Limitations in the curricula of American medical
schools may be preventing students from getting enough
basic skills training to succeed in clinical settings,
according to two Johns Hopkins studies published in the
January issue of the journal Academic Medicine.
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 vary
greatly 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 [are] looking for new and
better ways to do that," said Eric Bass, senior author of
both studies and associate professor of medicine at Johns
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 was designed to help address the issue, according
to Donna M. Windish, lead study author and postdoctoral
fellow in medicine at Hopkins. In the six-week course,
offered during the second year of medical school, groups of
six students are paired with one or two faculty members and
discuss communication skills and reasoning. The course work
involves role playing, interviewing 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 the
directors to rate the level of student preparation needed
(none, minimal, intermediate or advanced) 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). They also asked them to rate the adequacy of the
preparation (ranging from "much less prepared than
necessary" to "much more prepared than necessary") they
observed among their students.
Of the 140 clerkship directors who responded (74
percent), 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.
Ninety-six percent of the 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 said that
level of ability is needed for identifying life cycle
stages; and 56 percent said that level is needed 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 preclerkship
curriculum," Windish said. "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.
Of 49 core skills, the directors surveyed rated 29
skills (59 percent) as at least moderately important,
though they addressed only 14 of those skills (29 percent)
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 competencies 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," said Hoangmai H. Pham, lead author of the
second study and a senior health researcher at the Center
for Studying Health System Change in Washington, D.C.
"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 funded partly by the
University of Nebraska College of Medicine. Co-authors were
Paul M. Paulman, of the University of Nebraska, and Allan
H. Goroll, 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. Co-authors were Lisa Simonson and
Linda P. Fried, both of Johns Hopkins; D.M. Elnicki, of the
University of Pittsburgh; and Allan H. Goroll, of
Harvard.