Using standardized patients to assess medical students' professionalism.

Context, conflict, and resolution: a new conceptual framework for evaluating professionalism.

Reliability and validity of an objective structured teaching examination for generalist resident teachers.

Context: Providing students reliable objective feedback regarding their clinical performance is of great value for ongoing clinical skill assessment. Since a standardized patient (SP) is trained to consistently portray the case, students can be assessed and receive immediate feedback within the same clinical encounter; however, no research, to our knowledge, has documented the reliability of the SP at assessing student performance. Objective: To determine if SPs provide a reliable assessment of athletic training students' performance in obtaining a patient history and completing a physical examination relative to athletic training faculty. Design: Reliability study. Setting: Athletic training simulation lab. Patients or Other Participants: Two SPs and 2 athletic training faculty assessed 35 students (n = 20 junior; n = 15 senior) in athletic training cohorts from a public liberal arts institution in southeast United States. Intervention(s): Athletic training students completed 2 SP encounters per semester throughout 1 academic year in the athletic training program, totaling 4 SP encounters. Main Outcome Measure(s): After each SP encounter, athletic training faculty and SPs completed the same clinical performance checklist developed specifically for each encounter. The checklist included yes/no items related to obtaining a patient history (10–12 items each) and completing a physical examination (12–15 items each). For each SP encounter, composite scores were computed for both history and physical examination items from the athletic training faculty and SPs. Intraclass correlation coefficients (ICC) determined interrater reliability between athletic training faculty and SPs for history and physical exam items. Results: Reliability coefficients between the SP and athletic training faculty indicated fair to strong agreement for most history and physical examination items. Significance was found for history items in the cervical spine emergency (ICC = 0.671, P = .002), knee (ICC = 0.696, P = .003), low back (ICC = 0.622, P = .002), concussion (ICC = 0.764, P = .004), general medical (ICC = 0.571, P = .008), and psychosocial intervention (ICC = 0.572, P = .008) encounters. The reliability coefficients were significant regarding physical exam items for the cervical spine emergency (ICC = 0.588, P = .01), low back (ICC = 0.766, P > .001), concussion (ICC = 0.792, P = .001), and general medical (ICC = 0.878, P > .001) encounters. Conclusions: Overall, the SPs provided a reliable assessment of the athletic training students' clinical performance for obtaining a patient history and completing a physical examination. Given these results, devoting additional time during SP training should increase the reliability of the SP.

Standardized patients (SPs), now a mainstay of the undergraduate medical education experience, are beginning to play larger roles in helping students build competencies to better serve patients who have disabilities, in educating students about the lived experiences of persons with disabilities, and in testing students' understanding of disability-related issues. In this article, the authors discuss several U.S. training programs that involve SPs who have disabilities or SPs who do not have disabilities but who portray patients who do. The authors review the goals of each program (e.g., to provide students with opportunities to gain experience with patients with disabilities), describe their commonalities (enhancing students' interview skills) and differences (some programs are educational; some are evaluative), and summarize the evaluative data of each. The authors also explore the benefits and challenges of working with SPs with disabilities and of working with SPs without disabilities. Finally, they consider the practical issues (e.g., recruiting SPs) of developing and implementing such programs.

To determine the level of agreement between standardized patient ratings and resident physician self-ratings of physician interpersonal skills and the level of agreement between faculty observer and standardized patient ratings of resident physicians' interpersonal skills. Structured clinical evaluation. A total of 25 resident physicians in physical medicine and rehabilitation conducted a 10-min interview of a standardized patient to obtain a history. A resident physician, a standardized patient, and a faculty observer rated the resident physician's interpersonal skills immediately after the interview. The main outcome measure was a modification of the patient assessment measure from the American Board of Internal Medicine, a 9-item rating scale assessing communication (score range, 9-45). There was a low level of agreement between standardized patient ratings and the resident physicians' self-ratings of interpersonal skills (Lin's concordance coefficient, rc = 0.11, P = 0.58). Conversely, there was a statistically significant degree of agreement between the standardized patient and faculty observer ratings of resident physician interpersonal skills (rc = 0.50, P = 0.006). Some resident physicians have significant difficulty accurately assessing how well they communicate with patients. Physicians in training rarely get feedback regarding their interpersonal skills and may have difficulty using social comparison. Conversely, standardized patients and faculty observers may have insight into interpersonal skills about which resident physicians are unaware.

Pharmacist Licensure: Time to Step It Up?

Curriculum Management and Governance Structure ♦ The medical school adopted a centralized governance structure with its revised curriculum in 1992. ♦ Centralized governance has worked very well to ensure student achievement, interdisciplinary approaches to teaching and learning, ample and centralized support for medical education, and high-quality courses and instructors. ♦ Under the guidance of the associate dean for medical education, the curriculum is managed by directors in Component I, Component II, and Components III and IV, who all meet biweekly as a working committee. ♦ Component directors and assistant directors are appointed and funded by the associate dean for medical education. ♦ Major policy issues are managed by the Curriculum Policy Committee (CPC), which is composed of elected and appointed faculty members and medical students. ♦ A rigorous evaluation system, managed by a distinct office and staff with direction from a medical school faculty member, is monitored by the CPC. Office of Education ♦ The school's centralized governance structure for undergraduate medical education is administered through the Office of Medical Education. ♦ The associate dean for medical education has consolidated all activities in support of the curriculum for the MD degree in the medical school's Learning Resource Center (LRC), where students and faculty have access to support staff and resources, computers and printers, professional computer consultants, computer-based faculty development stations, small-group study rooms, classrooms and lecture halls, microscopes, the standardized patient program, and clinical skills examination rooms. Budget to Support Educational Programs ♦ The associate dean for medical education provides guidance and funding to faculty who lead each of the components of the curriculum (component directors and assistant directors), as well as the director and assistant directors of the Introduction to the Patient course, the standardized patient program, and the comprehensive clinical assessment. ♦ There is also centralized funding available for curriculum innovations and improvements, including development of new courses, sequences, and electives; new approaches to education and assessment; and computer-based enhancements and exercises. Funding for the curriculum and curriculum leaders was established in 1992 and has been increased by the dean over the last several years. ♦ In 1997, the school began quantifying the cost of medical education using an activity-based cost-accounting model. With information from faculty and administrators applied to the model, the school is now redistributing funding to departments based on actual educational costs, and also centralizing additional funding to support medical education under the aegis of the associate dean for medical education. Valuing Teaching ♦ The dean's office directly funds faculty members who are key leaders and administrators in the medical school curriculum. ♦ In the first two years, every faculty member with three or more contact hours in the curriculum is evaluated by students; in the clinical years students evaluate residents and faculty with whom they work. ♦ Individual faculty, course/clerkship directors, and department chairs may request student evaluations at any time. ♦ Documentation of the amount and quality of teaching provided is required by the medical school's promotion committees; a teaching portfolio template is provided via the Web for faculty to document their teaching contributions. ♦ All teaching faculty are encouraged to use evaluations of their courses and access to educational experts and computer consultants to develop innovative approaches to teaching and learning. Funding for such efforts is provided to faculty by the associate dean for medical education. ♦ The medical school has expanded its recognition of teaching by adding the Medical Student Award for Teaching Excellence to its more traditional awards. This award recognizes those faculty evaluated most highly by the medical students for their outstanding teaching, and is bestowed on eight faculty each year. CURRICULUM RENEWAL PROCESS Learning Outcomes ♦ The school's goals of medical education were created by the faculty in 1991, prior to development of the revised curriculum. The goals state specifically expectations for medical student progress and achievement in the curriculum. ♦ The goals were reviewed and formally reaffirmed by the faculty and the medical school executive committee in 1996. ♦ A curriculum blueprint, updated by faculty every two or three years, identifies specific knowledge, skills, and competencies every medical student must possess prior to graduation from medical school. This blueprint is used as a guide for content in all four years of the curriculum. ♦ Each course, sequence, and clerkship has specific published objectives to be met by medical students as measured by the course director; each clerkship director also has responsibility for ensuring student learning in specific areas (e.g., signs and symptoms) identified and agreed upon by the faculty director of the clinical years and the clerkship directors. Changes in Pedagogy Over the past decade biomedical research has become less based in the traditional scientific disciplines, and more integrative, especially with the expansion of knowledge in molecular biology and medical genetics. Further, learning occurs most effectively in a context that simulates the setting in which knowledge and skills will be applied. ♦ The first- and second-year medical curriculum is designed to enhance integration across the biomedical sciences with presentation of material and learning experiences in a clinical context, including communication and physical examination skills. ♦ Small-group discussions, laboratories, and computer/Web-based exercises augment traditional instruction, and weekly clinically-based multidisciplinary conferences re-inforce learning. ♦ The school is in the process of integrating specific disciplines into segments of the curriculum across all four years. ♦ Multiculturalism, complementary medicine, and geriatrics are just a few of the topics that are being integrated into the context of existing courses and sequences, with a focus on the patient's perspective. The topics are presented to students in the manner in which patients will present their medical problems to their physicians. This approach will encompass traditional and computer/Web-based instruction, standardized patient exercises, and patients and role models in clinics and hospitals. ♦ The effectiveness of the core curriculum and its integration into existing educational programs is assessed annually; methods will include the Comprehensive Clinical Assessment. ♦ An “educational consultant” model will also be implemented, which will allow students who have seen a particular patient in the clinic or who have worked through a case to present questions via the Web to a UM specialist, who will respond within 24 hours. ♦ Student progress in the specific disciplines is assessed at least once a year, and models to allow students to assess their own knowledge and skill in these areas are being developed. ♦ Instructional modules available via the Web have been introduced in several of the required clerkships to ensure consistent student learning and mastery of required material. The modules were developed by clerkship directors and their colleagues with computer consultants in the Office of Medical Education; they are case-based, interactive, and incorporate self-paced instruction and self-assessment components. ♦ Instructional standardized patient instructor (SPI) exercises have been incorporated across all four years of the curriculum; SPIs are also used for assessment of student knowledge and skills in most of the stations on the Comprehensive Clinical Assessment. ♦ All of the student encounters are videotaped, and students with marginal or failing performances return to review and discuss their encounters with the faculty director of the SPI program, prior to repeating the exercise. ♦ Communications skills and professionalism in encounters with SPIs are reviewed separately, and students must perform satisfactorily to receive a passing grade. Students must pass all SPI exercises to be promoted and to graduate. Application of Computer Technology ♦ Medical students are not required to own their own computers, but support is available to those who bring computers with them to medical school. ♦ There are 90 computers in the Learning Resource Center (LRC), another 26 computers in medical student study areas to which they have access 24 hours a day, seven days a week, and 15 computers in the UM Hospitals medical student call rooms. There are also “E-mail express” computers available to students in the LRC and the student study areas. ♦ The school has created Web-based “Coursepages” for medical students, through which students have access to a variety of information, services, and original educational materials developed by LRC computer consultants with medical school faculty. Using the Coursepages, students can access a variety of administrative and educational materials, including interactive educational materials developed by medical school faculty, calendars and schedules, and quiz and exam scores. They can submit “queries” about exam items, check course and clerkship grades, complete course and teacher evaluations, submit changes of their addresses, check their university accounts, and access Medline and other Web-based resources. Students can use and take practice quizzes. ♦ Required first-year quizzes are administered weekly to students via the Web in the LRC. The third-year pattern-recognition examinations, administered five times throughout the year, are also available to students via the Web. ♦ The LRC's faculty development stations provide faculty with state-of-the-art hardware, software, and professional consultation to introduce them to technology they can use to upgrade existing teaching materials or create new computer-based materials for use in the classroom. There is no charge to the faculty for use of the stations or for consultation. Changes in Assessment ♦ The Comprehensive Clinical Assessment (CCA), an OSCE-format examination, measures knowledge, skills, and competencies the faculty have identified as fundamental for graduation. ♦ The CCA is a four-hour examination comprising 12 stations that each student undergoes early in the fourth year. ♦ Content varies year to year to ensure appropriate sampling of critical clinical skills and competencies, and is determined by a faculty director and committee using the curriculum blueprint as a guide. ♦ To graduate, students must pass each station and the CCA overall, and must also pass a cross-station professional-skills component of the exam. ♦ With funding from the National Board of Medical Examiners Medical Education Research Fund, the school has expanded efforts to learn more about medical student self-assessment. Over the last several years, the school has examined self-assessment in each year of medical school and across a wide range of tasks, and has also explored predictors and behavioral implications of self-assessment accuracy. Studies to date have yielded a number of findings, including (1) self-assessment accuracy does not appear to relate to personal or academic variables, including academic performance, academic background or preparation, ethnicity, or gender, and (2) self-assessment accuracy may be slightly greater with more familiar tasks, suggesting a possible role for learning and experience. Upcoming studies focus on the dynamics of self-assessment and self-directed learning in medical education, and begin to examine interventions that might augment these skills. One study extends previous work from undergraduate medical education into graduate medical education, and another compares problem-based learning with learning in a more traditional curriculum to study both generalizability of previous results and the impact of curricular format on self-assessment and self-directed learning. Clinical Experiences ♦ Clinical experiences begin early in the first year with students' shadowing physicians in physicians' offices and clinic settings. Small-group discussions of specific topics, with each group facilitated by a physician and an educational expert, augment the shadowing experience. ♦ In the second year, each student is assigned to a clinical skills instructor (CSI) with whom the student will conduct five histories and physical exams throughout the year. There are two new models in place for the CSI experiences: The first model is focused on early clinical skills and is predicated on bringing the patient and the physician—teacher to the student in a student-centered educational setting within the LRC. Physicians and their patients meet with individual students in the LRC clinical skills laboratories. Students do a history and physical exam on the patient under supervision, write up findings/observations, and present the patient to the faculty. This approach provides the opportunity for direct real-time feedback to the students, with videotaping availability to critique student—patient interactions, including communication skills. The second model is based at the Northeast Ann Arbor ambulatory care facility, and is designed to enhance clinical education in the ambulatory setting in a structured rotation involving student, patient, and physician. Again, the experience is centered on the student—patient interaction, with supervision and feedback from the physician—teacher. Students spend one half day in clinic with physicians. Each student meets independently with a patient and conducts a history and physical exam. While the student writes up findings and observations, the physician examines the patient the student has seen. The student then presents the patient to the physician, who provides direct real-time feedback/instruction to the student, which may include returning to meet with the patient. ♦ Each of the clinical clerkships provides students with in-patient and outpatient educational experiences to ensure that specific learning objectives are met. “Educational consultants” (see changes in Pedagogy section above) who are specialists in specific domains will augment learning that occurs as students encounter real patients in the hospitals and clinics. Clerkship faculty can also develop computer- and patient-based cases; students can work through the cases to ensure mastery of specific competencies and seek input and guidance from the Educational Consultants. Curriculum Review Process ♦ In 1992 the school developed and adopted a centralized system for evaluation of the curriculum and teaching. ♦ The Curriculum Evaluation Office is managed by the director of the Office of Educational Resources and Research (OERR), who provides analyses of evaluation data and information and recommendations to faculty curriculum directors, the associate dean for medical education, and the Curriculum Policy Committee. A research associate manages the curriculum evaluation process and data, with assistance from an academic secretary. ♦ The Curriculum Policy Committee oversees the evaluation process and receives and acts on evaluation reports. ♦ The school evaluates six distinct areas of the curriculum, using a variety of internal and external measurements. Data are collected throughout each of the four years and at the conclusion of each academic year, and a full evaluation cycle is completed every four years. Follow-up evaluations of students by residency program directors occur one and three years after graduation. See Table 1 for more information about the evaluation process.TABLE 1: The Evaluation Process♦ Evaluation instruments. The annual survey instruments are organized to measure achievement of the ten goals of medical education. To facilitate the comparison of students' educational experiences across all four components, comparable evaluation instruments are structured with a core of common items. Though different evaluation forms are used to assess clinical and basic science teaching, core evaluation items are included on all forms. Course, sequence, and clerkship directors may add additional items to their course, sequence, or clerkship evaluation instruments in order to capture information relevant to their unique educational offerings. ♦ Student evaluations of teachers and curriculum Components I and II: Students are randomly assigned to four different cohorts (approximately 42 students per cohort), each of which is responsible for evaluating selected educational experiences during a half semester. Thus, 100% of the class is involved in the evaluation process, but no student is involved for more than half of a term. During their assigned half-term, students are asked to complete evaluations of faculty presentations, courses, and multidisciplinary conferences. All faculty with three or more hours of contact with students are evaluated, and faculty with fewer contact hours can request to be evaluated. All students participate in end-of-year component surveys. Components III and IV: In Component III, all students complete clerkship and clinical faculty teaching evaluations at the conclusion of each of the required clerkships. Each Friday, all students complete an evaluation on the Component III weekly seminars. The overall Component III experience is evaluated at the middle and end of the academic year by all students. In Component IV, all students are asked to complete an evaluation of their first six months of clinical rotations. At the end of Component IV, students are asked to complete an evaluation of Component IV overall, and also to share their impressions of the four-year curriculum. Two years ago, the school shifted its evaluation process from paper-and-pencil to Web entry. Students can now enter their evaluations and comments directly via the Web, and the program allows easy tracking of students to remind those who have not completed their evaluations. Program in Professionalism ♦ The University of Michigan Medical School has developed a comprehensive program to ensure that students understand the importance of professionalism in medical practice and acquire appropriate professional skills prior to graduation. ♦ The program begins during orientation to medical school with an oncologist who presents one of his or her patients and the patient's spouse. They all speak candidly to the class about the patient's cancer, the patient's relationship with the physician, the patient's personal and medical experiences since diagnosis, and the effects of the illness on the patient's life and family. Students are then encouraged to participate, and many ask probing and thoughtful questions about the difficulty of breaking bad news to patients, the essence and significance of the physician—patient—family relationship, trust, compassion, ethics, and personal and professional values and beliefs. ♦ The program in professionalism is incorporated throughout the four years of medical school, with assessments and feedback along the way. Specific components are physician—patient presentations (in the first and second years) small-group discussions (based on specific cases and experiences) scripted encounters with standardized patients (in all four years) role models (in all four years) concern/commendation cards assessment of professional behavior on all clinical clerkships assessment of professional behavior on the annual Comprehensive Clinical Assessment formal presentations by physicians about professional behavior (orientation, seminars in medicine, specific course/clerkship exercises) ♦ During the standardized patient encounters, the clinical clerkships, and the Comprehensive Clinical Assessment, student professionalism is assessed as a separate domain and followed longitudinally. Those students whose skills are below a certain level are provided with feedback and required to complete and pass remedial exercises. Demonstration of appropriate and consistent professional characteristics is a stated and published requirement for graduation. Future Goals and Challenges ♦ There will be an increased emphasis on the development of communication skills and recognition of the importance of the personal and social context in providing health care to patients. ♦ There will be a continued emphasis on and assessment of professionalism and professional characteristics. ♦ There will be incorporation of additional student-centered learning approaches into the curriculum (e.g., the Educational Consultant model). ♦ The integration of specific topics and assessment of mastery throughout the four-year curriculum will be continued. ♦ There will be continued development of educational experiences to prepare students for practice in evolving health care delivery settings and medical management models.

Health professional learners have limited exposure to breastfeeding patients from diverse backgrounds in clinical rotations. Instead, simulation-based training is used for lactation skills training. There are no validated or standardized simulations and assessment rubrics for lactation. In this pilot, breastfeeding telesimulations with standardized patients (SPs) wearing a high-fidelity breast model matching their skin tone were developed. The validity of Formative and Summative Assessment Rubrics (FAR, SAR) were assessed following Kane's validity framework. The objective was to provide initial evidence for the validity of the FAR and SAR as constructs of competence in lactation support at the entry to practice or practice level. Three breastfeeding case scenarios, FAR, and SAR were developed and evaluated with clinical lactation specialists (evaluators, n = 17) and SPs. The FAR was used in practice telesimulations where SPs' (n = 14) performance and telesimulation feasibility were assessed. The FAR was updated in preparation for a pilot study where medical students (n = 13) completed the 3 telesimulations. In the pilot, the updated FAR was used by SPs (n = 6) to assess medical students' performance of clinical skills. After the pilot, rubrics were updated after focus groups with SPs and discussions with evaluators. Evaluators (n = 3) graded students' posttelesimulation documentations using the SAR. Cronbach ɑ level and the intraclass correlation coefficient were assessed iteratively to collect evidence for the scoring, generalizability, and extrapolation of the FAR and SAR according to Kane's framework. The FAR and SAR were found to have acceptable internal consistency and moderate to high interrater reliability (intraclass correlation coefficient, 0.55-0.94), which provided evidence for scoring and generalizability of the instruments. Evaluators agreed that SPs' performances were realistic (5.6/6), and SPs' feedback was organized (5.5/6) and helpful (5.6/6), which provided evidence for extrapolation. Initial evidence for validity of scoring, generalization, and extrapolation FAR and SAR (according to Kane's framework) in assessing health professional learner's performance of clinical lactation skills has been presented. These results from a pilot study suggest that the FAR and SAR are reliable instruments for assessing learners' clinical performance in a breastfeeding-focused telesimulation where the SP wears a high-fidelity breast model matching their skin tone. Additional studies will be required to collect evidence according to all 4 categories of Kane's framework for the validity of the FAR and SAR.

BackgroundProfessionalism and communication skills constitute important components of the integral formation of physicians which has repercussion on the quality of health care and medical education. The objective of this study was to assess medical graduates’ professionalism and communication skills from the patients’ perspective and to examine its association with patients’ socio-demographic variables.MethodsThis is a hospital based cross-sectional study. It involved 315 patients and 105 medical graduates selected by convenient sampling method. A modified and validated version of the American Board of Internal Medicine’s (ABIM) Patient Assessment survey questionnaire was used for data collection through a face to face interview. Data processing and analysis were performed using the Statistical Package for Social Science (SPSS) 16.0. Mean, frequency distribution, and percentage of the variables were calculated. A non-parametric Kruskal Wallis test was applied to verify whether the patients’ assessment was influenced by variables such as age, gender, education, at a level of significance, p ≤ 0.05.ResultsFemale patients constituted 46% of the sample, whereas males constituted 54%. The mean age was 36 ± 16. Patients’ scoring of the graduate’s skills ranged from 3.29 to 3.83 with a mean of 3.64 on a five-point Likert scale. Items assessing the “patient involvement in decision-making” were assigned the minimum mean values, while items dealing with “establishing adequate communication with patient” assigned the maximum mean values. Patients, who were older than 45 years, gave higher scores than younger ones (p < 0.001). Patients with higher education reported much lower scores than those with lower education (p = 0.003). Patients’ gender did not show any statistically significant influence on the rating level.ConclusionGenerally patients rated the medical graduates’ professionalism and communication skills at a good level. Patients’ age and educational level were significantly associated with the rating level.

University of South Alabama College of Medicine.

University of Florida College of Medicine

Parents as Teachers and Evaluators of Medical Student Professionalism

WHILE THE IDEA THAT COMMUNICATION IS AN ESSENTIAL ASpect of medicine is not new, communication skills teaching and assessment have recently become more visible in medical education. For instance, communication skills feature prominently in a new national initiative: The National Board of Medical Examiners, the Federation of State Medical Boards, and the Educational Commission for Foreign Medical Graduates are working together to implement a clinical skills examination using standardized patients, to be taken between the third and fourth years of medical school as part of the United States Medical Licensing Examination (USMLE). This examination will “require students to demonstrate they can gather information from patients, perform a physical examination, and communicate their findings to patients and colleagues.” In 1995, the 2 bodies that accredit North American programs leading to the MD degree adopted a resolution stating that “there must be specific instruction and evaluation of [communication] skills as they relate to physician responsibilities, including communication with patients, families, colleagues and other health professionals.” While past initiatives did not generate much curricular change in medical schools, this resolution is likely to have a significant effect, given its link to program accreditation. It is important to note, however, that the standard requires only the presence of instruction and evaluation; it says nothing about the specific timing, quality, or quantity of the education. There is tremendous variation among medical schools in the way, and extent to which, communication skills are taught and assessed. The most recent and comprehensive survey on communication skills education in North American medical schools was conducted by the Association of American Medical Colleges (AAMC), and published in a 1999 report. Eighty-nine of the 144 medical schools responded to questions on the AAMC survey regarding communication skills teaching. Of these, 85% reported they use a combination of discussion, observation, and practice in teaching such skills. The primary teaching methods were small-group discussions and seminars (91%), lectures and presentations (82%), student interviews with simulated patients (79%), student observation of faculty with real patients (74%), and student interviews with real patients (72%). Nearly half of the schools (45%) reported using rounds to teach communication skills. All of these forms have value, but without a model to help structure and focus attention on communication, teaching is less likely to be consistent and effective. Ninety-two schools responded to the portion of the AAMC survey on communication skills assessment. Most of these schools (92%)reported that theyassessedcommunicationskills informally, through faculty feedback to students during teaching sessions. The next most frequently cited form of assessment was formal faculty feedback and observation (78%). More objective assessment methods, such as the use of standardized patients, were less widespread (70%). Again, the reliability and effectiveness of observation and feedback, regardless of the particular method, are likely to be compromised unless they are grounded in a coherent conceptual framework. While schools use a variety of teaching and assessment methods, many of these activities lack such a structure: At the time of the AAMC survey, less than one-third (32%) of medical schools were using a structured model to organize their communication skills teaching and assessment. Of the schools using a model, most used either the SEGUE Framework for Teaching and Assessing Communication Skills or the CalgaryCambridge Observation Guide. The focus on communication skills extends into residency and clinical practice, and is now linked specifically to accreditation of residency programs and maintenance of certification for practicing physicians. In 1999, the Accreditation Council for Graduate Medical Education, which oversees US residency programs, and the American Board of Medical Specialties, the umbrella organization for specialty boards that certify physicians, stated that “interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and other health professionals” is a core area of competency. The idea of communication as bedside manner or history taking has given way to a reconceptualization of communication as a measurable clinical skill.

IntroductionThe ability to utilize the electronic health record (EHR) without compromising the doctor-patient relationship (DPR) is an essential skill of all physicians and trainees, yet little time is spent on educating or assessing learners on needed techniques. To address this gap, we developed a conventional OSCE station coupled with a simulated patient chart within the Epic program in order to assess our students' skills utilizing the EHR during a patient encounter.MethodsOf third-year medical students, 119 were given full access to the patient's simulated chart 24 hours in advance of their OSCE to review clinical data. During an in-person OSCE with a standardized patient (SP), students performed a focused history and physical, using the EHR to verify allergies and medications. Students completed an electronic patient note graded by faculty. SPs evaluated the students on communication and interpersonal skills with specific rubric elements. Faculty graded the students' notes to evaluate their expression of clinical reasoning in the assessment and plan.ResultsTraining SPs and faculty to assess students on EHR skills was feasible. After implementation of a comprehensive curriculum focused on EHR and DPR, there was a significant difference on EHR-related communication skills (M = 76.4, SD = 17.6) versus (M = 37, SD = 28.9) before curriculum enhancement t (117.9) = −12.4, p <.001.DiscussionThe EHR OSCE station provided a standardized method of assessing students' EHR skills during a patient encounter. Challenges still exist in the technological requirements to develop and deliver cases in today's EHR platform.

Curriculum Management and Governance Structure ♦ The executive vice dean is appointed by the dean with the authority over all educational programs at the School of Medicine, including undergraduate, graduate, continuing medical education, graduate education (master's and PhD), and all services that support the educational mission. ♦ The associate dean reports to the executive vice dean and is responsible for the Office of Academic and Student Programs (OASP), whose divisions support the medical education program. ♦ The divisions include education management, evaluation, and medical education research, admissions, diversity, records and registration, student affairs, curriculum, conjoint teaching services, clinical skills center, and all biomedical communication functions. ♦ The governance of the curriculum is more centralized, with increased authority for the curriculum placed in the hands of the associate dean. ♦ There is still considerable decentralized authority for delivery of the curriculum at the departmental level in the hands of course and clerkship directors reporting to department chairs. ♦ The curriculum is managed using a hybrid system to ensure that the curriculum topics are delivered appropriately. ♦ The various management methods include CurrMIT, curricular maps, organization and review through the basic science and clinical science course/clerkship directors committees, student reporting, education core group, and the education deans. ♦ Final approval of the Curriculum Committee and executive vice dean is required (see Figure 1).FIGURE 1:: Curriculum Management Structure♦ The Curriculum Committee members are appointed by the Faculty Senate and monitor the content of required courses and clerkships, identifying gaps and redundancies through the work and subsequent reporting of the Course and Clerkship Directors Committees. ♦ The assistant deans of basic sciences, clinical sciences, and evaluation and medical education research annually review the course and clerkship content with the executive vice dean to further identify gaps and redundancies. ♦ When changes occur, a “planned incremental change” strategy is used, which focuses on the gradual implementation of curricula. This type of strategy allows for careful implementation, monitoring, and assessment of curricular components. Office of Education ♦ The Office of Academic and Student Programs (OASP) was established in 1992. ♦ Within OASP resides the division of education management, which consists of four full-time support staff, associate dean, assistant deans for basic sciences, clinical sciences, and evaluation and education research. ♦ The division of education management supports all undergraduate medical education (UME) curriculum activities for Years 1–4, including scheduling, evaluation of faculty and courses, testing services, grade reporting, academic support services, and co-curricular programs. ♦ In 2005, a division of evaluation and education research was developed as part of the division. Financial Management of Educational Programs ♦ The Department of Academic and Student Programs manages the budget for undergraduate medical education. ♦ Undergraduate medical education is funded by the University in a variety of ways: state support, tuition, student fees, and revenue from external clients (users of clinical skills center and media services). Valuing Teaching ♦ In 2008, a teaching academy was developed under the OASP, division of education management to promote and improve faculty teaching for all the medical education programs. ♦ The university uses a teaching portfolio for all issues regarding promotion and tenure. This has provided an opportunity to highlight the importance of teaching and encourage the faculty to also carefully document teaching accomplishments. ♦ Approximately 10% of our full-time faculty (80–100 faculty) are honored each year with the university teaching award program ($1,000 stipend plus recognition). ♦ The students have teaching awards for full-time and voluntary faculty. ♦ All course and clerkship directors are given a stipend for their work on a yearly basis. Curriculum Renewal Process ♦ Following a faculty retreat in 1995, the school adopted a five-year plan for curriculum renewal. It was referred to as “radical incrementalism” and identified a series of incremental steps, which faculty believe were necessary to effect a major curricular reform. ♦ In 2004, the Curriculum Committee conducted a review of the institutional learning objectives. The objectives were modified, and a set of competencies was developed to meet the educational needs of students. ♦ On-going changes in the curriculum can be proposed by faculty, administrators, or students. All requests must go through and be approved by the Curriculum Committee and executive vice dean. ♦ In 2010, the Curriculum Committee and associated subcommittees will undertake another extensive review of the learning objectives and competencies. Learning Outcomes/Competencies ♦ In 2004, the institutional learning objectives were carefully reviewed and compared/contrasted to the objectives from the Medical School Objectives Project (MSOP). From this review, the learning objectives were modified. ♦ In 2004, a set of medical school competencies were designed to align with the ACGME core set of competencies when relevant to undergraduate medical education. These competencies include the following: integration of the basic sciences in medicine, integration of clinical knowledge and skills to patient care, interpersonal and communication skills, professionalism, organization and systems-based approach to medicine, and life-long learning and self-improvement. ♦ The competencies and institutional learning objectives formalize the objectives of a WSU medical education, define what a graduating physician should know, and provide the measurement and evaluation mechanisms to ensure that objectives are being met. For further information go to http://www.med.wayne.edu/academic_student_programs/overview.asp. New Topics in the Curriculum Since 2000 ♦ Development of an ultrasound curriculum during Years 1–2. ♦ Development of a vertically integrated Clinical Medicine course to address a variety of public health and psychosocial topics. The Clinical Medicine course comprises a variety of longitudinal curricular themes. ♦ Year 1 Clinical Medicine Achievements and Challenges in Public Health The Aging Patient Clinical Preventive Medicine Cultural Competence Evidence-Based Medicine Exposure History Family History Exercises Human Sexuality Professionalism Terminology in Clinical Medicine ♦ Year 2 Clinical Medicine Advanced Care Decisions Adverse Health Outcomes Behavioral Risk Factors Community Health Assessment End-of-Life Decision Making Ethnic and Racial Disparities Health Care Disparities Health Care Financing/Allocation of Resources Persons with Disabilities Quality Health Care Assessment ♦ There have been some changes in the Year 3 clerkship curriculum, including the following: ♦ Development and implementation of a six-month Continuity Clinic Clerkship in Year 3. ♦ Minor changes in the Year 3 Clerkships, including the following topic areas: Barriers and Incentives Characteristics of Medicare Clinical Quality Benchmarks Confidentiality: Health Care Literacy and Patient Education Disease Prevalence in a Community Impact of Health Care Disparities Managed Care and Other Health Plans Treatment Expectations, Outcomes Changes in Pedagogy ♦ The enhanced use of small groups, computer assisted instruction, self-study, conferences, and panel discussions in place of large-group lectures. ♦ The integration of virtual microscopy in pathophysiology. ♦ Streaming video was introduced for all large-group lectures to meet the learning styles of our students. ♦ Increase in case studies in all preclinical courses. ♦ Increased use of standardized patients. ♦ Continuing efforts to empower students through committee work, community service, and student organizations. ♦ Integration of a clinical campus model for all Year 3 clinical rotations. ♦ Development of methods to identify students at-risk for failing Step 1. ♦ New programs to provide Step 1 support services during Year 1 and 2. ♦ Development of an education commons with state-of-the-art computers and smart classrooms, promoting life-long learning and self improvement. ♦ A state-of-the-art library in the new Richard J. Mazurek, MD, Medical Education Commons provides students electronic delivery of documents. ♦ Development of a clinical skills center, including standardized patients and patient simulation. Changes in Assessment ♦ Standardized patients are used in the Clinical Medicine 1 and Clinical Medicine 2 courses. ♦ A web-based student encounter tracking system was developed for students in clinical clerkships. ♦ Students must pass Step 1 CK and take Step 1 CS before being promoted to Year 3. ♦ Numerous clerkships have introduced OSCEs at the end of their clerkship. ♦ The comprehensive basic science NBME exam is required at the end of Year 2 to develop a baseline of student deficiencies. ♦ Faculty observations in small group settings are used to assess student knowledge and clinical skills in the Clinical Medicine 1 and 2 Course. ♦ All student evaluation of faculty and courses are conducted through a web-based interface. ♦ Currently piloting computer-based testing. Clinical Experiences ♦ In 2008, a clinical campus model was developed for students' Year 3 clerkship rotations. Under this model, students conduct a majority of their Year 3 course work at one partner affiliated hospital rather than rotating among our eight affiliated hospital sites. ♦ Students go to physicians' offices in the Year 1 Clinical Medicine Course. ♦ Students interact with patients in the hospital setting during the Year 2 Clinical Medicine Course. ♦ During Year 3, students are in physicians' offices for the continuity clinic clerkship, as well as an ambulatory block rotation in the fourth year. ♦ Co-curricular programs in Years 1–2 offer students experiences in nursing homes, hospice, as well as other community health organizations. Highlights of the Program/School ♦ The new Richard J. Mazurek, MD, Medical Education Commons provides students with state-of-the-art classrooms and computer laboratories and new opportunities in the latest patient simulation technology. ♦ A unique co-curricular program that recognizes students who have dedicated themselves to building partnerships with surrounding communities through a variety of sponsored outreach and volunteer activities. ♦ Students acquire a greater understanding of human needs, concerns, interests, and values through their participation in these programs, learning to interact with area residents by providing services in their communities. ♦ A diverse student body with a focus on student-centered learning.