The need to watch medical students interact with patients

I’ve written about this before, but some recent encounters with medical students have me thinking about it again. I went off to medical school thirty-eight 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?

An 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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  • Patricia Kelly

    When I was in PA school (34 years ago), faculty from the program came to clinic at least three times over the course of 12 months to watch us for an entire day seeing patients, presenting the patients to our preceptors, and then finishing the encounters. We were also videotaped with standardized patients for three long encounters and graded in minute detail. This is above and beyond working with physician preceptors daily as a student. Now, direct observation is almost unheard of for either PA or medical students. I have seen medical students perform physical examinations in the most innovative ways, only to be told that no one had ever observed them before “The way you auscultate the heart is, uhmmmmm, very interesting, but…….”. After their short history and PE course no one ever observes these basic skills again.

  • voitokas

    When a medical student goes into the room before the physician, it seems to the patient like just another stage of the visit, like another nurse (or at best like another doctor). Some patients really resent having students perform the H&P if the physician is in the room, as it makes them feel like guinea pigs, or that they are not getting the full value out of their visit. It’s difficult, too, because very few attendings or residents can sit in a room with a student and patient and not get engaged in the conversation, especially by the parents during a pediatric visit. This is one instance where having a computer in the room is helpful – the resident or attending can scribe while the student conducts the visit. This does not work with every resident or every patient or every EMR (if the EMR is an endless nested series of checkboxes, you can’t scribe if the student is not working through the precise flowchart assigned by the computer). I have rotated at a few residencies that videorecord almost all visits (theoretically with the permission of patients, though I never saw how that part of the process worked). The idea seems weird at fist, but it can be very helpful to go over your visit with an attending. Once you’ve satisfied yourself that the student’s manner and H&P skills are up to snuff, though, they should see patients alone.

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