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Changes in patient expectations and in student requirements, together with other factors, have demanded modifications to the undergraduate medical curriculum1,2. One of these, prompted by recognition that clerkships alone cannot be relied on to provide comprehensive training in clinical skills3, is the introduction of clinical skill centres (CSCs). CSCs have been rapidly adopted4,5 and are now an established part of training for healthcare professionals from Glasgow to Gezira.
The original aim was simply to provide a safe environment for learning clinical and communication skills and for practising clinical procedures6, but CSCs can be more than just skills training laboratories for junior students7. They can be of value to newly qualified doctors8; additional time in the CSC has been suggested as a component of induction programmes for preregistration house officers9. However, the activities of CSCs are at present limited—focusing on elementary communication skills, physical examination of volunteer colleagues or techniques such as intravenous cannulation. Their content may not be seen as part of an integrated programme; shared sessions with students from other healthcare disciplines may not be available; and self-assessment and constructive feedback opportunities may not be provided. Finally, staff development sessions for clinical tutors may not be seen as part of the CSC's responsibility.
CSCs must develop continuously if they are to respond to current demands and future challenges—whether these come from medical or nursing students or graduates, or from other healthcare professionals. However, their role and the strategies that contribute to their success can now be more clearly defined. Four current trends have been described10—the provision of various delivery methods, the adoption of educational strategies, the creation of self-assessment opportunities and the recognition of support mechanisms for both students and staff. Centres that pursue these trends can expand their contribution in several areas. More elements can be added to the CSC pie (Figure 1).
We are familiar with the use of simulated consulting rooms for training in communication skills and physical examination, but with imagination these can be developed for learning the more complex communication skills required to conduct an interview with, say, an aggressive or hearing-impaired patient, or via a third party. Examining a patient at home may be quite different from seeing one in a hospital bed. A domestic environment with its attendant risks and difficulties can be created to simulate a general-practitioner or district-nurse visit. A small room provided with well-worn domestic furniture creates a realistic environment for a home visit.
To provide opportunities for practice in ward-based procedures, such as bedside nursing care, a large, appropriately equipped simulated ward is required, while messy procedures such as ‘scrubbing-up’ or applying plaster-of-paris casts are best practised in a simulated prep-room area. Experience with complex practical procedures requiring teamwork and decision-making may be provided in a simulated accident and emergency room or resuscitation suite. The addition of appropriate equipment and tape recordings of background noises adds reality to these simulated environments. Purpose-built facilities are unlikely to be available, but a disused ward can provide flexible space, convertible from one use to another by room dividers. Simulated venues require simulated patients (Box 1)11. These can be recruited from volunteers or actors. They will require careful selection, training and monitoring. A coordinator is required to arrange training, organize attendances, facilitate briefing sessions and take care of reimbursement and any special events that recognize their contribution. Non-acute patients with ‘real’ diagnoses can be recruited by clinician colleagues and added to this resource bank. They require to be registered according to the body system they most appropriately illustrate, the procedures they are willing to undergo and the extent to which they are available. Records of their attendance should be kept for feedback and monitoring.
Box 1 A simulated clinical venue
A group of male students are talking to an elderly Asian woman sitting in an easy chair in a living room. They are hearing a history suggestive of chronic obstructive airways disease and now wish to examine her chest.
These third-year medical students studying the respiratory system are in a simulated domestic environment created in the clinical skills centre. Having previously learned the basics of history taking and the approach to physical examination for this system they now have to adapt their clinical skills to the situation as it may present to a general practitioner in a patient's home. A simulated patient volunteer who had learned an appropriate script for this scenario is working with the students and has agreed to be examined.
A tutor stands by to comment on their performance and to discuss the management and ethical problems that arise.
Increasingly sophisticated technology is now available to support teaching and learning in these simulated venues, with advantages for both students and patients12.
At their simplest, CSCs use physical body simulators for such purposes as demonstrating nursing-care procedures. Anatomic-pathological simulators can be used for the practice of invasive or painful procedures such as otoscopy, rectal examination or delivery of a baby. Procedural skills simulators are used for practical skills such as soft-tissue or intra-articular injection, catheterization and airway management. An innovative integration of simulated patients and plastic models enables clinical procedures to be practised in conjunction with communicating with the ‘patient’13. Surgical simulators allow practice with wound closure, episiotomy and laparotomy. The realistic high-tech simulator ‘Harvey’, which reproduces various cardiac conditions and their associated heart sounds, pulses and chest wall movements, is now available in most UK medical schools (Box 2).
Virtual reality systems provide training in cannulation, catheterization and local anaesthetic nerve blocks. In these the computer not only visualizes the procedures but also replicates the associated sensations by sophisticated haptic devices so that, as the procedure progresses, the sensations produced are transmitted to the student via the instrument being manipulated on the adjacent model14.
Finally, robotic manikins (virtual reality simulators) which react with proxy endoscopes can replicate the sights and sensations encountered during procedures such as bronchoscopy and colonoscopy.
Such additional equipment requires storage space as well as maintenance by trained technicians. Initial and recurring costs must be included in the centre's budget.
Today's students are well accustomed to audio-video facilities, and these will be increasingly used in demonstrating concepts, principles, procedures and attitudes15. Closed-circuit television (CCTV) links from theatre or clinics bring to the centre procedures that would otherwise be seen by only a few. Links from the centre to other sites can bring the CSC experience to areas outwith the main campus—the ‘hub and satellite’ model7. The role of teleconferencing between CSCs is still to be fully developed. The additional use of CCTV for security monitoring allows out-of-hours opening of the CSC, thus fostering independent learning.
Screen-based computer-assisted learning programmes based on CD-ROM are extensively available. With the development of on-line technology, a virtual medical school has been described, using a hybrid of electronic learning (e-learning) and face-to-face tuition16. CSCs are well placed to become the lynchpin of such a virtual medical school programme.
Box 2 Utilizing sophisticated ancillary technology
20 second-year students are seated in a seminar room wearing adapted stethoscopes connected to infrared receivers. A tutor is using a three-quarter-size manikin to demonstrate auscultation of basic heart sounds. The volume of the different heart sounds can be adjusted so they can more readily be heard and so related to the palpated carotid pulse or jugular venous pressure. Once the class is confident that they have heard the various sounds the tutor can vary the manikin's controls to reproduce various murmurs and demonstrate where they are best heard over the chest wall.
The tutor is using the advanced cardiac simulator ‘Harvey’ to teach auscultation of the heart. All the class can hear the various heart sounds, observe where they are best heard and relate these sounds to the underlying physiology of the cardiac cycle as represented in the accompanying UMEDICS computer-assisted learning programme.
Box 3 An integrated clinical skill centre session
A group of 36 students are taking part in four integrated activities during their musculoskeletal course in the third year. They are progressing round a circuit of tasks at half-hourly intervals during which they will:
The students can use their study guide to relate the material they have learned to other aspects of this core clinical problem as it is presented in other parts of the course.
Whatever is done in the CSC must encourage the adoption of student-centred learning styles16. Whether we teach in an outcome-based curriculum, a task-based programme or a problem-based programme, CSCs should implement strategies that support the move towards an adaptive curriculum, integrated learning (Box 3) and interprofessional education.
In this way students are enabled to study at their own pace and at times and places which suit them. They can relate what is experienced in the CSC to material learned elsewhere or on previous occasions, and opportunities to learn with students from other disciplines can be provided. Creating such structured programmes requires cooperation between programme developers and deliverers. The role of study guides in supporting independent learning is well known, but further progress with their use (perhaps in electronic format) and the introduction of curriculum mapping facilities will all help students to develop adult learning styles16.
There is a current move towards shared learning, especially between medical and nursing students at undergraduate level. This is possibly the most difficult learning strategy to adopt. We have not moved far along the eleven steps of the ‘multiprofessional education ladder’ from isolationism towards full cultural integration17. Shared learning programmes require a rethinking of traditional professional boundaries and roles. Although opportunities can be imagined for multiprofessional and interprofessional learning—for instance, in communication skills and general physical examination—the creation of facilities and opportunities that provide simultaneous structured programmes is a formidable task18.
A multiprofessional practice ward has been described19, as an integrated learning activity aimed at developing team-working and individual professional goals. In a simulated ward exercise in our own institution, groups of medical and nursing students are given several tasks linked to simulated patients to work on together as they learn how to cooperate in the delivery of a patient-centred healthcare programme (Box 4).
Finally, learning in a structured way should promote ‘assessment awareness’. The style in which clinical tasks are presented in the CSC should prepare students for future examinations by reflecting the style of the summative assessment.
Open access to the CSC promotes opportunities for self-administered assessment. Students working singly or in small groups may choose to use the centre in their own time for peer-assisted learning and feedback. The role of constructive feedback on videotaped student/patient interactions is well accepted by students as a powerful learning tool20 and is reported as having benefits that are retained over subsequent years21. The use of real-time video monitoring with subsequent peer critique (Box 5), tutor feedback and self-review has also been piloted22.
Opportunities can be taken for full CSC sessions to be used for formative objective structured clinical examinations (OSCEs)23. This might be towards the end of a systems block of teaching when sample OSCE stations can be used, similar to those the students will encounter in the forthcoming summative examination. Exposure, practice and assessment (Box 6) ensure that clinical skills are mastered and maintained24.
Box 4 A multiprofessional learning exercise
A group of 4 medical and nursing students are interviewing a man who has arrived in the ward for preoperative assessment before a hemicolectomy. A general surgeon and a stoma therapist are present. The students are required to work together as they share out the tasks associated with admitting the patient to the ward, assessing him for surgery and talking about issues related to informed consent and postoperative recovery. Issues to do with social support and the proposed colostomy are to be discussed.
The group is taking part in a shared ward exercise in the simulated ward area. A simulated patient is taking the role of the man admitted for hemicolectomy. The medical students are in their third year and the nursing students have completed their second clinical placement. The surgeon/tutor and the stoma therapist observe the students' interaction both with each other and with the patient. They will subsequently discuss aspects of the patient's care with them and the stoma therapist will demonstrate details of stoma care.
Box 5 Peer critique and personal reflection
A group of third year students have previously watched a video of a surgeon demonstrating the medical school's preferred approach to abdominal examination. Together with a clinical tutor they are now watching a split-screen TV monitor which shows 4 of their colleagues practising abdominal examination with the help of four simulated patients. The tutor and student group are commenting on the performance of each of these four examinations as they simultaneously take place and can talk to each of the students performing in turn to comment on their examination technique before it is their turn to do the same.
The students will later give their perception of their own performances, hear their colleagues' comments and receive feedback from the tutor. Later, students will be able to reflect on their own performance by reviewing a video of their own examination of the simulated patient.
The CSC has been fitted with a two-way audio-video monitoring link which allows multiple observations at one time. Students' own learning is being reinforced by observing their colleagues on the video-link monitor, by practising with the simulated patient themselves, and by subsequent peer critique, tutor feedback and personal reflection. The examination skills originally observed on the demonstration video are being reinforced.
CSCs can be used for training of clinical tutors although as yet this role is underdeveloped. More emphasis on this can be expected. The call for greater professionalism in teaching and learning in higher education, together with other recommendations of the Dearing report25 emphasizing the importance of competence in clinical teaching, has led to the establishment of the Institute for Learning and Teaching26. Formal attendance at clinical teaching courses may become a recognized part of specialist registrar and senior house officer training programmes. Harden and Crosby27 describe the twelve roles of the teacher but as yet most clinicians undergo little training to develop their teaching role. Shadowing of experienced clinical skills tutors (as an apprentice) is the most readily available learning method and can be especially helpful for junior doctors. CSCs should actively try to attract clinicians with a special interest in teaching. The centres should help provide courses relating to practical clinical teaching, in cooperation with those who run diploma or degree courses in medical education28. Box 7 illustrates a staff development initiative.
Although progress in these other areas is desirable, we must not forget that the fundamental activity of CSCs is to provide a safe and supportive learning environment for students to practise clinical and communication skills and practical procedures. The CSC provides space for students to learn these skills without the risk of humiliation or of compromise to patient care which may arise in traditional clinical settings. Because the CSC is familiar to them it is well-placed to provide a venue for supporting students in areas of potential academic stress31. One-to-one tuition, remedial courses and counselling may be provided by the CSC staff in an environment in which students feel comfortable.
Box 6 A self-assessment opportunity
A formative OSCE (objective structured clinical examination) has been set up at the end of the gastrointestinal course. An area of the clinical skill centre has been arranged as a small OSCE of four-minute stations. Pairs of students are working together on the various competencies which are to be assessed:
After four minutes a bell indicates the end of the station but before the second bell at five minutes the students receive feedback from the observer, from the simulated patient and from the answer sheets provided at the ‘unmanned’ stations.
By working in paris the students employ peer-assisted learning opportunities to assist them in this formative exercise. The immediate feedback provided in the session is a powerful learning tool.
Box 7 A staff development initiative
A group of postgraduates, interested in medical education, are working in pairs under the direction of a senior member of the CSC staff who is collating the results of their discussions for display on an overhead projector. As the list develops, a discussion on the advantages and disadvantages of each idea takes place.
A workshop on how to facilitate small-group learning is being held as part of a course in clinical teaching for both local and visiting clinicians. By working together and sharing experiences the participants are actively involved in the learning process. Later in the day they will have the opportunity to role-play the different types of small-group learning activities they have been discussing.
The day's activities can contribute to a certificate or diploma course in medical education.
What do CSCs need in order to supply this additional material to the pie? If they are to expand their activity in the ways described they must be certain to:
Expansion of their activity in these six areas can increase the contribution made by CSCs. Individual centres may not be able to make progress in all areas simultaneously, but can identify opportunities to expand their activity in one or another as circumstances allow.
I thank Professor Ronald Harden for his idea of adding practical examples to illustrate the text.