Reducing Reliance on Hospitalized Patients for Undergraduate Clinical Skills Teaching in Internal Medicine

Objective: Teaching clinical skills to undergraduates in internal medicine traditionally has relied on an accessible pool of hospitalized patients. Changes in health care delivery, however, have challenged this model significantly: Reductions in hospital beds and compressed lengths of stay have created a smaller, highly selected population of inpatients whose severity of illness and frailty often make them unsuitable for encounters with medical students. We designed and pilot-tested a model of clinical skills teaching that reduces reliance on hospitalized patients by using a combination of ambulatory clinic encounters and inpatient case scenarios. Description: At Queen's University, the undergraduate clinical skills program spans each of the first three years. While the first and second years emphasize communication skills, history taking, and physical examination, the goal of the third year is to provide a consolidative experience with greater emphasis on applying clinical and basic science knowledge to the data they collect through history taking and physical examination. In the third year, students meet in groups of four with a faculty tutor on two half-days per week for six consecutive weeks. In the traditional model, students interview and examine an inpatient on the first half-day and present their findings on the second half-day. In the new model, two students attend an internal medicine consultation clinic on the first half-day to see a newly referred patient and then, with the tutor, formulate a plan of management and follow-up. The remaining two students are given an inpatient case scenario outlining a patient's presenting history, physical findings, and laboratory data and are asked to prepare a written assessment of the patient's problem(s) in the same format that would be required in a hospital admission note, including a set of admission orders. The scenarios are selected so as to provide a sampling of the most common acute medical problems requiring hospitalization. On the second half-day, the students present their ambulatory cases and inpatient scenarios to the group. Assignments alternate biweekly, so that over the six-week course each student attends three clinics and analyzes three case scenarios. Direct faculty observation of the student's performance of the history and physical examination is mandatory in the first ambulatory encounter and optional in subsequent ones. Discussion: Pilot-testing of the new model has yielded very positive feedback. Strengths of the ambulatory component, as cited by the students, include the breadth of clinical problems, the opportunity for immediate feedback from the tutor, and the sense of contributing to patient care in “real time.” Moreover, the students feel that the inpatient scenarios provide a practical opportunity to prepare for their upcoming clerkship in medicine. Challenges to the new model include the constraints on ambulatory clinic space and the additional time commitment required by faculty tutors. We plan to expand this program in 2000–01 to include a greater proportion of the third-year class, and to undertake a formal evaluation in comparison with the traditional approach.

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