Lessons learned
An innovative program assesses the clinical skills and styles of students through their second year.
By Michael Wentzel
Meena Elanchenny
When Meena Elanchenny watched the video of her examination of a patient reporting persistent abdominal pain and diarrhea, she liked most of what she saw.
“When I was talking to the patient, I was more at ease,” she said. “I asked the questions I was worried I would forget. I’ve also become more aware of certain gestures and things I say and I did better with those. For instance, instead of replying ‘great’ to everything the patient said, I said ‘I see.’ ’’
But Elanchenny, a second-year University of Rochester School of Medicine and Dentistry student, also spotted some flaws she wants to address.
“I tend to talk very quickly,” the Swarthmore College graduate said. “Sometimes, I am so interested in getting information from patients that I interject before they finish, asking the next question while the patient is still answering the last. When you watch the video, you’re not in the moment. You’re not nervous. I can detach myself and say: ‘I need to wait a little longer. I have to let the patient finish and speak more slowly so they can understand me.’ ”
For the first time at the School of Medicine and Dentistry, second-year students have received multiple clinical assessments during the academic year and have been graded on their performance. The innovation in the curriculum emphasizes the connection between the basic science the students learn and the clinical world by presenting the science in the context of a patient. The assessments, given much more frequently than most, if not all, other medical schools, also give faculty and students a unique opportunity early in their medical education to see how they communicate with patients.
“The assessments have really helped with patient relationships,” Elanchenny said. “You learn to organize your thoughts and approach patients so that when you go into your clinic offices and encounter patients with different complaints, you are better prepared. I’ve come a long way, particularly in interacting with patients, because of the assessments.”
The development Elanchenny has found through her clinical assessments highlights one of the goals of the program, said Anne Nofziger, M.D. (R ’00, FLW ’07), director of the Primary Care Clerkship who oversees the assessments.
“Being able to ask the right questions in real time and to think diagnostically is really different from answering a multiple-choice question based on a clinical vignette,” Nofziger said. “This type of assessment requires that students demonstrate skills and apply their knowledge in an active way, and then connect the basic science to the ‘patient’ they just saw.”
The clinical assessments are conducted with standardized patients and sometimes with computerized mannequins. The well-trained standardized patients write evaluations for each student who examines them. Videos of the exam enable students to match the evaluation with their performance. Students also are graded on a patient note on the case or on an essay in response to a question linked to the case. This year, the students have encountered cases of back pain, chest pain, a urinary tract infection, gastrointestinal problems and a shoulder injury. They also have conducted breast and prostate exams.
“We have a very robust early clinical experience. It is key that we understand how a student approaches focused problems presented by outpatients and assess this encounter,” said David R. Lambert, M.D., the School’s senior associate dean for medical student education who initiated the assessments. “By creating standardized patient encounters with patient problems that mirror the course material taught in the concurrent scientific foundations of medicine courses, we emphasize the integration with clinical care. Â All of these assessments strengthen the model of the Double Helix curriculum.”
Fidgeting, flipping and using a stethoscope
Most medical schools require some clinical assessments, usually what is called an OSCE, or Objective Structured Clinical Exam. But few schools, if any, conduct as many clinical assessments as Rochester during the second year, or combine clinical and basic science courses assessments in one format.
In the past, clinical assessment of second-year students primarily came from preceptors, the physicians in the community who work with the students a few times a week for several months in their offices. But School officials viewed these assessments as subjective and variable, depending on how much the preceptor observed a student.
“Written exams always will be part of medical training, and provide an efficient way to assess knowledge. They aren’t so good at predicting what a person will actually do in a real clinical encounter,” Nofziger said. “Our assessments get us a little bit closer to knowing how a student will be with a patient. It is obviously artificial. The students know they are being tested and videotaped.
“But as clerkship director, I want to know: Did the student gather appropriate behavior to make a diagnosis? Did they conduct a patient-centered interview? Did they do the appropriate physical exam, and was it performed correctly?  What does this student need to work on in order to become a better clinician? Some students are good test-takers, but struggle on the ground with patients, and some are the opposite. It is good for the students to identify their mistakes or flaws. As learners, they benefit from a culture that recognizes that everyone has something they have to work on, and that provides opportunities to improve based on feedback as well as self-assessments.”
Although some students acknowledged the multiple clinical assessments increased stress and caused anxiety, they also said they welcomed the experience as a chance to learn.
Oluwateniola “Teni” Brown
Oluwateniola “Teni” Brown called the clinical assessment days “safe opportunities to put what we learn in the classroom into practice.” For an assessment involving a gastrointestinal case in February, she found herself “really nervous,” an atypical state for the Duke University graduate.
“I was not sure I did well in the assessment,” Brown said.
The tricky diagnosis of the case could have gone in a couple directions, but Brown did not get the correct one. Still, her review of the video encouraged her.
“I thought it was worse than it was,” Brown said. “I went through the process with the patient. I asked the appropriate questions. I did fine. I did develop a diagnosis properly. I told the patient that I wasn’t quite sure what her illness was. I share my differential and what I thought was most likely. I also talked about follow-up testing. Not being 100 percent sure and sharing this with the patient was uncomfortable but I realize that I need to be comfortable with uncertainty when working with patients.”
The video also highlighted some areas for Brown to address.
“In watching the video, I realized the patient must have felt bombarded with questions. It was like I was grilling her,” she said. “I need to let the patient respond to one question at a time.”
Brown also noticed she was fidgeting at some points in the interview.
“I kept flipping my papers constantly. That had to be so distracting,” she said. “I had no idea I did that. I have learned, and am still learning how to effectively relay my assessment of the problem to patients, and actively and appropriately engage them in the development of the plan.”
The standardized patient marked down Brown for her method of listening to the heart. She listened with her stethoscope on the patient’s blouse, not on skin.
A more efficient learning style
For Shadab Khan, the clinical assessments enable him to evaluate whether he is making connections between the pathology he is learning in class to real life cases.
Shadab Khan
“I learned from all the assessments, especially the standardized patient encounters,” the graduate of the Rochester Institute of Technology said. “When you work with a standardized patient and you spot a mistake or learn something, it sticks a lot more. You don’t forget.”
“We work with actual patients with our preceptors,” Khan said. “I see the patient’s chart ahead of time. I generally know what the patient wants to talk about. It is rare to go in with no idea of what we’re supposed to be looking for. But that is what happens in a clinical assessment. It’s interesting to see what your mind goes through as you are getting the history, making a differential and prioritizing a list of possibilities. Sometimes, you are thinking so much you forget to respond to the patient. My history-taking skills are getting better, but it’s definitely something I am still working on.”
In a review of a video of the February assessment, Khan noticed that he used many medical terms, technical words he might not have known himself a few months before, he said.
“It’s important to explain your reasoning to the patient, discuss with them treatment options and share guidance about how the illness may or may not proceed,” Khan said “It’s also important to understand the information well enough that you can explain it to another individual who may not have a medical background.”
Katherine Herman
Katherine Herman did well in February’s clinical assessment. She received a “very positive evaluation” from the standardized patient, who also gave her good advice on a more correct and thorough way to do an abdominal exam.
“It is very helpful to practice taking a patient history and to perform a focused physical exam with a patient who is trained to give you feedback based on the questions you ask – or don't ask,” the Eastman School of Music graduate said. “It is also nice to receive comments from the patients as to how effective you were in communicating your ideas, though I've found that most of the time you leave the encounter knowing what you need to work on. There are always little gems you can take out of a patient encounter.”
Herman, an M.D./Ph.D. student, also did well on the patient note, a requirement that caused problems for a number of students.
“I’ve been lucky with my preceptors,” she said. “They expect a lot from me. I’ve been doing notes for each patient I’ve examined so I’ve learned to do them. In the clinical assessments, I am working on timing, getting through the exam efficiently, using efficient language, painting a picture without being wordy. It is great to have the assessments through the second year, not just at the end when we can’t implement what we have learned in past assessments.”
Anthony Carnicelli
To Anthony Carnicelli, the clinical assessments are “a great way to get us to think more like clinicians.”
“They change the exper dience of being a medical student,” he said. “They turn the traditional exams into something to look forward to instead of something to dread. Previously, you learn a bunch of material, memorize as much as you can, go and regurgitate it into an electronic device and come out feeling like you’ve been battered. With the assessment days, it changes the way you approach learning because you know you have to apply it with a patient.”
Carnicelli, a graduate of the Berklee College of Music and a former music teacher, praised his preceptors, who have encouraged him to do physicals, get a full history and present in front of the patient.
“With the assessments, you can integrate skills you learn with your preceptor in the community with information you learn in lecture and combine them into one structured format,” he said. “The evaluations from the standardized patients, at the very least, make you more aware of what you’re doing in the clinic. The video is the great equalizer. When the standardized patients give you feedback, you can go back to the video and see where they are coming from.”
“This is the way medicine should be taught, applying the basic sciences in a clinical setting,” Carnicelli said. “It is much more practical than learning facts for the first two years and then only getting to apply them in the third and fourth. That doesn’t translate properly. The clinical assessments encourage a more efficient style of learning.”
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