Why medical students should be closely observed with patients

I went off to medical school thirty-seven years ago.

For the era, I went to what folks regarded as a very progressive place. It had a curriculum that was quite revolutionary for the time. Among other things, we started having interactions with actual patients during our first year, rather than the third year, as was traditional then.

These days many, probably most, medical schools get their students seeing real patients sooner. That’s good. But do these students get any sort of planned, structured assessments with how they’re doing with those real patients? Does anybody watch them, encourage what they’re doing right and correct what they’re doing wrong?

A recent editorial in the journal Pediatrics, the official journal of the American Academy of Pediatrics, has an enlightening title: “Oh, what you can see: the role of observation in medical student education.” It turns out that students often don’t get what they need to learn how to do things right.

It turns out that during their pediatric rotation only 57% of students have a faculty member observe them throughout the entire process of meeting a child and family, taking a medical history, and doing a physical examination. In my day I think it was worse than that: I can’t even recall having a teacher watch me go through the entire process; generally, the students would watch the teacher, then go off and try things on their own. Of course we weren’t allowed to do anything involving needles and such without training and supervision (at least at first), but thinking back it is surprising that we were mostly left to ourselves.

The rationale for direct observation is straightforward and obvious. In the words of the authors:

The aim of direct clinical observation is clear — to help preceptors gather accurate information about students’ actual performance in real-life clinical settings rather than inferring performance. Preceptors can then provide effective, timely, and specific feedback on observed skills that can be incorporated into subsequent clinical encounters. With better supervision of learners, both student skills and clinical care improve.

It seems obvious. Our colleagues in internal medicine are doing even worse they we are in pediatrics, though: the survey found that only 22% of students had an in-depth patient encounter observed by one of their teachers. Teachers of surgery, too, evaluated students “primarily on the basis of their own interactions with students rather than on observed clinical interactions with patients.”

The authors’ conclusion is self-evident, but at times somebody needs to point out the obvious:

Focused, direct observation of medical students in clinical settings provides valuable information about learners’ skills in history-taking, communication, physical examination, and providing information to children and parents. Observing students’ encounters with patients improves teaching, evaluation, preceptor satisfaction, student satisfaction, and, ultimately, patient care. For the great clinical teacher, direct observation is worth the effort.

Christopher Johnson is a pediatric intensive care physician and author of Your Critically Ill Child: Life and Death Choices Parents Must Face, How to Talk to Your Child’s Doctor: A Handbook for Parents, and How Your Child Heals: An Inside Look At Common Childhood Ailments.  He blogs at his self-titled site, Christopher Johnson, MD.

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  • http://www.BocaConciergeDoc.com Steven Reznick MD

    I have had the privilege the last few years of acting as a preceptor for the University of Miami Miller School of Medicine FAU campus outpatient history and physical teaching program. It begins with lectures and meetings between full time faculty and volunteer staff to review the curriculum and techniques being taught . We are given video access to the correct methods. These meetings are then followed up with quarterly meetings to discuss our observations, suggestions, concerns and to share teaching techniques that have been successful in our offices. The students start in the first year coming once a week to our office and once a week to the public health department with faculty. They are closely observed while they take their history and perform their exam adding on additional body systems as they are taught it. They then go back to their campus and discuss their techniques with their classmates and the full time faculty. There additional exams and histories are video taped and reviewed with the group for suggesstions. Every year they have a competency testing week where they are given real patients to evaluate and diagnose. Their technique is filmed then critiqued and graded with feedback given to the community faculty on their achievments in teaching the material and to the students on their grasp of the material. The program works.
    With Miami giving up its FAU campus and the opening of the FAU medical program I am told this program will continue. I believe the early exposure to patient care plus the close observation by two levels of faculty gives the students the knowledge and materials they need to be successful

  • http://strangelydiabetic.com Scott Strange

    I think it would also be useful for a non-medical observer, a patient advocate perhaps, to evaluate as well. The patient perspective can be quite different from a professional medical one

    • http://www.dialdoctors.com Dial Doctors

      I agree with you Scott that patient advocates would be an important addition. Doctors in training are the best way to ensure that the health care system is changing for patients. These new doctors will be trained in different areas and skills which will allow them to be better doctors.

      • ninguem

        How about a couple of lawyers too?

        And don’t forget an architect, ’cause you’re gonna need to build a bigger room.

  • Kevin

    In my psychiatry residency we had to have a handful of documented, 100% supervised, clinical encounters (usually new pt evals). Additionally, we did oral board prep which involved interviewing a ward patient (unknown to interviewer) in front of 3 attendings (as well as the entire residency class!). Nerve-wracking at the time, but in retrospect I think that was good training.

  • http://drsamgirgis.com Dr Sam Girgis

    I precept medical students from Cornell Medical School during their second year physical diagnosis course. I always observe the initial history and physical that the students perform. When I was a medical student, I also remember being observed. I think the breakdown in patient encounter observations occurs during the third year clinical rotations, and fourth year sub-internships. I guess by that point it is thought that they should be more proficient with patient encounters.

    Dr Sam Girgis

  • Mindi

    From a patient perspective, sometimes I think interpersonal skills need to be taught also. I’ve had the most rude, arrogant doctors. On one occasion I had a neurologist tell me I absolutely had a certain disease and my internal med/rheumatologist told me that absolutely wasn’t it. Period. I went back and forth between the two for 3 or 4 months before I just got my records and went to Mayo. (The neurologist was right.) If they had taken 5 minutes to sit down and explain why they thought I did or didn’t have this problem, maybe I wouldn’t have had to make the trip and end up paying a boat load of money. It all turned out well in the end though, I quit going to both of them and found another internal medicine doctor – who doesn’t speak down to me.

  • anne

    i agree with the idea of having a non-physician observer. as a surgical photographer i have often had the experience of being in a clinic with a patient, the physician and student comes in, they both explain to the patient what will happen, and ask if there are any questions. the patient has no questions. the medical professionals leave the room, and the patient inevitably asks me, “did you understand what he/she said?” 100% of the time for the past 3 years.

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