Measuring Clinical Skills
Moderator: Alex Mechaber, MD
Discussant: Mark Albanese, PhD
Early Introduction of Clinical Skills Improves
Medical Student Comfort at the Start of
Third-Year Clerkships
Mark E. Whipple, Courtenay B. Barlow, Sherilyn Smith, and Erika A. Goldstein
Abstract
Background
To determine whether introducing
clinical skills during the second year of
medical school, via a competency-based
College system approach, improves
comfort level for medical students
entering third-year clinical rotations.
Method
From 2003–2005, two cohorts of thirdyear medical students at the University of
Anxiety in medical students has been
recognized in the literature for many
years1–3 and may center around first
patient encounters and first physical
examinations performed on actual
patients.4 Data suggest that students feel
most prepared when clinical skills are
introduced early in their curriculum,
and that students typically value
opportunities to interview and examine
patients, as opposed to passive learning
via lectures.5–7 Approaches to better
prepare medical students include
improving students’ physical diagnosis8,9
and communication skills.10 –12 Additional
research supports the importance of
mentoring relationships in alleviating
medical student anxiety.13,14 Many of these
studies focus on changes either to a
particular course or to the medical school
curriculum during the clinical years.
However, medical student anxiety is often
most prevalent when first entering the
clinical years (i.e., at the beginning of the
third year of a traditional four-year medical
school curriculum).
The University of Washington School of
Medicine (UWSOM) developed a
competency-based College approach to
Correspondence: Mark E. Whipple, MD, 325 Ninth
Avenue, Box 359894, Seattle, WA 98104-2499;
e-mail: (mwhipple@u.washington.edu).
S40
Washington were surveyed on their
comfort level in the categories of history
taking, physical examination,
communication, and patient care.
Results
The cohort of students exposed to the
College system reported a statistically
significant greater comfort level in half of
the measured areas, and in at least one
area within each general category. No
the early introduction of clinical skills to
medical students, which is currently in its
fourth year of practice. The Colleges
provide a consistent faculty
mentor/advisor to each student, who
oversees and teaches a four-year
curriculum of clinical skills and
professionalism including a restructured
introduction to clinical medicine II (ICM
II) course in the second year. The ICM II
course includes one morning a week
throughout the second year of medical
school, in which each faculty member
teaches clinical skills and professionalism
to their group of 6 students in an
inpatient, bedside setting.15
The goal of our current study is to
determine whether the College system
and the revised ICM II course are
improving comfort level with clinical
skills for medical students entering their
third year clinical rotations. Our
hypothesis is that those third-year
students exposed to the College system
will have an improved comfort level in
the core clinical skills, as compared to
those third-year students who were not
exposed to the College system and revised
ICM II course during their second year.
These core clinical skills consist of proper
physical examination techniques, relevant
history taking and communication skills,
and experience in the patient care setting.
area of study showed a statistically
significant decline.
Conclusion
A competency-based College system
improves medical student comfort in
core clinical skills at the start of the third
year curriculum.
Acad Med. 2006;81(10 Suppl):S40–S43.
Method
The design is a nonrandomized,
prospective cohort study conducted from
2003–2005. The target population
consisted of two cohorts of medical
students at the UWSOM: those third year
students who entered medical school in
2000 (E-00), and those third year
students who entered medical school in
2001 (E-01) or 2002 (E-02). The E-00
students completed the second year of
medical school and entered the third year
prior to the curriculum changes that are
the subject of this study. Both the E-01
and E-02 students participated in the
College system and the revised ICM II
course during their second year of
medical school. Students were identified
as being members of a certain class based
upon UWSOM-compiled e-mail lists.
Those members of a third year class who
were not involved in third year clinical
clerkships (e.g., MD/PhD students and
those students who had expanded their
medical school curriculum) were
requested to not fill out the survey. The
survey instrument was developed as an
anonymous, web-based questionnaire
(Table 1) with multiple-choice questions
using a 5-point Likert scale and grouped
in the following categories: history taking
skills, physical examination techniques,
communication skills, and patient care.
Academic Medicine, Vol. 81, No. 10 / October 2006 Supplement
Measuring Clinical Skills
Table 1
Survey Questions with p Values for the Wilcoxon-Mann-Whitney Test Comparing
the E-00 Class (Not Exposed) to the Combined E-01 and E-02 Classes (Exposed to
College System)
Survey question
p Value
For each question, please consider your first 12 weeks of your
third year and rate how comfortable you felt:
.........................................................................................................................................................................................................
1. Eliciting a thorough history of present illness (HPI), including the chief
complaint
0.2
.........................................................................................................................................................................................................
2. Eliciting a thorough social history, including questions about tobacco, alcohol
and other/illicit drug use
0.3
.........................................................................................................................................................................................................
3. Eliciting a comprehensive review of systems (ROS)
0.01
.........................................................................................................................................................................................................
4. Performing a complete, thorough physical examination (PE) on a patient in an
inpatient setting
0.02
5. Performing the Rinne and Weber tests (tuning fork tests for hearing)
0.04
.........................................................................................................................................................................................................
.........................................................................................................................................................................................................
⬍0.01
6. Measuring the jugular venous pressure (JVP)
.........................................................................................................................................................................................................
7. Percussing the lungs
0.01
.........................................................................................................................................................................................................
8. Palpating the liver edge
0.3
9. Testing for intact cerebellar function
0.1
.........................................................................................................................................................................................................
addressing competencies in these skills
are currently taking place at the
UWSOM. However, based on our results,
we feel that exposure to the College
system and revised ICM II course has an
overall positive impact on students’
perspectives regarding their comfort with
clinical skills and may help to alleviate
some of the anxiety that third year
students experience when beginning
clinical rotations. Those third year
students involved in the College system
reported a statistically significant (p ⬍
.05) greater comfort level in half of the
measured areas, and in at least one area
in each of the general categories (history
taking, physical examination,
communication, and patient care). No
specific area showed a statistically
significant decline.
.........................................................................................................................................................................................................
10. Testing for the triceps reflex
0.1
11. Performing a female breast examination
0.2
12. Performing a male prostate examination
⬍0.01
.........................................................................................................................................................................................................
.........................................................................................................................................................................................................
.........................................................................................................................................................................................................
13. Performing oral case presentations (OCPs) on the wards
0.3
.........................................................................................................................................................................................................
14. Writing a complete history and physical (H&P) in a timely fashion
0.08
.........................................................................................................................................................................................................
15. Constructing a differential diagnosis (Diff Dx)
0.3
.........................................................................................................................................................................................................
16. Discussing patient cases with your peers
0.03
.........................................................................................................................................................................................................
17. Discussing patient cases with attendings and preceptors
0.1
.........................................................................................................................................................................................................
18. Interacting with patients
0.03
.........................................................................................................................................................................................................
19. Using medical equipment (i,e., oto/ophthalmoscope, blood pressure cuff, etc)
0.03
20. Being in a patient care setting
0.02
.........................................................................................................................................................................................................
In March 2003, an e-mail was sent to the
E-00 third year class requesting completion
of a brief, anonymous online survey. Two
follow-up emails were sent over the next
month. In March 2004 and 2005, emails
were sent to the current third year class
(E-01 and E-02, respectively) requesting
completion of the survey. Responses were
compiled and the results from each cohort
were compared using the one-tailed
Wilcoxon-Mann-Whitney nonparametric
test for ordinal data in Matlab (Mathworks,
Inc., Natick, MA).
The Institutional Review Board, Human
Subjects Division, of the UWSOM
exempted this study from further review
in March 2003 (exemption reference
number 03– 6855-X.) No funding sources
were used for this study.
results of the survey are shown in Table 2
along with the p values for the WilcoxonMann-Whitney test comparing the E-00
cohort with the combined E-01 and E-02
cohort.
As noted in Tables 1 and Table 2,
statistically significant improvement in
students’ self-reported comfort levels
were found for the following skills:
obtaining a history of present illness,
performing a complete physical exam,
specific exam maneuvers chosen to
represent the head and neck,
cardiovascular, pulmonary, and
abdominal exam, oral case presentations,
discussing patients with attending
physicians, using medical equipment and
working in the patient care setting.
Discussion
Results
Overall, 99 of 135 (73%) respondents
from the E-00 class, 95/128 (74%) from
the E-01 class and 94 of 129 (73%) from
the E-02 class completed the survey. The
Our study focuses on students’ comfort
level in a variety of different areas, rather
than on the competencies of third year
medical students during their core
clinical rotations. Additional studies
Academic Medicine, Vol. 81, No. 10 / October 2006 Supplement
We decided to question students
regarding comfort levels with specific
physical examination maneuvers rather
than with a certain part of the physical
exam in the abstract. Our thinking was
that the student would be able to provide
a more accurate self-assessment when
considering a concrete maneuver, which
could serve as a proxy measure. In
choosing which specific “benchmark”
physical examination techniques to
represent a particular body or organ
system, we attempted to filter out those
techniques that may have been learned
during the first year of medical school
(e.g., auscultation of normal heart
sounds), as well as those techniques that
tend to be part of a more advanced
physical examination (e.g., eliciting a
Murphy’s sign during an abdominal
examination). Those techniques that are
represented in the survey were specifically
chosen because they are considered to be
“benchmark” requirements for successful
completion of the revised ICM II course.
However, considering the broad range of
maneuvers that are part of a complete
physical examination, it becomes
recognizably difficult to choose the
perfect representative maneuver for each
system.
Several areas did not show an
improvement between the cohorts.
Certain survey questions, such as those
focused on perceived comfort level in
obtaining a complete social history and
review of systems, are not primary
focuses of the ICM II course, but rather
the focus of the introduction to clinical
medicine I course (ICM I) taught during
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Measuring Clinical Skills
Table 2
Comparison of Survey Responses by Third-Year Classes (E-00 Class Not Exposed,
E-01 and E-02 Classes Exposed to College System)
Percent of respondents to questions (E-00 円 E01ⴙE02)
Extremely
comfortable
Comfortable
Q1: History of present illness
18% 兩 28%
58% 兩 56%
12% 兩 9%
11% 兩 7%
1% 兩 1%
Q2: Social history
29% 兩 31%
52% 兩 55%
13% 兩 9%
6% 兩 5%
0% 兩 0%
Q3: Review of symptoms
13% 兩 15%
38% 兩 41%
28% 兩 25%
19% 兩 16%
1% 兩 3%
Q4: Physical examination
6% 兩 5%
34% 兩 47%
26% 兩 29%
29% 兩 16%
5% 兩 3%
Q5: Tuning forks
4% 兩 7%
19% 兩 21%
20% 兩 28%
38% 兩 33%
20% 兩 12%
Q6: Jugular venous pressure
2% 兩 5%
16% 兩 17%
21% 兩 27%
43% 兩 42%
18% 兩 9%
Q7: Percussion
13% 兩 18%
39% 兩 50%
22% 兩 20%
23% 兩 11%
3% 兩 2%
Q8: Liver edge
6% 兩 13%
33% 兩 37%
28% 兩 28%
28% 兩 20%
6% 兩 3%
Q9: Cerebellar
13% 兩 11%
39% 兩 42%
15% 兩 25%
24% 兩 14%
9% 兩 8%
Q10: Triceps
19% 兩 11%
37% 兩 43%
28% 兩 26%
11% 兩 16%
5% 兩 4%
Q11: Breast
15% 兩 17%
46% 兩 51%
23% 兩 19%
15% 兩 12%
1% 兩 2%
9% 兩 4%
29% 兩 28%
23% 兩 30%
34% 兩 31%
6% 兩 7%
Q13: Oral case presentation
5% 兩 6%
21% 兩 34%
16% 兩 19%
44% 兩 36%
13% 兩 5%
Q14: History and physical
9% 兩 14%
34% 兩 32%
28% 兩 29%
24% 兩 21%
4% 兩 5%
Q15: Differential diagnosis
4% 兩 5%
27% 兩 32%
33% 兩 34%
33% 兩 28%
4% 兩 2%
30% 兩 32%
53% 兩 53%
12% 兩 10%
4% 兩 4%
1% 兩 1%
Survey question
Neutral
Uncomfortable
Extremely
uncomfortable
...................................................................................................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................................................................................
Q12: Prostate
...................................................................................................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................................................................................
Q16: Peers
...................................................................................................................................................................................................................................................................................................................
8% 兩 13%
42% 兩 41%
18% 兩 29%
29% 兩 15%
3% 兩 2%
Q18: Patient interaction
35% 兩 44%
60% 兩 48%
5% 兩 6%
0% 兩 1%
0% 兩 1%
Q19: Equipment
18% 兩 29%
55% 兩 49%
17% 兩 18%
10% 兩 4%
0% 兩 1%
Q20: Patient care
26% 兩 37%
57% 兩 50%
12% 兩 10%
5% 兩 3%
0% 兩 1%
Q17: Attending
...................................................................................................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................................................................................
the first year of medical school. In
addition, the teaching of the female
breast exam and the male prostate exam
occurs in the ICM I course and have not
yet been the focus of change in the
revised ICM II format. However, we note
that the continued discomfort that
students’ experience with the prostate
exam highlights our need for added focus
on teaching this important clinical skill.
Other areas that failed to show
improvement include the maneuvers for
the neurological and musculoskeletal
exam, and these results will also help to
tailor future teaching efforts.
Several other questions did not show a
statistically significant improvement,
largely because students were already
relatively comfortable with these areas.
Only a few students in either cohort felt
uncomfortable discussing patients with
peers or with patient interaction.
Comfort with formulating a differential
diagnosis (p ⫽ .081) and comfort with
patient interaction (p ⫽ .13) showed
improvement but did not meet the
criteria for statistical significance. For
patient interaction, part of the lack of
statistical significance likely resulted from
S42
the relatively high comfort level in both
groups as noted above. However, these
questions also represent two areas,
clinical reasoning and communication
skills, that lacked specific curricula
during the time studied. We have
subsequently developed and
implemented curricula for clinical
reasoning and communication and will
be interested to see if comfort levels in
these areas continue to improve.
Our study has a number of limitations.
This is a single institutional study limited
to the Colleges curriculum at the
UWSOM. Moreover, since we
investigated a curriculum-wide change,
the subjects were not randomized and
therefore a historical cohort was used as a
control population. Due to the time
required for study design and human
subjects approval, our survey was
administered approximately eight
months after the initiation of third year
clinical rotations. This required medical
students to reflect back on perceptions
they had during their first two rotations
of third year, approximately 5– 8 months
prior to survey administration. However,
even with the timing delay, we believe
that our study was worth pursuing, given
the opportunity to take advantage of a
transition in the medical school
curriculum. We made efforts to avoid
recall bias by retaining the same timing of
survey administration for all three
groups. Our initial concern was that the
delay would tend to underestimate
differences between the cohorts. As time
elapsed between the different second year
exposures, any differences may become
increasingly mitigated by the common
third year experience. If such a
‘regression towards the mean’ did occur,
it would tend to reduce rather than
amplify any differences between cohorts,
in which case our observed findings
would be overly conservative.
Despite some of the limitations noted
above, our results are encouraging that a
College-based approach and expanded
clinical experience during the second year
of medical school help to increase
students’ comfort level at the beginning
of their third year.
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