Clinical Skills Assessment
Introduction

The Clinical Skills Assessment Program includes a Year 2 assessment of comprehensive history and physical examination skills, a Year 4 assessment of focused history and physical exam skills, and remediation assessments.

Clinical Skills Assessment Year 2

Who Must Go: All Yale medical students in the second year are required to demonstrate the capacity to perform a complete History and Physical (H & P) before starting the third year clerkships.

Purpose: The purpose of the Clinical Skills Assessment (CSA) in January or February of the second year is to assess students’ capacity to demonstrate a patient-centered approach, to ask all the questions in a complete History, to perform all the component maneuvers of a comprehensive Physical Examination and to demonstrate a flow for the head-to-toe Physical Examination. Even though all Physical Exam maneuvers may not be used in a given visit in practice, your ability to perform them is being assessed at this time.

What You Will Be Expected to Do: Students are expected to do a complete History and Physical Examination on two standardized patients (SP’s). The SP’s are also known as Patient Instructors (PI’s) because they have been trained to give you feedback on your inclusion or omission of pertinent History questions or Physical Exam maneuvers and on the quality of your techniques. You are given 65 minutes for each patient encounter. Once time is up, you will hear an announcement saying you are needed in the hallway.

Breast Exam, Pelvic Exam, Male Genital Exam, Rectal Exam: Students are expected to perform the breast exam on both male and female patients. You are not expected to perform the pelvic, male genital, or rectal exam.

What to Bring: Wear your white coat and bring your stethoscope. All other equipment is supplied in the rooms.

Scoring of Questions and Maneuvers: Students receive points for components of the complete History and Physical performed. A maneuver is scored as not done, done incorrectly or done correctly. For maneuvers such as inspecting the skin, it is important to tell the SP’s/PI’s what you are examining as that is the only way they will know you are performing the maneuver. Similarly, if you have a stethoscope without a bell, you must remember to tell the SP when you are applying appropriate pressure to listen as if with a bell. That is the only way they will know to score the maneuver. Students also receive a score on PE Process including hand washing before the exam, the ease of flow of the exam, and attention to patient comfort and modesty. Communication skills are scored using the Master Interview Rating Scale (MIRS).

SP/PI Feedback/Videotape: Students are given immediate feedback from each SP/PI you see. Students also receive individual password protected on-line access limited to streaming video of their individual encounter with the male patient they examined (encounters with female patients are not filmed because of the sensitive nature of the breast exam).

What Happens with the Results: After the last student has been assessed, the aggregate scores are analyzed. Students who perform one or more Standard Deviations below the Class Mean for both Histories or both Physicals are contacted for remediation. This involves meeting with your tutor or a member of the Yale Clinical Skills Assessment Faculty to review your video and performing extra practice on areas in need of improvement. You may also be retested with an SP/PI (done in the Office of Education).

Write-ups: Students are required to submit a write-up of each H & P within 24 hours for review and constructive feedback from dedicated Clinical Skills Faculty.

Click here to view the checklist for "STRUCTURED OBSERVATION OF APPROACH TO THE PATIENT AND MEDICAL HISTORY-TAKING SKILLS".

Click here to view the "YEAR 2 CLINICAL SKILLS ASSESSMENT PHYSICAL EXAMINATION CHECKLIST"  used by SP's to observe and score student skills performance.

Clinical Skills Assessment Year 4

Who Must Go: All students completing the third year required clerkships (Medicine, Surgery, Pediatrics, Core OB/GYN, Neurology, and Core Psychiatry) by June must demonstrate proficiency on the Year 4 Clinical Skills Assessment (CSA) as a Yale School of Medicine graduation requirement. Students doing fifth and sixth years need go only once, but are welcome to go again if they think the practice would be helpful.

Purpose: The purpose of the CSA exercise, beginning in the last two weeks of the last rotation block in third year and running throughout June and July in the fourth year, is to assess your capacity to demonstrate a patient-centered approach, to ask the relevant questions in a focused History, and to perform relevant component maneuvers of a focused Physical Examination. The seven-case exercise developed by expert faculty at UConn and Yale has been shown to be a valid assessment of these skills basic to the practice of medicine.

What You Will Be Expected to Do: Students are expected to see seven standardized patients (SP’s) with problems spanning the clerkships in a simulated clinic (or urgent visit or ER) setting at the UConn CSA Program test site. You will be expected to do a focused History and Physical (H & P) on five standardized patients (SP’s), and to do a focused History and Counseling on two SP’s. The SP’s are also known as Patient Instructors (PI’s) because they have been trained to give you feedback on your inclusion or omission of pertinent History, Counseling, or Physical Exam questions or maneuvers and on the quality of your techniques. You are given 20 minutes for each SP/PI visit, and may use the time however you like. Once time is up, you will hear an announcement saying you are needed in the hallway. Do not do more, as the SP stops scoring after the announcement. After each 20-minute SP/PI visit, there is a 5-minute pen and paper exercise. Most of these involve listing your top three thoughts for differential diagnoses explaining the patient’s chief complaint, and listing the H & P findings that support or refute these diagnoses.

Breast Exam, Pelvic Exam, Male Genital Exam, Rectal Exam: Students are not expected to perform the breast, pelvic, male genital, or rectal exam. If one of these exams is indicated based on history of physical exam findings, you may either mention to the patient that the particular exam is indicated, or ask if the particular exam has been done. The patient will direct you to a description of the physical findings in one of the drawers.

What to Bring: Wear your white coat and bring your stethoscope. All other equipment is supplied in the rooms.

Scoring of Questions and Maneuvers: Students will receive credit for relevant components of the focused History and Physical you perform. Please review the components of the problem focused visit. History skills are scored for every visit. Physical Exam skills are scored for five visits. A Physical Exam maneuver is scored as not done, done incorrectly or done correctly. Remember to wash your hands before each examination. For maneuvers such as inspecting the skin, it is important to tell the SP’s/PI’s what you are examining as that is the only way they will know you are performing the maneuver. Similarly, if you have a stethoscope without a bell, you must remember to tell the SP when you are applying appropriate pressure to listen as if with a bell. That is the only way they will know to score the maneuver. Communication skills are scored for every visit using the Master Interview Rating Scale (MIRS). For two of the cases, Counseling skills are scored using a checklist for including appropriate questions, patient education, emotional support, and specific plans. There is no penalty for including additional History, Physical, or Counseling questions or maneuvers. If time permits, and you feel a step is important, include it.

Do not worry about minor details. Scoring is designed to take into account variations in technique and case specificity. For each SP/PI visit, 1 point is given for receiving credit for successfully performing a majority (varies from about 50% to 75% based on normative data) of the checklist items for the focused History, 1 point for the focused Physical Exam or Counselling, and 1 point for Communication skills. For the seven patient visits, 21 points is the maximum possible score. To demonstrate proficiency, you must attain a score equivalent to ≥ 70% of the maximum 21 points.

SP/PI Feedback/Videotape: Each student will receive immediate feedback from two SP/PI’s during the CSA. At the end of the CSA, you will also have an informal group debriefing over lunch with a member of the Yale Clinical Skills Assessment Faculty to discuss highpoints of each case. A video is recorded of all seven SP/PI visits. Using standardized checklists, visits are scored by each SP/PI and scoring is checked for accuracy by a second trained observer. After all students taking the CSA this summer have been assessed, normative data will be generated. In late August, each student will receive a letter including personal scores and normative scores for the class. We also encourage you to review your videotape with a faculty member. To preserve confidentiality, videos are kept in a secure location in the Office of Education. You may make arrangements to review your tape with a faculty member by contacting the Director of the Clinical Skills Assessment Program, Cheryl Walters, MD, in the Office of Education.


Clinical Skills Assessment
Original Scholarly Research

Haeseler F, Fortin VI AH, Pfeiffer C, Walters C, et al. Assessment of a Motivational Interviewing Curriculum for Year 3 Medical Students Using a Standardized Patient Case. Patient Education and Counseling. 2011;84(1):27-30.

Walters CA, Kosowicz L, Pfeiffer CA. Cohort Data Suggest Patterns of Student Errors in Performing Focused Physical Exams. 12th International Ottawa Conference on Clinical Competence. 2006;May 21;OS9-2.

Ortiz-Neu C, Walters CA, Tenenbaum J, Colliver JA, Schmidt HJ. Error Patterns of Third-Year Medical Students on the Cardiovascular Physical Examination. Teaching and Learning in Medicine. 2001;13(3):161-166.

Walters CA. and Schmidt HJ. US Department of Education FIPSE Grant # P1168960417 Report, A Model Office-based Mentoring Program: Improving Teaching and Learning in Clinical Medical Education. Sep 1, 1996 to Jun 30, 2000.

Walters, CA. The Need for Office-Based Precepting. Hospital Practice. 1993;48:7-13 (invited editorial)