Clinical-skills course prepares students for the wards and a new Step 2

Medicine became very personal for Jessica Kattan, a second-year student, shortly after she took a patient’s history. “I figured he probably had the flu,” Kattan said. But tests revealed Burkitt’s lymphoma, a rare and aggressive form of cancer.

“The next time I saw him, he was very ill from his chemo,” Kattan remembered. “Before that, this disease had just been some words in a book to me.”

Kattan’s experience was part of the “Doctor-Patient Encounter.” Now called the “Preclinical Clerkship,” it is a two-year course aimed at teaching skills that students will need to care for patients when they begin their clinical rotations. Margaret J. Bia, M.D., who has directed the course since 1999, sums up its content as the heart of “doctoring”—sensitive interactions with patients, thoughtful diagnoses and effective treatment plans.

For the past five years, Yale students have had their history and physical exam skills assessed at the nearby University of Connecticut assessment center at the end of their second year. This year, students are returning to the center at the end of their third year for an assessment of history and physical exam skills.

Students will also have to demonstrate their mastery of these skills on a new national exam that all medical students must pass in order to obtain a medical license. The exam, a new, second component of Step 2 of the United States Medical Licensing Exam (USMLE), will be required of all medical students graduating in 2005.

This emphasis on skills assessment is part of a national movement recognizing the importance of clinical skills in medical training and clinical care. According to a Harris Poll, two-thirds of Americans support the new national exam, a one-day test that strives to replicate a typical doctor’s work day. Students will examine 10 standardized patients—actors feigning symptoms and ailments—and formulate diagnoses and treatment plans.

The board that oversees the USMLE sees this as a matter of public safety, since good clinical and communication skills correlate with a lower incidence of malpractice suits, better treatment compliance and greater patient satisfaction. Slightly more than half of the medical schools in the United States now require a clinical-skills exam before graduation, yet a survey by the USMLE found that 4 percent of medical students had never taken a history or conducted a physical under the tutelage of a faculty member.

The exam is meeting resistance from the American Medical Student Association, because it will increase students’ debt burdens by $975, the cost of the exam, plus expenses to travel to testing sites—Philadelphia, Atlanta, Chicago, Los Angeles and Houston.

The new exam reflects a change from times past, when students picked up their clinical skills in large part by observing physicians. “Now we have 20-minute clinic visits, which markedly reduces the available time for students to practice and receive feedback,” Bia said.

The “Preclinical Clerkship,” taken in the first two years of medical school, fills that gap with weekly sessions that emphasize history taking and physical examinations. Students work with faculty to develop specific skills and meet weekly with clinical tutors who observe them taking histories and performing physical exams. Students learn communication skills—history taking, social history taking, breaking difficult news—in workshops where they practice on standardized patients before seeing real patients.

“Hopefully these developments in clinical-skills acquisition and assessment will lead to students graduating with a greater mastery of the skills they need to be compassionate, competent physicians,” Bia said.