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Jackson MB, Keen M, Wenrich MD, Schaad DC, Robins L, Goldstein EA. J Gen intern Med 2009; 001: 10.1007/s11606-009-1032-7 (print citation not available as of 7/13/09). Impact ofa Pre-Clinical Clinical Skills Curriculum on Student Perfonnance in Third-Year Clerkships.


Jackson MB, Keen M, Wenrich MD, Schaad DC, Robins L, Goldstein EA. J Gen intern Med 2009; 001: 10.1007/s11606-009-1032-7 (print citation not available as of 7/13/09). Impact ofa Pre-Clinical Clinical Skills Curriculum on Student Perfonnance in Third-Year Clerkships.

Reviewer: Chris White, MD Medical College of Georgia

What is the problem and what is known about It so far?
Increasingly clinical skills are being introduced and taught in the pre-clinical years. The University of Washington has developed a comprehensive longitudinal program (The "Colleges") to teach fundamental clinical skills to 2nd year medical students. Thirty-six faculty mentors meet weekly with six students throughout their 2nd year. By the end ofthe year, each student has interviewed, examined. and made a bedside oral presentation on six hospitalized patients under the supervision ofhislher mentor. The student also presents the patient to hiYher colleagues and demonstrates physical exam findings so that by the end ofthe year, each 2nd year student has heard bedside presentations and observed physical exam findings on an additional 30 patients. This program requires significant faculty time and resources. The impact of this effort on student clerkship performance is unknown.

Why did the researcbers do this partieular study?
The impact ofnew curriculum changes can be difficult to show. The authors hypothesized that the Colleges curriculum would result in improved medical student performance in their 3'" year clinical clerkships in the areas stressed by the curriculum (communication, history-taking, physical exam, oral case presentations. preparing write-ups).

Who was studied?
Six classes of UW third year students were studied: three classes before and three classes after the implementation ofthe new curriculum.

How was the study done?
The authors conducted a non-randomized, retrospective review of student performance evaluations from 3rd year clerk ships before and after the implementation ofthe new curriculum. All third year students who advanced directly to third year c1erkships were included (students taking lime out to get an advanced degree such as a PhD were excluded). Student clerkship performance was measured by a standardized cbkship evaluation form covering 12 clinical skills domains (problem-solving ability. data gathering skills, technical communication skills. procedural skills, communication skills, relationships with patients, professional relationships, educational altitudes. initiative and interest, attendance/preparation, and dependability). Students were rated on the fonn by facully and residents using a Liken scale (1-7). The same evaluation form was used in all derkships throughout the study period. The mean scores for each class in each ofthe domains in each of the clerkships were compared.

What did the researchers find?
Students participating in the Colleges curriculum achieved statistically higher clerkship performance evaluations in 9 of 12 clinical skill s domains in their Intemal Medicine clerkship compared with students in the clerkship before the introduction ofthe new curriculum. The largest effect sizes were in the domains of educational attitudes, patient relationships, and communication skills. Students also had higher evaluations in 3 of 12 domains in Surgery, and 1 domain in Pediatrics and Family Medicine. However, students had lower evaluations in 2 domains in Family Medicine, 1 domain in Psychiatry, and no changes in any domains noted in Ob/Gyn.

What were the limitations of the study?
For reasons that are not clear, not all student evaluations were included in the analysis -the authors state that, " ... for most years and clerkships, the data represent well over 90% of the class." Also, clerkship evaluations do not measure the entire range ofstudent performance. Because the numbers were quite large. the statistical differences (about 0.1 points higher on the Likert scale in the post•Colleges classes) may not be as educationally significant as one would think. For example, the change in the domain ofpatient relationships improved from 6.59 to 6.7 on a scale of 1-7, Finally, most ofthe patients used for clinical skills training in the Colleges curriculum were adult patients on the general medicine wards, and 113 of the Colleges faculty are internists. Thus, although the clinical skills taught should be general izable to all disciplines. it is nO{ surprising that the greatest impact was seen on the Internal Medicine clerkship.

What are the implications of the study?
This study represents a nice effort to learn the impact ofa major curricular change on student performance. It is a bit disappointing that a major impact was only seen in Internal Medicine. This may be related to the limitations ofthe evaluation method used. Other medical schools have developed similar "colleges" in their preclinical curriculum, yet there are few published studies showing the impact ofsuch interventions. At the Medical College ofGeorgia, we teach pediatric physical diagnosis using a similar model. limiting each 2nd year student's experience with a pediatric mentor to 2 pediatric patients and a newborn infant. We think it is making a difference. but we also struggle with how to measure the impact of our efforts on the clinical skills development ofour students.

Ed note: This is always a killer. We spend oodles of time developing and implementing a really cool and valuable intervention and find. much to our dismay, that we cannot either design the right assessment or that we cannot prove that we have made a difference. While the old saw, "good students in, good students ouf' may be true, we need to continue to encourage this type ofoutcomes driven research. (WVR)

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