Kasuya, Richard T.

Melish, John S.

eVols at University of Hawaii at Manoa

EditorialSpecial Issue: American College of Physicians — American Society of Internal Medicine Hawaii ChapterNorman Goldstein MDEditor, Hawaii Medical JournalThis Special Issue features two societies comprised of specialistsand internists: The American College of Physicians, and the American Society of Internal Medicine. Many excellent papers and posterswere presented at the last Hawaii Chapter meeting on March 19,1999. Five of these presentations are published in this issue, whichwill also be distributed to attendees and exhibitors at the ACP-ASIMHawaii Chapter meeting to be held on March 3 and 4, 2000.Also within, are presentations made on December 8, 1999 at theinformational program for our State legislators sponsored by theHawaii Coalition for Health. Included are remarks by Coalitionfounder and president, Arlene Jouxson-Meyers, MD JD, MPH; newMedical School Dean. Edwin Cadman: Dean of the School ofNursing, Dr. Roseanne Harrigan; Associate Dean of Wm. S.Richardson School of Law and Professor of Law, Medicine andPsychiatry at NYU Law School, Sylvia Law; and Regent of theUniversity of Hawaii, A.Q. McElrath.In addition, this Special Issue contains an insert and membershipapplication for the Hawaii Medical Association. If you are notalready a member of the HMA, now is the time to join. We needemerging as well as established physicians in the HMA to maintainand improve the practice of medicine in Hawaii. Our Hawaiimedical community values your participation. Join us today.Norman Goldstein MD, FACP, EditorUntil there’s a cure,there’s theAmerican DiabetesAssociation.Medical School HotlineClinical Skills Training at John A. BurnsSchool of Medicine (JABSOM): Teachingand Learning the Art, Craft and Science ofClinical PracticeJohn S. Melish MD and Richard T. Kasuya MDThe medical profession combines a variety of skills, attitudes, anda scientific knowledge base. The capacity of an individual physicianto care for an individual patient requires that the physician establishes trust and collects appropriate data in relation to the patient’sconcerns, signs, and symptoms. He or she then establishes reasonable diagnostic hypotheses based on that data, and then prescribesevidence-based treatments. This requires the understanding andconsent of the patient, making the doctor a teacher and guide. Ourstudent-physicians refine these skills over a lifetime of practice.This process begins at the JABSOM the first week of medical schooland continues for the next four years.As central as these skills have been to the practice of medicine,they have gained even more importance in this day of resourceallocation and managed care. Physicians in general, and primarycare physicians in particular, have been asked to rely more on theirclinical data collection and acumen and less on the non-judicious useof technological tools, in their care of patients. Our goal andcommitment is to provide excellent and qualified practitioners to ourcommunity.At the JABSOM, history taking and physical examination skillshave been taught in first two years of medical school since itsinception in 1970. At that time, JABSOM was a two-year medicalschool whose graduates finished their training at Mainland schools.Our students appreciated that they were as well or even betterprepared than their Mainland counterparts to challenge the third yearclinical clerkships.When the JABSOM became a four-year institution in 1975, thispolicy of early introduction to patients continued. In the first year,students were instructed in the elements of a standard physicalexamination that they practiced on each other and learned interviewing skills beginning with a patient profile. The students learned thebasic physical exam maneuvers on each other but practiced interviewing skills on volunteer patients in an outpatient setting. In thesecond year, students learned organ-directed interviewing and physical examination skills in the context of a lecture-based clinicalcorrelation course, Introduction to Clinical Medicine, throughoutthe second year. (This course ran concurrently with basic sciencecourses in physiology, pharmacology, psychiatry, and pathology,and public health, the familiar medical school curriculum of the timefor second year students.) Clinicians lectured on approaches toclinical evaluation of diseases by systems. With each block oflectures, a specific laboratory was held where “extended physicalexamination skills” were taught. At the same time, individualstudents were assigned to a tutor who found them patients withproblems corresponding to the unit of study. They observed thestudents during the interview and examination process, giving themHAWAII MEDICAL JOURNAL, VOL 59, FEBRUARY 200040valuable feedback on their skills and their effectiveness in obtainingdata and reporting it both orally and in written form. This experienceoccurred every other week and represented a time commitment ofsix to eight weeks from members of the clinical faculty. This meantrecruiting between 20 and 30 faculty members (sometimes more)every 6 to 8 weeks, a full time job for the coordinator of theIntroduction to the Clinical Medicine Course. Again, studentsgenerally made an easy transition to the third year clerkships as aresult of this patient-related experience.In both the first and second years, students learned to use theProblem Oriented Medical Record System developed and promotedby Dr. Lawrence Weed. This was adapted to JAB SOM and becamethe standard format for both the students and for the residents in ourintegrated residency training program. Progress note writing in thisformat was taught as they entered the third year clerkships. Thisapproach to documentation continues to the present.Prior to 1989 and the curricular reform of that year, a facultymember evaluated the students’ clinical skills at the end of themedical clerkship. In this exercise, the faculty member observed thestudent performing a complete history and physical examination ona hospitalized patient. making an oral presentation, and completinga problem oriented medical record. The examiner reviewed a writtenHistory and Physical Examination Report, a complete problem list,and an assessment of the three most important clinical problems,along with a diagnostic and treatment plan and plans for patienteducation. The students’ findings were confirmed at the bedside,with immediate feedback to the student. The student then requestedadditional data based on his or her plan. This was obtained by theobserver from the chart and reported to the student who then wrotea progress note on the three major problems. The observer gradedthe student based on a standard form, gave feedback as to all of theelements of the exercise, including the professional impression andattitude evinced by the student.In 1989, the then medical school dean, Christian Gulbrandsen,instituted a wide-ranging curricular change. At that time, problem-based learning (PBL) became JABSOM’ sway of integrating appropriate medical information with the data collection and reasoningprocesses unique to medical diagnosis and management. Clinicalskills became an integral part of the curriculum.1 In this context,students interview and examine patients that fall within the differential diagnosis of the patient problems they study in the classroomsetting. This integration provides additional relevance and meaningfulness to all aspects ofJABSOM’s students educational experience.In Unit 1 of the M.D. Program curriculum, students learn basicphysical examination skills and clinical anatomy in an integratedcourse.2For example, in one week students will be studying the PBLhealth care problem of a patient suffering from an acute myocardialinfarction. They will spend one morning that week with clinicalfaculty learning the basic cardiac physical examination and spendthat same afternoon with faculty from the Department of Anatomyreviewing the heart and mediastinal anatomic relationships oncadavers and instructional models. Students also spend one afternoon every-other week in the community interviewing and examining actual patients under the supervision of practicing physicians.Patient contact and the learning of the clinical skills relevant to theHealth Care Problems under study in the core PBL curriculumcontinue throughout the remainder of years 1 and 2. Facultypreceptors work with small groups of students, and demonstrate andteach the skills required to collect data by interview and physicalexamination at the bedside in both ambulatory and hospital settings.These sessions are held for three hours each week, and are supplemented by periodic large group clinical skills demonstration andpractice laboratories led by experienced and expert clinical facultyfrom various disciplines in medicine.In Unit 6 (the clinical clerkships) and Unit 7 (the senior electives),clinical skills training becomes intertwined with the students’ day-to-day experiences in their required clinical clerkships (Surgery,Obstetrics and Gynecology, Internal Medicine, Family Practice,Pediatrics and Psychiatry), required senior Emergency Medicinerotation and senior clinical electives. Under the guidance andsupervision of clinical faculty, students continue to develop theirskills in professional communication, history taking, physical examination and physical diagnosis, and medical decision-making.It is very important to recognize that clinical skills experiencerelies heavily on the generosity and support of volunteer physiciansacross all disciplines and located throughout the community. Thesephysicians volunteer their time and expertise to teach medicalstudents the art and science of clinical medicine. This is a tremendous investment in the future quality of medical care in our community.Evaluation of students’ clinical skills performance is done via anumber of methods. Throughout the four years, faculty evaluateeach student using a checklist of skills and learning objectives.Students are videotaped performing the physical examination sequence for formative feedback. Students are also evaluated usingstandardized patients in Objective Structured Clinical Examinations (OSCEs) periodically throughout the four years of medicalschool training. The JABSOM’s Center for Clinical Skills administers these examinations, and also trains and provides standardizedpatients for learning experiences throughout the first two years oftraining. Early in their training, students have the opportunity tointeract with these standardized patients to practice skills rangingfrom counseling an adolescent on the dangers ofhigh risk behaviors,to providing smoking cessation education to a patient at risk forheart disease, to comforting the grieving mother of a child injuredin the home. Later in their training, students are expected to obtainsatisfactorily complete histories, perform focused physical examinations and demonstrate exemplary professional and communication skills with standardized patients in formal OSCEs. Of note, theUnited States Medical Licensing Examination (USMLE) Step 2expects to begin incorporating an OSCE component in the nearfuture. JABSOM’s strong standardized patient program will definitely help its students best prepare for this national requirement.Clinical skills are a central component of the education of futurephysicians. The University of Hawaii JABSOM is fully committedto producing outstanding clinicians by providing a clinical skillseducational experience that is integrated, innovative, rigorous andprogressive.References1 Universityof HawaiiJohn A. Bums School of Medicine. 1999-2000 General Guideto the M.D. Program.August 1999.2. Kasuya Ri, Nelson M. Melish J. The Integration of Clinical Skills and Clinical Anatomy in MedicalEducation. HMJ 56(4):89.HAWAII MEDICAL JOURNAL, VOL 59, FEBRUARY 200041

Clinical skills training at John A. Burns School of Medicine (JABSOM): teaching and learning the art, craft and science of clinical practice.

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Clinical skills training at John A. Burns School of Medicine (JABSOM): teaching and learning the art, craft and science of clinical practice.

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