance scores were the key outcome measure of interest. This need for increased standardization of medical education interventions has also been advocated in the literature (Colliver, 2003). In addition to program implementation challenges, several methodological challenges were encountered including: (a) limitations in identifying appropriate comparison groups, (b) inability to use randomization in the study design given system and policy restrictions, and (c) insufficient statistical power to detect measurable differences. In accordance with policies instituted by the School of Medicine at SUNY Stony Brook, medical students are able to select the location of their clerkships. Therefore, participants in the ACT Pilot Program had self-selected to undergo their clerkships at SUNY Stony Brook for each of the ACT sessions. Given that system restrictions did not permit randomization, the modules were implemented to groups of students throughout the academic year in order to gain enough subjects. Students who received the ACT sessions early on in their third year may have had different baseline skills and knowledge relevant to clinical reasoning from those whose sessions were held later on in their training. Thus, determination of true comparability between ACT Program participants and non-ACT participants with confidence is limited. There also may have been meaningful differences between the two groups in terms of motivations to select SUNY Stony Brook relative to other affiliated clinic sites for clerkship rotations and site-level differences in clerkship trainings. In addition, in the intervention, there were many factors that changed including students, physician trainers, clerkship sites, and training modules. Hence, it is difficult to ascertain which programmatic component may have had the strongest pull to make a difference in enhancing clinical reasoning skills. Moreover, small sample sizes limited power for more robust analytic applications. In hindsight, it may have been a better approach to have matched ACT participants with a comparable group of non-ACT participants using relevant characteristics. In the absence of randomization, to ensure comparability between the two groups, a single cohort of students could be followed through all ACT modules and compared to a matched cohort of students at non-SUNY clerkship sites. As one strategic approach to increase the study’s sample size (and thus statistical power), multiple intervention sites could have been identified and compared with non-intervention sites with sites serving as the unit of analysis rather than the students themselves. The feasibility of implementing these potential strategies would have to be examined given added layers of complexity in implementation and analyses. Opportunities for Enhancing Clinical Reasoning Skills of Medical Students Medical education is structured as a sequence of stages, whereby more advanced levels are built on the foundations laid in the preceding levels (Benbassat et al., 2005; Benbassat and Bauman, 2007). Based on the secondary findings of the ACT Pilot Program, challenges faced by medical students were apparent in their interactions with Master Clinical Instructors in all dimensions of clinical transactions including technical, interpersonal, and interpretive. An understanding of clinical diagnostic pathways appeared to pose difficulties for students in far greater intensity than initially anticipated by the medical faculty. Unexpected disparities in clinical competency perceptions between the ACT Program’s Master Clinical Instructors and actual abilities of medical students provided some empirical evidence that students struggle in their transition from a more passive clinical learning setting in classrooms to a more active, hands-on approach in clerkships. In addition, teachings about basic clinical reasoning pathways were de-contextualized and not well integrated into the medical curriculum, further exacerbating difficulties faced by students. Deficiencies were prevalent in high-value practical skills such as real-time documentation and subsequent data interpretation. Core clinical skills including interviewing, physical exam, communication skills, medical ethics, and professional responsibility required additional emphasis and repetitive introduction to crystallize new learning among medical students. The most functional opportunity to address this disconnect at SUNY Stony Brook was the formal incorporation of clinical reasoning pathway instruction into the University’s medical education curriculum. One innovative solution to facilitate documentation, advancement in acquiring clinical exposure to enhance diagnostic differentiation skills, and monitoring student and faculty interactions at SUNY Stony Brook has been the introduction of a standardized assessment tool named Clinical Skills Passport (aka Passport). This tool formally captures the interpretive and procedural skill sets required for solid clinical reasoning among students in their clerkship trainings. The Passport tracks 91 clinical domains that include procedural and technical skills such as venipuncture and bladder catheterization as well as interpretive skills such as analysis of electrocardiograms and blood gases. Students are required to bring their Passports to patient encounters and clinical assessors (e.g., Master Clinical Instructors) are required to complete the tool with students, an approach to teaching and learning in medicine that has shown promising preliminary results in other similar competency-based curricula (Denton et al., 2006; Madigosky et al., 2006). Another approach to enhancing clinical reasoning sills that surfaced in designing the ACT Pilot Program was the use of multiple instructional modalities. The ACT Program’s instructional modalities included interactive problem-based learning, simulated exercises, standardized patients using actors, and real patient encounters through mini-clinical evaluation exercises. Past studies have examined the strength (S), weaknesses (W), opportunities (O), and threats (T) (i.e., SWOT) for each of these educational options (Charlin et al., 2000; Goldstein et al., 2005; McGovern et al., 2006; Peltier et al., 2007; Palmer and Devitt, 2007; Steadman et al., 2006). The general consensus among medical educators is that a hybrid combination of these instructional modalities is best, with emphasis on improving knowledge, skill, and self-confidence. The experiences of this study’s authors suggest the following stepwise progression for teaching clinical reasoning mastery is advisable: (1) build knowledge base, (2) teach patient interviewing skills, (3) provide hands-on instruction specific to physical examination skills, (4) teach data interpretation and results documentation skills, and (5) build communication and patient counseling skills related to negotiating care plan development. Practice Implications for Teaching and Learning in Medicine Insights derived from the planning, design, implementation, and results generation phases of the ACT Pilot Program have several practice implications that illuminate the potential for future efforts to impact clinical diagnostic reasoning in academic medicine. Specifically, the authors pose the following recommendations: • Findings from the ACT Program concur with past studies that suggest student difficulties in mastery of clinical diagnostic reasoning skills may be more complex than clerkship directors perceive (O’Brien et al., 2007). Thus, medical schools should consider presenting learning experiences that introduce pathways for clinical reasoning and differential diagnosis early in their curriculum. Since learning in clerkships is an active and experiential process, success depends, in part, on the students’ capacity for reflective practice and accurate self-assessment (Eva, 2005; Eva et al., 2007). Therefore, integration of relevant knowledge domains and skills occurs through opportunities to perform and improve on sets of highly differentiated tasks; deliberate mixed practice and feedback should be strongly encouraged. • To promote ample opportunities to practice clinical reasoning skills and diagnosis identification among undergraduate medical students, medical schools should consider utilizing a combination of instructional modalities. Instructional options should include a hybrid of multi-media computerized patient simulation (Gordon et al., 2004; Hanna and Fins, 2006; Feldman et al., 2006), standardized patients (Fletcher et al., 2004), case-based small group feedback involving Master Clinical Instructors or Clinical Scholars (Srinivasan et al., 2007), web-based interactive teaching (Kerfoot et al., 2006), and live patient encounters. • Use of learning communities to enhance medical school education has recently gained favorable review (Rosenbaum et al., 2007). Hence, in addition to learning from medical faculty, peer-to-peer mentoring communities could be established so that support could be gained by more junior students from upper classmen. • Academic institutions should prioritize developing a cadre of teaching faculty whose main responsibility would be the education of students. Medical schools should also institute initiatives that ensure that students are exposed during their clinical education to members of clinical faculty who are recognized to be outstanding clinicians and clinician educators. Investing in faculty development and academic vitality cannot be successfully achieved without instituting organizational policies and procedures that encourage and reward teaching by faculty (Muller and Irby, 2006; Steinert et al., 2006). Therefore, leadership support needs to be secured to champion such undertaking. • Establishing specific learning objectives as well as rigorous formative and summative evaluations to ensure that students are acquiring the knowledge, skills, attitudes, and values deemed necessary at their stage of learning is imperative. Students need to perform in a developmentally appropriate manner to integrate complex tasks in their clinical repertoire to ensure the provision of high quality and safe patient care. Without thoughtful measurement that permits the application of analytic rigor, it would be difficult for demonstration programs to gain sufficient traction to be adopted into the mainstream curriculum at medical schools, a challenge faced by investigators undertaking the ACT Pilot Program. Despite the study’s limitations, this article contributes to the void in the clinical reasoning literature on several levels. First, it provides an overview of the ACT Pilot Program’s key components and implementation procedures thereby informing the literature on a curriculum designed to enhance clinical reasoning skills. Second, the ACT Program’s primary as well as unexpected secondary findings are highlighted providing a quantitative overview of programmatic impact as well as more qualitative results from group observations by Master Clinical Instructors. Third, the article describes programmatic and methodological challenges encountered during the ACT Program, with translatable implications for future programs intending to enhance clinical diagnostic reasoning skills of medical students. Lastly, possible solutions related to implementing future programs as well as practical considerations are presented to illuminate future directions for teaching and learning in academic medicine. 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Please forward all future correspondence to: Primary Correspondent Latha Chandran, MD, MPH Associate Dean for Academic and Faculty Affairs Vice Chair for Education, Department of Pediatrics Office of the Dean, School of Medicine Stony Brook University Hospital and Medical Center Health Sciences Center, L4-175 Stony Brook, NY 11794 Tel: (631) 638-2005 Fax: (631) 444-7865 E-mail: latha.chandran@stonybrook.edu Alternate Correspondent: Maryam Navaie, DrPH Senior Vice President Advance Health Solutions, LLC 7660 Fay Avenue, Suite H530 La Jolla, CA 92037 Tel: (858) 456-3592 Tel: (866) 330-0596 (toll free) Fax: (858) 876-0132 E-mail: mnavaie@advancehealthsolutions.com © Copyright 2009 by Academic Leadership |
