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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_112_библиотеки_им_акад_М_И_Перельмана
.pdf
Statement
Mitigating Bias
Opportunities for Additional Practice
Practicing Skills in Feedback After Direct
Observation
Implementing Workplace-Based Assessment
Increasing Faculty Buy-In for Direct Observation
Finding Time for Direct Observation
Preparing Learners for Direct Observation
Preparing Faculty for Performing the Observation
Assigning Responsibility for Direct Observation
Tracking Observations
Key Messages About Faculty Development and
Implementation
Annotated Bibliography
References
Introduction
Medical educators are responsible for evaluating the clinical
skills of learners and providing learners with timely, useful
feedback to ensure continued growth and development of
competence. Despite advances in diagnostic technology, the
basic clinical skills of taking a medical history, doing a
physical examination, and counseling remain essential to
successful patient care. In the United States, for example, the
Association of American Medical Colleges (AAMC), the
Liaison Committee of Medical Education (LCME), the
Accreditation Council for Graduate Medical Education
(ACGME), and the American Board of Medical Specialties
(ABMS) strongly endorse the evaluation of students,
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residents, and fellows in these clinical skills.
1–4
Furthermore,
the Institute of Medicine (now the National Academy of
Medicine; NAM) placed patient-centered care at the heart of its
five core competencies for all health professionals, including
physicians, in its 2003 competency framework.
5
Direct
observation of learners performing a medical interview,
physical examination, and counseling is mandatory to assess
these skills with reliability and validity. This chapter focuses
on direct observation of clinical skills (history, physical exam,
and counseling), an assessment strategy that is foundational
to competency-based medical education.6 Direct observation
of procedural skills is discussed in Chapter 9
.
In this chapter we contextualize direct observation of
clinical skills as a form of workplace-based assessment
(WBA). We review four reasons why direct observation is
important: to ensure assessment of clinical skills that are
essential to patient care; to facilitate deliberate practice,
coaching, and feedback; to inform assessment in competencybased education; and to promote high-quality supervision.
Next, we review assessment tool formats and factors that
explain the poor reliability and validity of direct observation
assessments. We discuss how poor reliability and validity can
undermine assessment quality and negatively impact patient
care. The remainder of the chapter focuses on how to
improve direct observation assessments. We describe rater
training faculty development approaches that can improve
assessment quality. We conclude by describing strategies that
can be used to implement direct observation at the
programmatic level. We describe barriers to frequent direct
observation and strategies to increase direct observation
frequency. We discuss how to engage learners and create
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systems for direct observation that consider the institutional
culture, the healthcare delivery system, and the educational
system in which direct observation is occurring. Faculty
development materials are provided throughout the chapter
and in the appendices.
Direct Observation as WorkplaceBased Assessment
Direct observation of clinical skills is defined as observing a
learner (i.e., medical student, resident, fellow) interacting
with a patient taking a history, doing a physical exam, or
counseling for the purpose of learner assessment. Direct
observation also includes observation of physician–physician
interactions (e.g., observing a learner doing a patient handoff
to another learner, observing a learner calling a consult),
physician–interprofessional team interactions (e.g., observing
a learner interacting with a nurse or social worker),
leadership activities (e.g., observing a resident leading a
team), or teaching (e.g., observing a resident teaching a
medical student). This chapter focuses on direct observation
of learners with patients, but many of the principles
discussed pertain to the other types of direct observation.
Direct observation is a workplace-based assessment (WBA).
WBA is the assessment of day-to-day practice in the clinical
environment; direct observation is assessment of what
doctors actually do in practice.
7,8
Therefore direct observation
captures what a learner “does” with patients (the top of
George Miller’s assessment pyramid),9 recognizing
observation may change learner behaviors (i.e., known as the
Hawthorne effect) (Fig. 5.1). An extended version of Miller’s
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pyramid was recently proposed in which being trusted for
future care sits at the top of the pyramid (Fig. 5.1
).
10
FIG. 5.1 Miller’s pyramid and the extended Miller’s pyramid.
As discussed in Chapter 6, standardized patients (SPs) are a
valuable assessment methodology to teach and evaluate
clinical skills. However, SP-based evaluation methods have
limitations. SPs are optimally used for clinical skills teaching
and assessment to supplement similar activities in the real
clinical setting. SP assessments cannot replace physician
educators routinely observing learners with actual
patients.
11–14
SPs may have less validity with more advanced
learners because assessment instruments used for SP
exercises, depending upon case development and standard
setting approaches, may favor completeness over efficiency
and the use of sophisticated illness scripts.
14–16
Direct
observation is an important assessment approach that more
closely replicates practice, particularly for more advanced
learners.
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Rationale for Direct Observation
Direct observation is required by medical education
accrediting bodies such as the LCME, the ACGME, and the
UK Foundation Program.
2,3,17
There are multiple reasons
direct observation of clinical skills is important and relevant
(Box 5.1). First, history taking, physical exam, and counseling
remain important to high-quality care but are often deficient
among physicians. Given the importance of these skills in
patient care, these skills must be assessed. Second, direct
observation is necessary to provide feedback and coach
learners as part of deliberate practice. Third, direct
observation is a key assessment strategy in competencybased education. Fourth, direct observation helps ensure
high-quality supervision. In the remainder of this section we
describe these reasons in more detail.
Box 5.1
Rationale for Direct Observation of
Clinical Skills
•. History taking, physical exam, and counseling are
fundamental to quality care but often deficient in
learners and physicians.
•. Observation is necessary for deliberate practice and
feedback.
•. Workplace-based assessment is essential in
competency-based education.
•. Medical education accrediting bodies require direct
observation.
•. Observation is necessary to inform high-quality
supervision to ensure that patients receive, at a
minimum, safe, effective, patient-centered care.
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Importance of and State of Core Clinical
Skills
It has long been recognized that students and residents have
variable skills, and sometimes substantial deficiencies, in
medical interviewing (e.g., history), physical examination,
and counseling.
18–25
For example, there have been long-
standing deficiencies in learners’ auscultatory skills,
26,27
and
poor clinical skills continue to plague US students and
residents today.
28–30
Furthermore, clinical skills do not necessarily improve after
training. In a study using unannounced standardized
patients (USPs), Ramsey and colleagues found that a group
of primary care physicians only asked 59% of essential
history items.31 Braddock and colleagues found that only 9%
of primary care physicians’ and surgeons’ counseling
encounters met basic criteria for effective informed decision-
making.32 Physicians frequently fail to elicit over half of
patients’ complaints, and many of the public’s complaints
about physicians relate to communication problems.
33–41
Because accurate data collection remains physicians’ most
potent diagnostic tool (even in the current era of diagnostic
technology), inadequate history and physical exam skills are
problematic.
42–44
The medical interview alone can lead to the
correct diagnosis in nearly 80% of patients presenting to an
ambulatory care clinic with a previously undiagnosed
condition.
42,43
Excellent history and physical exam skills are
necessary to provide high-value, cost-conscious care that
avoids unnecessary expensive diagnostic tests. The 2015
NAM report, “Improving Diagnosis in Medicine,”
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highlighted the persistent and pernicious problem of
diagnostic error. This report found that data collection errors
are one of the principal factors causing physician diagnostic
errors.
45
In fact, diagnostic error may be the third most
common cause of death in the United States.46 In 2012,
national organizations representing medical specialties in the
United States asked their members to identify commonly
ordered tests or performed procedures whose necessity
should be questioned and discussed as part of the Choosing
Wisely Campaign. The Choosing Wisely Campaign, now in
multiple countries including Canada, helps physicians
provide care that is supported by evidence, free of harm, and
truly necessary.
47,48
In addition to data collection and diagnostic evaluation and
management, effective physician–patient communication
improves patient outcomes. Improved outcomes include
patients’ involvement in their care, self-efficacy, adherence,
and well-being while decreasing costs.
49–52
Furthermore,
most patients want an active role in decision-making.
53,54
These findings reemphasize the importance of teaching and
evaluating physician–patient communication.55 Assessing
history taking, physical exam, and counseling via direct
observation legitimizes the importance of these skills while
simultaneously assessing clinical skills that are important for
high-quality care.
Direct Observation as an Educational
Tool for Feedback and Deliberate
Practice
Medical educators must ensure the professional development
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of their learners who begin training as novices and must
graduate competent to practice unsupervised (in the case of
residents and fellows). The goal, however, is not for learners
to just be competent. Rather, medical educators should strive
for learners to achieve proficiency, expertise, and mastery.
Achieving expertise requires deliberate practice, and
receiving feedback and coaching from others is a key
component of deliberate practice.
56
Feedback from others is
important because physicians often self-assess inaccurately,
especially when self-assessment occurs without external
guidance and data.
57–59
Feedback from others provides the
external data that helps learners calibrate their selfassessments.
60,61
Direct observation of clinical skills is an
important source of this meaningful external data. Just as an
athletics coach could not give effective feedback to their
players if they did not observe them on the field during a
game, medical educators cannot effectively provide
meaningful feedback to learners if they have not observed the
skills about which they are providing feedback. Direct
observation is important to generate the firsthand
observations that become the feedback that learners can use
to calibrate their self-assessments. Learners can then work
with a faculty coach to define an action plan, and set new
learning goals62 (see Chapter 14).
Direct Observation as an Assessment
Method in Competency-Based Medical
Education
In competency-based medical education medical educators
must ensure that all graduates are competent, at a minimum,
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in the essential domains needed for modern clinical practice
(see Chapter 1
).
63,64
Training programs/specialties,
depending on the locale, are expected to implement and
assess required competencies, competency components,
developmental milestones, Entrustable Professional
Activities (EPAs), and performance levels. As discussed in
Chapter 1
, the competency Milestones currently used in the
United States are demonstrable abilities that can be observed
and assessed. Direct observation assessment tools should
measure progress along the milestones.
65
,66
To effectively assess the milestones, learners must be
observed engaged in real patient care/clinical activities.
6
Historically, knowledge examinations, oral patient
presentations, and written notes have served as proxy
measures of history taking, physical exam, and counseling
skills. In competency-based medical education, the
predominant evaluation setting should be “in the trenches”
rather than a setting removed from practice (e.g., conference
room or hallway).6 The only way to determine whether
graduating residents and fellows are clinically competent is
by having skilled clinicians repeatedly observe them
providing care for the kinds of patients (in the appropriate
practice settings) whom they will encounter when they enter
practice.67 Both the ACGME and the LCME, the accrediting
bodies in the United States for graduate and undergraduate
medical education, respectively, have emphasized the
importance of direct observation as a key assessment
strategy.
2,3
Direct Observation as a Method to Guide
Supervision
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A learner’s skills directly affect patient experience and
outcomes, and effective supervision of learners is important
to improve patient safety and care quality.
68–70
However,
leaners often receive inadequate supervision in the clinical
setting even though many learners want better
supervision!
69,71
Patients must receive high-quality care (i.e.,
defined by the NAM as care that is safe, effective, efficient,
equitable, timely, and patient centered).5 This standard of
care should not be compromised because a patient is cared
for by a team that includes learners.
Learners’ competence is influenced by content and context.
For example, a learner may be competent caring for a patient
with pneumonia but not a patient with an acute myocardial
infarction (case specificity). A learner might be less
competent working in a new hospital where they are
unfamiliar with the electronic health record or EHR (context
specificity). Clinical supervisors are expected to fill in the gap
between what a learner can do and what a patient needs to
receive safe, effective patient-centered care.
Supervisors must observe learners to know what they can
and cannot do. Inferring history, physical exam, and
counseling skills indirectly (e.g., how well the learner
presents and/or writes notes) may result in erroneous
conclusions about a learner’s competence and the amount of
supervision they require. Ideally, direct observation
assessment tools focus on evidence-based skills that help
assessors identify what a learner has done well and what
should be improved, increasing the likelihood of high-quality
care. Therefore direct observation of clinical encounters
serves the dual purpose of assessing learners and ensuring
that patients receive, at a minimum, safe, effective, and
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