Traditionally, educators have taught physical examination (PE) to medical newcomers (trainees), despite challenges with recruitment and costs, as well as challenges with standardized techniques.
We propose a model that uses standardized teams of patient instructors (SPIs) and fourth-year medical students (MS4s) to teach physical education classes to premedical students, taking full advantage of collaborative and peer-assisted learning.
Surveys of pre-service, MS4 and SPI students revealed positive perceptions of the program, with MS4 students reporting significant improvements in their professional identity as educators. Pre-practice students’ performance on spring clinical skills exams was equal to or better than their pre-program peers’ performance.
The SPI-MS4 team can effectively teach novice students the mechanics and clinical basis of the novice physical examination.
New medical students (pre-medical students) learn the basic physical examination (PE) at the beginning of medical school. Conduct physical education classes for preparatory school students. Traditionally, the use of teachers also has disadvantages, namely: 1) they are expensive; 3) they are difficult to recruit; 4) they are difficult to standardize; 5) nuances may arise; missed and obvious errors [1, 2] 6) May not be familiar with evidence-based teaching methods [3] 7) May feel that physical education teaching abilities are insufficient [4];
Successful exercise training models have been developed using real patients [5], senior medical students or residents [6, 7], and lay people [8] as instructors. It is important to note that all of these models have in common that student performance in physical education lessons does not decrease due to the exclusion of teacher participation [5, 7]. However, lay educators lack experience in the clinical context [9], which is critical for students to be able to use athletic data to test diagnostic hypotheses. To address the need for standardization and a clinical context in physical education teaching, a group of teachers added hypothesis-driven diagnostic exercises to their lay teaching [10]. At the George Washington University (GWU) School of Medicine, we are addressing this need through a model of standardized teams of patient educators (SPIs) and senior medical students (MS4s). (Figure 1) SPI is paired with MS4 to teach PE to trainees. SPI provides expertise in the mechanics of MS4 examination in a clinical context. This model uses collaborative learning, which is a powerful learning tool [11]. Because SP is used in nearly all U.S. medical schools and many international schools [12, 13], and many medical schools have student-faculty programs, this model has the potential for wider application. The purpose of this article is to describe this unique SPI-MS4 team sport training model (Figure 1).
Brief description of the MS4-SPI collaborative learning model. MS4: Fourth Year Medical Student SPI: Standardized Patient Instructor;
The required physical diagnosis (PDX) at GWU is one component of the pre-clerkship clinical skills course in medicine. Other components: 1) Clinical integration (group sessions based on the PBL principle); 2) Interview; 3) Formative exercises OSCE; 4) Clinical training (application of clinical skills by practicing physicians); 5) Coaching for professional development; PDX works in groups of 4-5 trainees working on the same SPI-MS4 team, meeting 6 times a year for 3 hours each. Class size is approximately 180 students, and each year between 60 and 90 MS4 students are selected as teachers for PDX courses.
MS4s receive teacher training through our TALKS (Teaching Knowledge and Skills) advanced teacher elective, which includes workshops on adult learning principles, teaching skills, and providing feedback [14]. SPIs undergo an intensive longitudinal training program developed by our CLASS Simulation Center Assistant Director (JO). SP courses are structured around teacher-developed guidelines that include principles of adult learning, learning styles, and group leadership and motivation. Specifically, SPI training and standardization occurs in several phases, starting in the summer and continuing throughout the school year. Lessons include how to teach, communicate and conduct classes; how the lesson fits into the rest of the course; how to provide feedback; how to conduct physical exercises and teach them to students. To assess competency for the program, SPIs must pass a placement test administered by the SP faculty member.
MS4 and SPI also took part in a two-hour team workshop together to describe their complementary roles in planning and implementing the curriculum and assessing students entering pre-service training. The basic structure of the workshop was the GRPI model (goals, roles, processes and interpersonal factors) and Mezirow’s theory of transformational learning (process, premises and content) for teaching interdisciplinary learning concepts (additional) [15, 16]. Working together as co-teachers is consistent with social and experiential learning theories: learning is created in social exchanges between team members [17].
The PDX curriculum is structured around the Core and Clusters (C+C) model [18] for teaching PE in the context of clinical reasoning over 18 months, with each cluster’s curriculum focused on typical patient presentations. Students will initially study the first component of C+C, a 40-question motor exam covering major organ systems. The baseline exam is a simplified and practical physical examination that is less cognitively taxing than a traditional general examination. Core exams are ideal for preparing students for early clinical experience and are accepted by many schools. Students then move on to the second component of C+C, the Diagnostic Cluster, which is a group of hypothesis-driven H&Ps organized around specific general clinical presentations designed to develop clinical reasoning skills. Chest pain is an example of such a clinical manifestation (Table 1). Clusters extract core activities from the primary examination (eg, basic cardiac auscultation) and add additional, specialized activities that help differentiate diagnostic capabilities (eg, listening for additional heart sounds in the lateral decubitus position). C+C is taught over an 18-month period and the curriculum is continuous, with students first being trained in approximately 40 core motor exams and then, when ready, moving into groups, each demonstrating a clinical performance representing an organ system module. the student experiences (eg, chest pain and shortness of breath during cardiorespiratory blockade) (Table 2).
In preparation for the PDX course, pre-doctoral students learn the appropriate diagnostic protocols (Figure 2) and physical training in the PDX manual, physical diagnostics textbook, and explanatory videos. The total time required for students to prepare for the course is approximately 60-90 minutes. It includes reading the Cluster Packet (12 pages), reading the Bates chapter (~20 pages), and watching a video (2–6 minutes) [19]. The MS4-SPI team conducts meetings in a consistent manner using the format specified in the manual (Table 1). They first take an oral test (usually 5-7 questions) on pre-session knowledge (eg, what is the physiology and significance of S3? What diagnosis supports its presence in patients with shortness of breath?). They then review the diagnostic protocols and clear the doubts of students entering pre-graduate training. The remainder of the course is final exercises. First, students preparing for practice practice physical exercises on each other and on SPI and provide feedback to the team. Finally, SPI presented them with a case study on “Small Formative OSCE.” Students worked in pairs to read the story and make inferences about the discriminative activities performed on the SPI. Then, based on the results of the physics simulation, pre-graduate students put forward hypotheses and propose the most likely diagnosis. After the course, the SPI-MS4 team assessed each student and then conducted a self-assessment and identified areas for improvement for the next training (Table 1). Feedback is a key element of the course. SPI and MS4 provide on-the-fly formative feedback during each session: 1) as students perform exercises on each other and on SPI 2) during Mini-OSCE, SPI focuses on mechanics and MS4 focuses on clinical reasoning; SPI and MS4 also provide formal written summative feedback at the end of each semester. This formal feedback is entered into the online medical education management system rubric at the end of each semester and affects the final grade.
Students preparing for internships shared their thoughts on the experience in a survey conducted by the George Washington University Department of Assessment and Educational Research. Ninety-seven percent of undergraduate students strongly agreed or agreed that the physical diagnostics course was valuable and included descriptive comments:
“I believe that physical diagnostic courses are the best medical education; for example, when you teach from the perspective of a fourth-year student and patient, the materials are relevant and reinforced by what is being done in class.
“SPI provides excellent advice on practical ways to perform procedures and provides excellent advice on nuances that may cause discomfort to patients.”
“SPI and MS4 work well together and provide a new perspective on teaching that is extremely valuable. MS4 provides insight into the objectives of teaching in clinical practice.
“I would like us to meet more often. This is my favorite part of the medical practice course and I feel like it ends too quickly.”
Among respondents, 100% of SPI (N=16 [100%]) and MS4 (N=44 [77%]) said their experience as a PDX instructor was positive; 91% and 93%, respectively, of SPIs and MS4s said they had experience as a PDX instructor; positive experience of working together.
Our qualitative analysis of MS4′s impressions of what they valued in their experiences as teachers resulted in the following themes: 1) Implementing adult learning theory: motivating students and creating a safe learning environment. 2) Preparing to teach: planning appropriate clinical application, anticipating trainee questions, and collaborating to find answers; 3) Modeling professionalism; 4) Exceeding expectations: arriving early and leaving late; 5) Feedback: prioritize timely, meaningful, reinforcing and constructive feedback; Provide trainees with advice on study habits, how best to complete physical assessment courses, and career advice.
Foundation students participate in a three-part final OSCE exam at the end of the spring semester. To evaluate the effectiveness of our program, we compared the performance of student interns in the physics component of the OSCE before and after the launch of the program in 2010. Prior to 2010, MS4 physician educators taught PDX to undergraduate students. With the exception of the 2010 transition year, we compared OSCE spring indicators for physical education for 2007–2009 with indicators for 2011–2014. The number of students participating in the OSCE ranged from 170 to 185 per year: 532 students in the pre-intervention group and 714 students in the post-intervention group.
OSCE scores from the 2007–2009 and 2011–2014 spring exams are summed, weighted by annual sample size. Use 2 samples to compare the cumulative GPA of each year of the previous period with the cumulative GPA of the later period using a t-test. The GW IRB exempted this study and obtained student consent to anonymously use their academic data for the study.
The mean physical examination component score increased significantly from 83.4 (SD=7.3, n=532) before the program to 89.9 (SD=8.6, n=714) after the program (mean change = 6, 5; 95% CI: 5.6 to 7.4; p<0.0001) (Table 3). However, since the transition from teaching to non-teaching staff coincides with changes in the curriculum, differences in OSCE scores cannot be clearly explained by innovation.
The SPI-MS4 team teaching model is an innovative approach to teaching basic physical education knowledge to medical students to prepare them for early clinical exposure. This provides an effective alternative by circumventing the barriers associated with teacher participation. It also provides added value to the teaching team and their pre-practice students: they all benefit from learning together. Benefits include exposing students prior to practice to different perspectives and role models for collaboration [23]. The alternative perspectives inherent in collaborative learning create a constructivist environment [10] in which these students gain knowledge from dual sources: 1) kinesthetic – building precise physical exercise techniques, 2) synthetic – building diagnostic reasoning. MS4s also benefit from collaborative learning, preparing them for future interdisciplinary work with allied health professionals.
Our model also includes the benefits of peer learning [24]. Pre-practice students benefit from cognitive alignment, a safe learning environment, MS4 socialization and role modeling, and “dual learning”—from their own initial learning and that of others; They also demonstrate their professional development by teaching younger peers and take advantage of teacher-led opportunities to develop and improve their teaching and examination skills. In addition, their teaching experience prepares them to become effective educators by training them to use evidence-based teaching methods.
Lessons were learned during the implementation of this model. First, it is important to recognize the complexity of the interdisciplinary relationship between MS4 and SPI, as some dyads lack a clear understanding of how best to work together. Clear roles, detailed manuals and group workshops effectively address these issues. Second, detailed training must be provided to optimize team functions. While both sets of instructors must be trained to teach, SPI also needs to be trained in how to perform the exam skills that MS4 has already mastered. Third, careful planning is required to accommodate MS4′s busy schedule and ensure that the entire team is present for each physical assessment session. Fourth, new programs are expected to face some resistance from faculty and management, with strong arguments in favor of cost-effectiveness;
In summary, the SPI-MS4 physical diagnostic teaching model represents a unique and practical curricular innovation through which medical students can successfully learn physical skills from carefully trained nonphysicians. Since nearly all medical schools in the United States and many foreign medical schools use SP, and many medical schools have student-faculty programs, this model has the potential for wider application.
The dataset for this study is available from Dr. Benjamin Blatt, MD, Director of the GWU Study Center. All our data is presented in the study.
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Post time: May-11-2024