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Even Better Together.

The quality and quantity of tools such as workshops, presentations and curriculum support is magnified when we work together.

Designing & Implementing Workshops

LuAnn Wilkerson, Ed.D.
UCLA School of Medicine

Case, Part 1: Planning

At the beginning of year three, medical students complete a physical examination OSCE in which they are provided with a patient and instructed to conduct a complete physical examination for designated systems, e.g., EENT, Cardiac, Pulmonary, and musculoskeletal. After each system, the student is instructed to pause while the patient completes a checklist of examination items indicating which were done correctly, done incorrectly, or not done. Students had used this same checklist in their second-year course, Fundamentals of Clinical Medicine (FCM).

The first year that the OSCE was implemented, the course director for the FCM course in the second year was very distressed with the large number of checklist items that were not attempted or performed incorrectly. Student did not perform up to the standards that he expected given the direct instruction and extensive preceptor experience that was part of his course. He was also distressed that student evaluations of the FCM preceptor experience indicated a great deal of variability in content and quality.

Hearing that you are involved in the GIMGEL Faculty Development Project, he has come to you to discuss what he might do to improve the teaching provided by the FCM faculty. He is particularly interested in setting up a workshop to address how to teach physical examination skills. What would you recommend?

Case, Part 2: Implementing

Twenty-five preceptors showed up for the evening workshop. Crushed into a room far too small, with chicken that was hard to eat without a table, and without adequate space for using the overhead projector, we were off to a bad start. Determined to make the most of the opportunity to influence this important group, we forged ahead. CLS, the Fundamental of Clinical Medicine course director, commented on the importance of the community physicians in teaching clinical skills to the medical students and asked each one to introduce himself (they were all male), indicating how many years they had been teaching in this second-year medical student course. Years of experience ranged from 2 to 25!

The FCM course director, his co-director and myself had written up a plan for the evening (below) and decided who would take on what responsibility. I presented the OSCE data which led to a lively debate about the importance of the physical examination in light of the accessibility of laboratory tests and imaging procedures. The course director added to the furor by citing the JAMA series on the Rationale Clinical Examination which he felt underlined the low sensitivity and specificity of most of the physical examination. History taking, on the other hand, he noted, was where the money is in clinical diagnosis. One experienced preceptor asked why he had never seen the checklist used in the OSCE and others began to complain about the poor communication between the course planners and themselves. Feeling somewhat attacked, the course director indicated that it must be the new course administrator since he had certainly intended for them to all receive the checklist.

Sensing that it was time to move on, I introduced the objectives for the workshop and provided a brief overview of the two teaching strategies that we were going to practice – activated demonstration and observation with feedback. I had intended to introduce this section with a video clip from the movie Footloose. The video clip was somehow cued up from the middle, rather than the beginning, of the selected clip so much of the point was lost. The music at least woke the group up! Essential steps for these two teaching strategies were outlined on a yellow index card which I encouraged preceptors to use as a reminder when they were teaching the students.

After each strategy was introduced, there was some discussion by the experienced preceptors of how they had used something along this line in their own practices. By the time we broke into three small groups and went to the exam rooms where the patients were waiting, it was 7:45.

When my group had completed the two simulations, I left the participants discussing personal strategies for finding the time to observe students to remind the other facilitators that we needed to finish up by 8:30. One group was being dominated by a very senior preceptor who had questioned how anyone less experienced than he was could tell him how to teach medical students. The facilitator, somewhat overwhelmed, had abandoned the simulations for a heated exchange between two of the participants over whether to teach a focused or thorough work-up to a beginning student. The second group was listening quietly as the facilitator talked about the fine features of the cardiac exam while the patient sat on the exam table with his gown draped low on his arms and a preceptor standing beside him with a stethescope in his hand. I reminded my colleagues that we had agreed to leave by 9:00 and left them to conclude their respective groups while I returned to wrap up mine.

Workshop Plan: Coaching Physical Examination Skills

Agenda
6:30 Introductions to one another and the workshop objectives (CLS)
· To understand the objectives of the FCM course regarding physical exam skills
· To develop strategies for teaching the physical examination
Activated Demonstration
Observation and Feedback

6:50 Presentation: OSCE results (WB)
1. What might explain these results?
2. Should we be teaching for thoroughness, accuracy, or focus?

7:10 Presentation and Discussion: Coaching the Physical Exam (WB)
1. Video Clip: Footloose
2. Activated Demonstration
3. Observation and Feedback

7:30 Strategy 1: Activated Demonstration (3 groups)
1. Discussion – When should we use this strategy?
2. Simulation – Ask for a participant to volunteer to be the student and another to be the preceptor. The patient is gowned and ready to be examined. Use the cardiac exam.

8:00 Strategy 2: Observation and Feedback
1. Discussion – How can we find time to observe? When should we give feedback?
2. Simulation – Ask for other volunteers to be the student and preceptor in each part. A. Prior to the observation. B. During the observation. C. After the observation.

8:30 Adjourn