Clinical Skills at Yale: Teaching Students the Essential Elements of “Doctoring”

Many faculty members from General Internal Medicine play leadership roles in the Clinical Skills Program, a thread that spans all four years of the medical school curriculum at Yale. At many medical schools, formal clinical skills education is limited to the pre-clerkship period, but since developing solid clinical skills is foundational and developmental, the Clinical Skills Program at Yale emphasizes multi-dimensional training over the entire span of medical school. Jaideep Talwalkar directs the program, overseeing the individual components, and collaborating with educators across the YSM curriculum to optimize clinical skills education in other coursework, clerkships, and the post-clerkship advanced training period.

In the Clinical Skills Program at Yale, students learn to communicate with patients, families, and other members of the care team; examine patients using traditional physical exam skills and point-of-care ultrasound; develop clinical reasoning skills; and understand the important role of medical students in a patient’s care.

Clinical skills training starts early in first year. The Clinical Skills Course meets weekly during the 18-month pre-clerkship period, with students spending most of their class time engaged in hands-on practice of basic skills. The Clinical Skills Program continues through the four-year curriculum with more advanced topics during the clerkship and elective years. Countless faculty, fellows, residents, and upper-level medical students are trained each year to run small groups and workshops designed to provide students with individualized attention and feedback about their clinical skills.

Auguste Fortin runs the communication skills curriculum in which students learn how to talk to patients. A typical session involves students interviewing an actor portraying a patient, or standardized patient, using a patient-centered interviewing model, while receiving feedback from faculty, peers, and the standardized patients. Joe Donroe directs physical examination. In a series of small group sessions, students practice core elements of physical exam with faculty observation and feedback. Additional workshops provide students with more time and attention to work on particularly challenging skills (e.g., use of the ophthalmoscope). Matt Ellman runs a developmental, longitudinal end-of-life and palliative care curriculum in which students, regardless of future specialty, acquire basic comfort, knowledge, and skill in the approach to patients with life-limiting illness. Rachel Liu from Emergency Medicine runs point-of-care ultrasound (POCUS) education, with the goal of helping all students see the connection between anatomy, physiology, and physical exam with the use of portable pocket-sized ultrasound devices that connect to tablets and smartphones. A subgroup of students develops higher level ultrasound skills through elective experiences. Because POCUS is a relative new technology, Dr. Liu also trains faculty on using POCUS to build a corps of instructors.

Thilan Wijesekera and Andrés Martin are the most recent additions to the Clinical Skills leadership team. Dr. Wijesekera directs clinical reasoning education. Simply stated, clinical reasoning is “how doctors think” – the process by which physicians consider a patient’s situation to develop ideas about diagnosis and appropriate testing and treatment. Case-based discussions are used to teach students clinical reasoning while exploring biases that can impact clinical judgment. Dr. Wijesekera is exploring novel ways to use technology and gamification to engage students in clinical reasoning workshops scattered across the four-year curriculum. Dr. Martin from the Child Study Center runs the standardized patient program through the Teaching and Learning Center and is increasing the diversity of case scenarios and actors to better reflect the greater New Haven community. Yale’s standardized patients are professional actors who can follow scripted roles, improvise as needed, and display emotional reactions indistinguishable from a real patient.

In the pre-clerkship period, students put their emerging clinical skills to use in weekly sessions with patients through the Interprofessional Longitudinal Clinical Experience (ILCE) and Medical Coach Experience (MCE). Kirsten Wilkins from Psychiatry directs the ILCE and Barry Wu directs the MCE. Dr. Wu facilitates the recruitment and training of over 200 faculty in these clinically-oriented courses that run parallel to the Clinical Skills Course. In ILCE, first year medical students learn alongside nurse practitioner and physician associate students to enhance their interprofessional education. In MCE, second year medical students work together with physician coaches to practice clinical skills and explore physician professional identity formation.

Beyond the pre-clerkship period, clinical skills are formally augmented in a variety of settings. Peter Ellis, (along with Ada Fenick from Pediatrics and Matthew Goldenberg from Psychiatry) co-directs the Biopsychosocial Approach to Health Clerkship and ensures that clinical skills are reinforced during the clerkship. For example, Susan Kashaf runs clerkship workshops on how to conduct a problem-focused visit, while other workshops focus on Office Orthopedics, Clinical Reasoning, and the mental status examination. Dr. Kashaf also directs remediation efforts to help students attain competency with their clinical skills. The Advanced Communication Skills Workshop is a more recent addition in David Rosenthal’s Capstone Course for graduating medical students. Students rotate through five stations with standardized patients in which they face potentially intensely emotional scenarios. In Capstone, students also discuss high-yield topics essential for the transition to residency such as reading electrocardiograms, ordering blood transfusions, and conducting safe end-of-shift patient hand-offs.

In addition to regular formative assessment and feedback during class sessions, students participate in two multi-station observed structured clinical examinations (OSCE) during the curriculum. As director of student assessment, Michael Green oversees the Pre-clerkship OSCE and Clerkship OSCE, working with other clinical skills team members to adjust content and scoring from year-to-year to maintain consistency with what is taught in the curriculum. The OSCEs also serve to identify students who need extra practice in clinical skills through the remediation program

Faculty in the clinical skills leadership group are regularly recognized for their excellence and innovation in teaching. Drs. Donroe, Ellman, Fortin, Green, Kashaf, Liu, Martin, Talwalkar, Wilkins, and Wu have all received teaching awards at medical school commencement or at the national level. Dr. Wijesekera won the best educational innovation award for his clinical reasoning gamification work at the Diagnostic Error in Medicine International Conference sponsored by the Society to Improve Diagnosis in Medicine. Additionally, team members have published extensively about their work. See below for a list of notable recent publications.

The Clinical Skills Program faces ongoing challenges. Most acutely, with the move to online learning for medical students in March 2020, faculty have overhauled sessions to use Zoom to meet learning objectives related to communication skills and clinical reasoning. Plans are underway to re-engage students with physical examination, POCUS, and in-person patient contact in the safest way possible. Additionally, with clinical work taking top priority, recruitment and retention of highly skilled volunteer teachers is never-ending, especially in domains that require extensive training (such as patient-centered interviewing and point-of-care ultrasound). Thankfully, dozens of faculty members from General Internal Medicine remain involved in this capacity and play highly visible roles as teachers and role models through their work with students in Clinical Skills.

Faculty interested in getting involved or learning more about Clinical Skills teaching in person or remotely can contact Jaideep Talwalkar or any members of the teaching team mentioned above.

The Clinical Skills Program receives generous support from the Peter B. Livingston M.D. ’63 Fund for Excellence in Teaching.

Selected bibliography from Yale Clinical Skills Program faculty (2016-2020):

Communication Skills

• Sanders L, Fortin AH, Schiff GD. Connecting with patients – the missing links. JAMA. 2020;323(2):33-34.
• Talwalkar JS, Murtha TD, Prozora S, Fortin AH, Morrison LJ, Ellman MS. Assessing advanced communication skills via objective structured clinical examination: a comparison of faculty versus self, peer, and standardized patient assessors. Teaching and Learning in Medicine. 2020; In press.
• Talwalkar JS, Cyrus K, Fortin AH. Twelve tips for running an effective session with standardized patients. Medical Teacher. 2019 Apr 29;1-6. doi: 10.1080/0142159X.2019.1607969
• Fortin AH 6th, et al. Smith’s Patient Centered Interviewing. 4th ed. New York, McGraw Hill, 2019.

Communication Skills

• Sanders L, Fortin AH, Schiff GD. Connecting with patients – the missing links. JAMA. 2020;323(2):33-34.
• Talwalkar JS, Murtha TD, Prozora S, Fortin AH, Morrison LJ, Ellman MS. Assessing advanced communication skills via objective structured clinical examination: a comparison of faculty versus self, peer, and standardized patient assessors. Teaching and Learning in Medicine. 2020; In press.
• Talwalkar JS, Cyrus K, Fortin AH. Twelve tips for running an effective session with standardized patients. Medical Teacher. 2019 Apr 29;1-6. doi: 10.1080/0142159X.2019.1607969
• Fortin AH 6th, et al. Smith’s Patient Centered Interviewing. 4th ed. New York, McGraw Hill, 2019.

Clinical Reasoning

• Fuehrlein B, Bhalla I, Goldenberg M, Trevisan L, Wilkins K. Simulate to Stimulate: Manikin-Based Simulation in the Psychiatry Clerkship. Academic Psychiatry. 2020;44(1):82-85.
• Wijesekera TP, Sanders L, Windish DM. Collaboration of Internal Medicine Physicians with Patients and Other Health Care Providers in the Diagnostic Process. Journal of General Internal Medicine 2019, 34:1083-1085.
• Wijesekera TP, Sanders L, Windish DM. Reflections on Diagnosis and Diagnostic Errors: a Survey of Internal Medicine Resident and Attending Physicians. Journal of General Internal Medicine 2019.
• Wijesekera TP, Sanders L, Windish DM. Education and Reporting of Diagnostic Errors Among Physicians in Internal Medicine Training Programs. JAMA Internal Medicine. 2018;178:1548-1549.

Point of Care Ultrasound

• Liu RB, Suwondo DN, Donroe JH, Encandela JA, Weisenthal KS, Moore CL. Point-of-Care Ultrasound: Does it Affect Scores on Standardized Assessment Tests Used Within the Preclinical Curriculum? J Ultrasound Med. 2019;38(2):433-40.

End-of-Life & Palliative Care

• Talwalkar JS, Moriarty JP, Ellman M. Students’ experiences with death and dying prior to medical school. Amer J Hospice & Palliative Medicine. 2019;36:999-1007.
• Kozhevnikov D, Morrison LJ, Ellman MS. Simulation training in palliative care: state of the art and future directions. Advances in Medical Education and Practice. 2018;9:915-924.
• Tse CS, Morrison LJ, Ellman MS. Pre-clinical medical students’ diverse educational and emotional responses to a required hospice experience. Amer J Hospice & Palliative Medicine. 2017;34(8):704-712.
• Tse CS, Ellman MS. Development, implementation, and evaluation of a terminal and hospice care educational online module for pre-clinical students. BMJ Support and Palliat Care. 2017;7:73-80.
• Ellman MS, Putnam A, Green M, Pfeiffer C, Bia M. Demonstrating Medical Student Competency in Palliative Care: Development and Evaluation of a New Objective Structured Clinical Examination Station. J Palliat Med. 2016;19(7):706-711.
• Ellman MS, Fortin AH, Putnam A, Bia M. Implementing and Evaluating a Four-Year Integrated End-of-Life Care Curriculum for Medical Students. Teaching and Learning In Medicine. 2016;28:229-39.

Assessment

• Green ML, Moeller JJ, Spak JM. Test-enhanced learning in health professions education: A systematic review: BEME Guide No. 48. Medical Teacher. 2018;40:337-350.
• Lomis K, Amiel JM, Ryan MS, Esposito K, Green M, Stagnaro-Green A, Bull J, Mejicano GC. Implementing an Entrustable Professional Activities Framework in Undergraduate Medical Education: Early Lessons from the AAMC Core Entrustable Professional Activities for Entering Residency Pilot. Academic Medicine. 2017;92:765-770.
• Green M, Angoff N, Encandela J. Test anxiety and United States Medical Licensing Examination scores. The Clinical Teacher. 2016;13:142-6.

Miscellaneous

• Martin A, Chilton J, Gothelf D, Amsalem D. Physician self-disclosure of lived experience improves mental health attitudes among medical students: a randomized study. Journal of Medical Education and Curriculum Development. 2020; In press.
• Ahuja C, Peck CJ, Wijesekera TP. Screens in the back: Medical student perspective on curriculum engagement. Medical Teacher. 2019;1-2.
• Oldfield BJ, Tetrault JM, Wilkins KM, Edelman EJ, Capurso NA. Simulate to Stimulate: Manikin-Based Simulation in the Psychiatry Clerkship. Subst Abus. 2019;18:1-6
• Jimenez MF, Laverty TM, Bombaci SP, Wilkins K, Bennett DE, Pejchar L. Underrepresented faculty play a disproportionate role in advancing diversity and inclusion. Nat Ecol Evol. 2019;3(7):1030-1033.
• De Aquino JP, Moore DT, Wilkins K, Fuehrlein B. Enhancement of Medical Student Attitudes in the Treatment of Patients with Substance Use Disorders: a Follow-up Study. Acad Psychiatry. 2019;43(3):350-351.
• Goldenberg MN, Cyrus KD, Wilkins KM. ERASE: a New Framework for Faculty to Manage Patient Mistreatment of Trainees. Acad Psychiatry. 2019;43(4):396-399.
• Cyrus KD, Angoff NR, Illuzzi JL, Schwartz ML, Wilkins KM. When patients hurt us. Med Teach. 2018;40(12):1308-1309.
• Wilkins KM, Fenick AM, Goldenberg MN, Ellis PJ, Barkil-Oteo A, Rohrbaugh RM. Integration of Primary Care and Psychiatry: A New Paradigm for Medical Student Clerkships. J Gen Intern Med. 2018;33(1):120-124.
• Wilkins KM, Moore D, Rohrbaugh RM, Briscoe GW. Integration of Basic and Clinical Science in the Psychiatry Clerkship. Acad Psychiatry. 2017 Jun;41(3):369-372.
• Ellman MS, Schwartz ML. Online learning tools as supplements for basic and clinical science education. J Med Educ and Curr Develop. 2016;3:109-114.