Medical School Hotline

The professional discipline of medicine is learned. It requires constant updating and practice. As physicians we attempt to prevent, diagnose, treat, and cure or ameliorate illness. We are committed to growing in skill and knowledge and apply that knowledge to the myriad of individuals who come to us for evaluation, treatment, and counsel. In addition, there is also the commitment to pass on our tradition and experience to the next generation of physicians. It is an important part of the Hippocratic Oath that the physician takes periodically in their professional lives. Medicine is still in many ways an apprenticeship. It is passed to the next generation by teachers and the written word, by observing role models, and by practice under expert observation and feedback. There are many roles for doctors—as clinical or basic scientists, as diagnosticians, as therapists, and as counselors. We must have skills in all of those areas to be effective physicians.

Since 1971, Clinical Skills training in Hawai‘i has involved patients, medical students and residents, and community physicians.¹ Clinical Skills is the set of behaviors, professional attitudes, thought processes, and procedural capabilities that continuously develop, improve, and allow physicians to interact with patients to solve medical problems. These are central to physician identity and practice. These skills are now so crucial to effective practice that they have become a part of medical student national testing before graduation. Because of John A. Burns School of Medicine's (JABSOM's) attention to teaching Clinical Skills, the students are well prepared and uniformly pass this challenge. This foundation begins early in the first year of medical school. It is an integral part of the student Problem Based Learning Curriculum^2,3 and life-long learning. Early training in Clinical Skills is an essential part of Problem Based Learning¹ and is congruent with the active learning process.

Those who are teachers of clinical skills were motivated even in medical school to transmit these essential skills often as junior or senior medical students teaching second year students prior to their clerkships. Carrying on that tradition, at JABSOM 3rd and 4th year students and medical residents are invited to help teach these basic physical examination skills under faculty supervision. Teaching truly solidifies these skills for young physicians-to-be.

In 1971, the Clinical Skills teaching at the new medical school was, as now, taught by volunteer clinical faculty. At that time, it was a two-year school and so students were prepared to take their clerkship and clinical years at Mainland medical institutions.

Teaching Clinical Skills in Hawai‘i has offered an unusual opportunity to learn about and teach cultural sensitivity. In addition to the indigenous Hawaiian population, the physician's care extended to all peoples who migrated to Hawai‘i: Caucasians, Japanese, Chinese, Portuguese, Filipinos, Pacific Islanders, Vietnamese, Koreans, as well as active duty military personnel, veterans living in Hawai‘i, and adult military dependent family members. Communicating with patients from so many different backgrounds teaches us the importance of respecting wide-ranging opinions, traditions, and economic and educational circumstances, as well as being empathetic and gaining their understanding for immediate and long term diagnostic and treatment goals. Today, this is called “Cultural Sensitivity” taught by lesson and example at JABSOM.

Dr. Lawrence Weed developed and promulgated the Problem Oriented Medical System.^3–6 Dr. Weed was an inspirational speaker and promotor in the early 1970's of a new approach to medical data gathering, recording, grouping, and formatting patient health information that furthered the objectives of comprehensive, scientific, and patient centered medical care. His was a magnificent effort to reconstruct the medical record into a more scientific document meant for patient care, medical audit, and education. Medical data useful in solving medical problems were addressed at the level of its understanding. It included a summary Problem List, followed by an Assessment of each problem. Each problem was followed by a Plan that was justified by the data pertinent to that problem. Each included further plan-specific laboratory information, treatments, and patient education. In addition, this method organized follow-up Progress Notes into separate sections: Subjective (symptomatic patient information), Objective data (physical and laboratory findings), and further Assessment and Plans under individual problem headings. The beauty of this system was that you could not go beyond your collected data in making diagnoses or designing treatment plans. It recognized that the diagnosis and treatment were an evolutionary and iterative process. His system recorded, interpreted, and proceeded upon data in a rational, systematic, and scientific retrievable way. It provided an ongoing audit trail for the treatment of the patient. It was a learning tool. Weed's precepts formed the basis for developing the JABSOM Problem Oriented Medical Record. Weed's format is now the standard method to record student and resident medical data across the country. We began using this format shortly after Weed invented it.

Over the ensuing years, educators at JABSOM increasingly recognized the limitations of the lecture based educational system. The faculty supported the then Dean Gulbrandsen's decision to begin JABSOM's dramatic conversion to Problem Based Learning. This occurred in 1989.

Educators recognize the importance of the setting for teaching. This was certainly true for Clinical Skills. A Clinical Skills teaching space was first created at Queens Medical Center at University Tower and subsequently at the medical school's Manoa campus. The director solicited excellent “used” examination tables from local physicians, the local medical association, and from hospitals to provide a realistic milieu for teaching physical examination. For 15 years those facilities provided a teaching laboratory for clinical skills until the move to a wellstocked, beautifully appointed clinical skills laboratory at the JABSOM Medical Education Building at Kaka‘ako, Honolulu, Hawai‘i.

When Problem Based Learning (PBL) became the Curricular Foundation, clinical skills were integrated over the next two years into Systems Based Units. This curriculum begins with Introduction to Problem Based Learning, followed by Cardiology and Pulmonology, Nephrology and Hematology, Endocrinology and Gastroenterology, Rheumatology and Neurology, and Behavioral Science. In addition, the final unit, the Life Cycle, acquainted the students with the data bases and skills needed for Pediatrics, Adolescent Medicine, Geriatrics, and Reproductive Health. In the first Unit, a basic physical exam was taught along with the other components of a medical history. With each subsequent organ system oriented subunit, the relevant portions of the history and physical examination were expanded

Teaching the motor and cognitive skills related to gathering historical and physical information from patients provides first and second year students with their initial trajectory into medical care and “Lifelong Learning” (the latter being constantly emphasized). These skills are necessarily taught in small units over long periods of time beginning in a laboratory setting. Each laboratory prepares students for their subsequent patient experiences. The laboratory is divided into the usual activities of examination: Inspection, Palpation, Percussion, and Auscultation. Each skill is taught in a standardized fashion first by classroom demonstration and followed by students examining each other under careful supervision. In addition to teaching motor skills and techniques, these labs require that students ask permission of each other to perform the exam and learn the appropriate draping necessary to preserve privacy. This skill set prepares first and second year students for their patient interactions in each subsequent PBL unit, in the third and fourth year hospital and outpatient clerkships, and subsequent residencies, fellowships, and practice careers.

Students learn most from patients. After acquiring basic skills in the laboratory, tutorial groups are paired with clinician preceptors who provide volunteer patients for the students to interview and examine. Students see how data collection and inductive reasoning lead to possible explanatory hypotheses and then diagnoses. These patient experiences are similar to classroom learning with “paper problems”, except the studentphysician must gather the data. These student-patient interactions mirror the doctor-patient relationship and teach professionalism as well as data collection skills in a realistic clinical setting. Pertinent patient experiences in each pre-clinical unit reinforce and complement the tutorial learning.

Directing and teaching clinical skills have meant interacting with many faculty members to assure constantly their integration into the greater educational whole. This includes coordinating direct clinical skills teaching with the Office of Clinical Skills chaired by Michael Nagoshi MD, and the clinical simulations laboratory (Sim-Tiki) headed by Joseph Turban MD. In the former, standardized patients (actors) are used for evaluating clinical skills and for teaching difficult portions of the clinical examination (female breast and pelvic examination; male genital and rectal exam).^7,8 The latter teaches and assesses procedural skills and simulates physiological responses to pharmacologic, diagnostic, and other treatment modalities.⁹

Directing and teaching this subject includes year-round recruiting and developing a clinical faculty capable of teaching clinical skills. Together, the faculty facilitates student-patient interactions that reinforce the classroom learning. This means professional development and professional education for this faculty to better prepare them for the clinical skills teaching program. This program recruits and orients about 130 volunteer clinical faculty members each year to assist in teaching clinical skills. Furthermore, interaction and coordination are necessary with those physicians involved with Clinical Skills in the various Clerkships in the third and fourth years. This maintains the integrity of clinical skills teaching and practice throughout the JABSOM experience. Each clinical skills instructor serves as a role model by supervising and guiding student interactions with volunteer patients.

Yearly, the Director reviews and updates the organized objectives and written materials that summarize what students in the first and second years will learn. Annually, the Clinical Skills Resource Manual,¹⁰ the written repository of what is taught in clinical skills, is reviewed and edited. A suggested textbook¹¹ is provided for the students as well as visual and auditory clips for the classrooms. Useful Internet sites for collections of breath sounds and heart tones supplement the laboratory experiences.

The impact of Clinical Skills in medical education at JABSOM has been significant as over one half of practicing physicians in Hawai‘i have come from our school. The Chair of this program has taught every student graduating from JABSOM since 1979 and actually was a preceptor teaching clinical skills while at Tripler from 1971–1974. Furthermore, the Chair teaches students, residents, and community physicians in his own discipline of Endocrinology, in general medicine, and in direct patient care. This enterprise has been made possible due to the combined supporting efforts of students, physician colleagues, the medical school, and the physician-patient community at large.

Future educational challenges include the following. (1) How will future physicians provide patient-centered care? (2) How will medical schools provide a medical education emphasizing primary care that takes care of the whole patient? (3) How will primary care physicians be taught to provide preventive care, as well as acute and chronic care for patients? (4) How can physicians provide comprehensive care to all patients associated with the practices? (5) How can information be shared to avoid duplication of services? (6) How will services be more efficiently and humanely provided? (7) How will adequate and appropriate care be provided to everyone; not just to those with medical insurance? (8) How do we make health care a right instead of a privilege?

The concept of the Medical Home¹² will provide a framework to respond to the above questions. It will allow better patient access to care, improve communication between providers, emphasize preventive medicine, and more efficiently care for the currently healthy as well as for the acutely and chronically ill. JABSOM will need to emphasize these goals in the future. In part, this can be done by returning to the first principles: Rather than increasing dependence on increasingly expensive technology for diagnosis and treatment, emphasize the inexpensive, effective and time-honored history and physical examination for planning and efficiently using more expensive laboratory and imaging tools for diagnosing and treating medical problems. Electronic medical records (EMR) need to be designed to communicate with each other and incorporate the principles of the Problem Based Medical Record. The EMR must include the diagnostic and decision support tools that are increasingly available. Doctor-patient interaction must be maintained. Technology that permits the physician to really listen to patients, to maintain eye contact, and to perform appropriate physical examination must be used to elicit and sift through pertinent medical information. The Medical Home will ideally incorporate the skills of professionals and para-professionals into Team Approaches to health care delivery. The challenge will be to introduce medical students to the new paradigm of the Patient-Centered Medical Home. There still remains a lot of learning and teaching that must be achieved.