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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