The first study indicates that medical students do not receive enough training during the first two years of medical school to adequately prepare them for the clinical rotations they perform during the third and fourth years. The second study demonstrates that course directors greatly vary in their teaching of how to care for the chronically ill, a growing population in the United States.
"Medical schools across the country are examining how they train medical students, and looking for new and better ways to do that," says Eric Bass, M.D., senior author of both studies and associate professor of medicine at Hopkins. "We conclude that many medical schools may need to give more attention to the clinical competency preparation of students for the core clerkships. We need to ensure that our students offer the best care possible, regardless of the specialty they choose."
A new course in patient-physician communication at Hopkins is designed to help address the issue, according to Donna M. Windish, M.D., lead study author and postdoctoral fellow in medicine at Hopkins. In the six-week course, offered during the second year of medical school, students are split into groups of six, paired with one or two faculty members, and discuss communication skills and reasoning. The coursework involves role playing, interviewing of actors portraying patients and incorporating patients' wishes in making decisions.
In the first study, Bass and colleagues surveyed 190 clerkship directors in internal medicine, family medicine, pediatrics, surgery, obstetrics/gynecology and psychiatry from 32 medical schools around the country. They asked directors to rate the level of student preparation (none, minimal, intermediate or advanced) needed for six key clinical competencies -- communication skills, professionalism, interviewing/physical examination, understanding life cycle stages, epidemiology and understanding systems of care (defined as changes in health care organizations and how that affects the practice of medicine) -- and the adequacy of that preparation (ranging from "much less prepared than necessary" to "much more prepared than necessary") they observed among their students.
Of the 140 clerkship directors (74 percent) who responded, the majority reported that students need at least intermediate ability in five of the six areas (all but systems of care) prior to entering their first core clerkship, though 30 percent to 50 percent reported that students were less prepared than necessary in all six competencies upon entering the clerkships.
A total 96 percent of directors felt that students need intermediate to advanced ability in communication skills and professionalism. In addition, 78 percent said intermediate to advanced ability is needed for interviewing/physical examination; 57 percent for identifying life cycle stages; and 56 percent for epidemiology. Only 27 percent felt this level of ability was necessary to understand systems of care.
Fifty percent said students were less prepared than necessary in epidemiology and probabilistic thinking, and 30 percent reported that students were less prepared than necessary in communication skills.
"Many directors indicated that their clerkship provides formal training in at least one of these six competencies, because they believe students do not receive as much instruction as necessary in the pre-clerkship curriculum," Windish says. "Medical schools may need to give more attention to the early preparation of these students in these high-priority areas."
When asked to identify the most important competency that needs more attention, 32 percent cited interviewing/physical examination, 21 percent said communication skills, 16 percent said professionalism, 16 percent said epidemiology, 8 percent said understanding life cycle stages and 6 percent said understanding systems of care.
In the second study, of chronic care preparedness, trained student assistants interviewed directors of required medical school courses (such as internal medicine, pediatrics, family practice and ambulatory care clerkships, among others) at 16 American medical schools. Course directors were asked to rate the importance of assorted skills in caring for the chronically ill on a 1 to 5 scale, with 5 being essential, and whether they addressed these competencies using specific curricular methods (i.e. written objectives, course materials, written/oral exams, etc.). A majority of course directors used training sites at community-based outpatient clinics, hospital-based outpatient clinics, private practitioner offices and university hospital acute care units.
The directors surveyed rated 29 (59 percent) of 49 core skills as at least moderately important, though they only addressed 14 (29 percent) of those skills using two or more specific curricular methods. Course directors gave the highest importance ratings to screening for abuse, awareness of patients' sociocultural perspectives and protecting patient confidentiality. They gave lowest importance ratings to knowing strategies to maximize patients' potential within the limits of their illness, ability to discuss alternative information sources and ability to assess equipment needs.
Five competencies were included in written materials for a majority of courses: screening for abuse; diagnosing drug addiction, dependence and tolerance; management of dementia/cognitive impairment; recognizing risk factors for nutritional deficiency; and awareness of ethical issues in end-of-life care. However, only two were included in required activities by a majority of courses - screening for abuse and ability to discuss death and dying with patients.
Only one skill --- ability to screen patients for physical, mental and emotional abuse --- was included in written objectives for a majority of courses, and only one other skill --- age-specific management of dementia/cognitive impairment --- was included in exams for a majority of courses.
"Overall, course directors agreed about the importance of many competencies in chronic care but reported considerable variation in how they addressed these competencies," says Hoangmai H. Pham, M.D., M.P.H., lead author of the second study and a senior health researcher at the Center for Studying Health System Change in Washington. "Medical schools can improve training in chronic care by paying greater attention to specific methods for teaching."
Pham was at Hopkins at the time the study was completed.
The clerkship study was partly funded by the University of Nebraska College of Medicine. Coauthors were Paul M. Paulman, M.D., of the University of Nebraska, and Allan H. Goroll, M.D., of Harvard Medical School.
The chronically ill study was funded by grants from the American College of Physicians-American Society of Internal Medicine Foundation and the National Heart, Lung and Blood Institute. Coauthors were Lisa Simonson, M.D, and Linda P. Fried, M.D., M.P.H., of Hopkins; D.M. Elnicki, M.D., of the University of Pittsburgh; and Allan H. Goroll, M.D., of Harvard.
Windish, D.M. et al, "Do Clerkship Directors Think Medical Students Are Prepared for the Clerkship Years?" Academic Medicine, January 2004, Vol. 79, Issue 1. Pham, H.H. et al, "Training U.S. Medical Students to Care for the Chronically Ill," Academic Medicine, January 2004, Vol. 79, Issue 1.
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