A Longitudinal Program for the Early Identification and Remediation of Medical Students' Clinical Skills

Idea: Identifying at-risk students with clinical skills deficiencies and initiating remediation early in their career will improve performance competency. Rationale: Studies show that students’ clinical skills are rarely observed by faculty, leading to the implementation of OSCEs to assess clinical competence. OSCEs often identify students with one or more skills deficiencies, and poor performance on OSCEs is associated with poor clinical evaluations. Although remediation is labor intensive, medical schools have an ethical duty to ensure all students have adequate clinical skills. At-risk students tend not to ask for help, so it is vital that medical schools develop ways to flag these weak students for early intervention. Most remediation interventions focus on enhancing a student’s skills just enough to pass a retest but not enough to develop lifelong skills. If at-risk students can be identified and remediated at an earlier stage in their education, lifelong skills will have a better chance of being established. Methods: The Clinical Skills Enhancement Track (CSET) program began as a one-month mandatory elective for medical students who failed the Senior CPX. In 2010, with approval by clerkship directors and the Curriculum Committee, third-year students who performed poorly on clerkship OSCEs or were referred by clinical faculty were included in CSET. In 2012, second-year OSCE’s provided an excellent tool to flag at-risk students, and the program expanded to include second-year students. Identification of students’ deficiencies is accomplished using faculty evaluations of SP encounters, SP checklists and feedback, student self-evaluations, and clerkship feedback. Students and faculty review their performance and develop an education prescription. Second year students attend workshops targeting their deficiencies, including case-based clinical reasoning, physical exam tutorial, and SP practice. Third year students meet with faculty for two-hour bi-monthly workshops, and continue in CSET until their skills have reached the required level of competence. Senior medical students are required to participate in a onemonth CSET elective, and must pass a remediation exam. Results: For class of 2012, 16/157 students participated in CSET in their second or third years. For class of 2013, 36/161 students participated in CSET in their second or third years. Of the 5 students from each class who failed the Senior CPX, only 1 from each class had participated in CSET. Senior medical students who complete CSET due to failure of the senior CPX have shown improvement of their skills on the retest, with 100% passing the CPX remediation exam. Only one student failed USMLE CS exam, and that student had not participated in CSET. The challenge continues to be identifying students in need and the occasional student with multiple areas of deficiency. 37 students from these classes either withdrew or delayed graduation, and 26 of these students had been identified and referred to CSET. Impact: Many students with weak clinical skills had delayed academic progress, supporting the need for early identification and intervention. Having consistent faculty working with CSET students allows faculty to adjust teaching methods, monitor improvement and develop a trusting relationship which enhances learning and motivation.