|Year : 2021 | Volume
| Issue : 3 | Page : 150-155
Checklist-based training for essential clinical skills in 3 term MBBS students
Professor, Department of Medicine, Convener, Medical Education Unit, Father Muller Medical College, Mangalore, Karnataka, India
|Date of Submission||21-Oct-2020|
|Date of Acceptance||28-Jan-2021|
|Date of Web Publication||28-Sep-2021|
Dr. Smitha Bhat
Department of Medicine Convener, Medical Education Unit, Father Muller Medical College, Mangalore - 575 002, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Undergraduate students find the correct sequence & method of eliciting clinical signs is ambiguous, leading to confusion & reluctance to demonstrate. The 3-term posting is the introduction to clinical skills & it is essential that bedside teaching is organized & delivered well. Studies have shown that a structured clinical training improves students' examination skills. This study aimed to estimate the difference in competence in basic physical examination in students taught by checklist-based training and those taught by standard clinical teaching.
Materials and Methods: This was a randomized crossover trial conducted on 3 term MBBS students posted to medicine. Checklists for general physical examination (GPE) and vital sign examination were framed, piloted. Students were divided in to control & test groups by simple randomization. In phase 1, the control group learnt measurement of vital signs by standard clinical teaching in the units. The test group learned using checklist-based demonstration. In phase 2, the groups were interchanged and GPE was taught by checklist method in the test group .Skills were assessed by OSCE after each training. OSCE scores between control & test groups were compared and analysed.
Results: Students showed significantly higher scores when GPE was taught by checklist-based method (Test 1.49, control 0.6. P – 0.000). There was no significant difference in OSCE scores in vital sign examination (Test – 1.15, Control 1.19 P – 0.378). Students found the checklist-based method systematic and easy to remember
Conclusion: Checklist-based training improves student clinical learning in GPE, though not in vital sign examination.
The following core competencies are addressed in this article: Medical knowledge, Patient care, Practice-based learning and improvement.
Keywords: Checklists, clinical skills, training
|How to cite this article:|
Bhat S. Checklist-based training for essential clinical skills in 3 term MBBS students. Int J Acad Med 2021;7:150-5
| Introduction|| |
Knowledge of medicine, clinical examination skills, and the ability to communicate effectively are required to function effectively as a clinician. Although a good clinical skills training program is the foundation of a good undergraduate medical program, often this training is not effective. Effective bedside teaching benefits the student, the doctor, as well as the patient. Worldwide, dwindling clinical skills among undergraduate medical students is a matter of concern. Students find that the correct sequence and method of eliciting clinical signs is ambiguous. This leads to confusion and reluctance to demonstrate physical signs. The 3-term posting is the introduction to clinical skills and if bedside teaching in the 3 terms is organized and delivered well, these skills will serve the student well, not only in their undergraduate MBBS (Bachelor of Medicine, Bachelor of Surgery) course, but later as physicians. At present, clinical skills training occurs in multiple settings including the outpatient department and the wards. Structured clinical training improves students' physical examination skills when compared to traditional teaching.
The aim was to find whether checklist-based training leads to the improved acquisition of clinical skills in third term MBBS students when compared to standard clinical training.
- To estimate the difference in competence in the basic physical examination as assessed by objective structured clinical examination (OSCE) scores in students taught by checklist-based training and those taught by standard clinical teaching
- To find how students perceive checklist-based training.
| Materials and Methods|| |
This was a mixed-methods study, using quantitative and qualitative analysis methods. The study was designed to be a randomized crossover trial, so both the study and control groups would receive the benefit of the intervention. The target group for this educational intervention was third term MBBS students posted to the Department of Medicine. Checklists for General Physical Examination (GPE) and vital sign examination were framed, piloted, and discussed with senior faculty. Ethical approval was obtained from Father Muller Medical College Ethics Committee on December 28, 2018 (FMMCIEC/CCM/728/2018). The project was set in the medicine wards of the teaching hospital. The educational strategy employed was face to face teaching at the bedside. The study occurred in the normal hours scheduled for clinical teaching i.e., 9.30 am to 12 noon. Third term students were divided into two groups, A and B, by simple randomization [Figure 1].
|Figure 1: A randomized crossover trial. IEC = Institutional Ethics Committee, GPE = General Physical Examination, OSCE = Objective structured clinical examination|
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Group A students learnt measurement of vital signs by checklist-based demonstration. In this process, students were provided with checklists, and the instructor demonstrated the signs as per the steps elucidated in the checklist. Later, the students were permitted self-directed learning in the form of checklist guided practice. Group B learnt vital sign examination by standard clinical teaching in the units. This teaching varies from unit to unit, but generally involves a brief discussion of the examination technique followed by demonstration at the bedside. Both groups then underwent an assessment on vital sign examination by OSCE.
Following this, in phase 2, Group A learnt GPE by standard teaching and group B learnt GPE by checklist-based teaching. Students were assessed by OSCE for demonstration of GPE. GPE included examining for anemia, icterus, clubbing, edema, and lymphadenopathy.
The test group had 2 sessions of training and the control groups underwent standard clinical teaching in the unit. The educational intervention was not modified during the course of the study. The total number of students in the batch was 30. Since there are 5 teaching units, the usual teacher to student ratio is 1:6. During the study, the teacher to student ratio in the test arm was 1:15, whereas in the control arm, it was 1:3. Attendance was taken at the end of each session, as per institution policy, by the teaching staff conducting the session. No incentives were provided to students or teachers for participation in the study and the educational intervention was not modified during the course of the project.
The author did not participate in either the training or the assessment. Training in the test group was conducted by Assistant Professors of Medicine who have been trained in the Basic Medical Education workshop prescribed by the Medical Council of India (MCI) for all medical college faculty. The OSCEs were conducted by similarly qualified teachers who did not participate in the checklist-based training of the students.
Mean, median, and standard deviation were calculated for student scores. Mann–Whitney U test was used to calculate the difference between the outcomes in the test and control groups for OSCE 1 and 2.
The teaching material was based on standard textbooks of clinical medicine - Hutchison's Clinical Methods: An Integrated Approach to Clinical Practice and Bates Guide to Physical Examination and History Taking. Each examination technique was divided into smaller subsets, specifying the position of the patient, the equipment used, and a detailed method of examination. The description was in simple language, with easy to follow instructions. The checklists were written by the author and validated by two senior professors in the department of medicine. The checklists were given to the students in the test group at the end of the session, so they could use it as a guide to practice examination in their free hours, for self-directed learning [Figure 2].
The assessment checklist for the OSCE was based on the examination pattern of the Royal College of Physicians, London checklist for their Member of the Royal College of Physicians Progressive Assessment of Clinical Examination Skills exam [Table 1]. The assessment was divided into three categories. “Physical examination” which focused on the technique of examination, “Identifying Physical Signs” which assessed whether signs present were elicited correctly, and “Patient comfort and safety” which looked at how the student behaved with the patient. On this checklist, assessors marked students as 0, 1, and 2 depending on whether their performance was unsatisfactory, borderline, or satisfactory.
Scores of the control and test groups in the 2 OSCEs were recorded and the mean difference in scores was calculated. Student perception of checklist-based training was elicited. Content analysis was done on responses to open-ended questions regarding the opinion of students of checklist-based training.
| Results|| |
Thirty students completed the training as per the checklist in 2 batches and were assessed by OSCE in 2 batches.
Student scores were significantly higher after the checklist based training in GPE (1.49 vs. 0.6, P = 0.000) but not in vital sign examination [Table 2] and [Table 3]. Students perceived the checklist-based training to be systematic, easy to remember, and informative [Figure 3].
|Table 2: OSCE 1 scores of test and control groups - vital sign examination|
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|Table 3: OSCE 2 scores of test and control groups - general physical examination|
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| Discussion|| |
The importance of proficiency in the skills of physical examination for doctors to provide quality, cost-effective care is an accepted fact. Also not contested is that history taking and physical examination skills are best picked up at the bedside. Skill acquisition followed by deliberate supervised practice increases retention and competence in physical examination. The decline in clinical skills parallels the decrease in bedside teaching time. In spite of this, however, time spent teaching physical examination skills is significantly less now than in the past. Busier hospitals, easier methods like simulation-based teaching, and increased dependence on laboratory tests rather than physical examination for diagnosis have all contributed to the decreasing importance given to teaching examination skills. Worryingly, both textbooks and journals of medical education lack sufficient practical advice on effective ways of teaching physical examination at the bedside.
In spite of many innovations in teaching and learning, clinical skills acquisition among undergraduate medical students is far from satisfactory. Checklists are simple cognitive guides which have been used to achieve quality in areas such as flight safety and critical care. They have been widely used in communication skills training as well. In this project, checklists were used to guide students in acquisition and repeated practice of basic clinical examination skills. We aimed to find whether using checklists in this context could improve student learning.
The learning objective was that, by the end of the teaching sessions, the student would know how to conduct a GPE looking for (pallor/icterus/clubbing/edema/cyanosis) or vital sign examination (pulse, blood pressure, jugular venous pressure [JVP]), following the correct methodology as described in standard textbooks of clinical medicine, identifying the findings correctly, and being mindful of patient safety, comfort, and privacy.
The key feature of our educational intervention was an innovative use of the checklist method i.e., training in basic physical examination. We then used OSCE to compare students trained by the checklist method and those trained by standard clinical teaching. We found that checklist based training enhanced skills acquisition in GPE but not in vital sign examination. The advantage that checklist based training seems to confer on GPE and not vital sign examination may be explained by certain factors. GPE and vital sign examination may not be comparable in complexity. Most students who scored badly in the vital sign examination received low scores in measuring JVP. The checklist for JVP measurement may have to be made more explicit and clear, or perhaps the teaching method improved.
The intervention was chosen to find whether the proven utility of the checklist method in critical care, aviation, and assessment might extend to training as well, and was planned according to the steps of evidence-based practice as follows:
- Step 1: asked whether an innovation could be devised to enhance acquisition of basic Clinical Skills in 3 Term MBBS Students
- Step 2: Performed literature search which revealed different ways of enhancing clinical teaching. However, innovations in clinical teaching at the bedside were few
- Step 3: critically appraised the published literature on the use of checklists in critical care, industry and assessment; evidence shows that it is effective in these areas
- Step 4: Applied the utility of checklists as a cognitive instrument to training in clinical medicine for 3 term MBBS students in their first clinical medicine posting
- Step 5: the assessment of the effectiveness of checklist-based training in clinical skills vis a vis the usual training in the units was by comparing OSCE scores between test and control groups.
The complex pathway in learning clinical skills: Acquisition, practice, and remediation
A skill is defined as an ability acquired through deliberate systematic and sustained effort. It can also be considered a discrete observable task during the provision of care. Skills may be cognitive, interpersonal, and technical. The word clinical is derived from the Greek word klinikos which means pertaining to 'at or around the sickbed'. 'Clinical skills' refers to the examination and procedural skills that occur in the clinical environment. Clinical skills were first practiced by the ancient Ayurvedic and Egyptian physicians. Later Galen and Hippocrates developed the idea of a detailed history taken from a patient followed by a focused physical examination.
Till recently, by and large, instruction in clinical skills was by the apprenticeship model where the student learned the art of examination by observation of a senior physician at the bedside. The MCI requires that clinical skills be taught during the undergraduate training period. Clinical skills learning in the present scenario is unsatisfactory. The last two decades have seen many innovations in training and assessment in clinical skills; however, it is a fact that doctors in training master many skills during postgraduate residency rather than during the undergraduate medical course. Thus, graduate doctors often are found inadequately trained in clinical skills.
The patient is the pivot upon which clinical medicine rotates, and to be effective, clinical teaching must involve and be centered upon the patient. William Osler, one of the best-known clinician-educators strongly advocated bedside teaching and said “no teaching without the patient for a text, and the best teaching is often that taught by the patient himself.” However, teaching a clinical skill depending solely on the presence of a patient with the concerned finding of interest may be a little haphazard, and it is difficult to accomplish the learning objectives of the session. Other disadvantages of bedside teaching include the fact that sometimes patient fatigue and disinterest make it difficult to complete the session. Students may find it overwhelming to absorb the vast information both stated and implicit that is conveyed in a clinical teaching session. This is more likely when, as often happens, students at different stages in their academic career (2nd and 3rd year students) are taught together.
A checklist is a common cognitive tool which standardizes processes to ensure that all elements and actions are addressed. It informs what, when, and how to do things. Checklists were first used in aviation to improve the performance of complicated tasks involving multiple steps. Checklists have been used in patient care as well, especially in critical care. Checklists have also been used to guide student assessment and training in communication skills. A checklist consists of a list of steps, each of which must be completed before proceeding to the next step on the list. Its compilation should be evidence-based and it should identify key points that are essential for the safe conduct of the procedure.
This study used checklists in a novel way to ensure that physical examination was carried out correctly, stepwise, and meticulously. Skills were broken down into very basic steps. All necessary information regarding the patient position, instrument requirements, and sequence of the examination was stated explicitly, leaving nothing ambiguous, or open to interpretation. Students learned better, as evidenced by better OSCE scores.
Strengths of the study
As the institute has been conducting exit exams before completion of the internship, staff are trained and experienced in conducting an assessment by OSCE. The training checklists were piloted and validated by senior experienced physicians. The cases were calibrated by the examiners before the OSCE. A list of findings which needed to be elicited for a “satisfactory” grade were made, as well as negative findings, which if falsely detected, would warrant an unsatisfactory grade. The author did not participate in training and the trainers did not participate in the assessment.
This study was limited by the small sample size. The fact that students may have been at different stages of learning in different clinical units where they were posted before entering this study may have influenced the results. The control group was not homogenous as teaching methods in the different units were not standardized and may have varied between units.
| Conclusion|| |
The effectiveness of checklists can be exploited in improving undergraduate training, as students learn clinical skills more effectively with the checklist based method. Formal checklists which include often missed facets of examination can ensure complete correct examination. Additionally, if checklists are standardized, they can bring in uniformity in not only the method of physical examination but the process of training as well.
Further research would include developing validated checklists for systemic examination and checking whether they improve physical examination skills for examination of the cardiovascular system, central nervous system, respiratory system, and abdomen. Faculty can be trained in the checklist method to ensure uniformity of student learning.
This project was done as part of the completion of the Advanced Course of Medical Education at St John's Medical College, Bangalore. I am grateful to the ACME faculty, Dr. Nachiket Shankar, in particular, for their constant encouragement and support. I acknowledge the invaluable assistance provided by Mr. Pramath Ram in data entry, and Mrs. Sucharitha Suresh for statistical analysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Ethical conduct of research
The author of this manuscript declares that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to require Institutional Review Board/Ethics Committee review, and the corresponding protocol/approval number is FMMCIEC/CCM/728/2018.
| References|| |
Benbassat J, Baumal R, Heyman SN, Brezis M. Viewpoint: Suggestions for a shift in teaching clinical skills to medical students: The reflective clinical examination. Acad Med 2005;80:1121-6.
Narayanan V, Nair BR. The value of bedside teaching in undergraduate medical education: A literature review. MedEdPublish 2020;9:1-10.
Alhaqvi AI, Taha WS. Promoting excellence in teaching and learning in clinical education. J Taibah Univ Med Sci 2015;10:97-101.
Goodwin J. The importance of clinical skills. BMJ 1995;310:1281-2.
Murray E, Jolly B, Modell M. Can students learn clinical method in general practice? A randomised crossover trial based on objective structured clinical examinations. BMJ 1997;315:920-3.
Régo P, Peterson R, Callaway L, Ward M, O'Brien C, Donald K. Using a structured clinical coaching program to improve clinical skills training and assessment, as well as teachers' and students' satisfaction. Med Teach 2009;31:e586-95.
Glynn M. & Drake WM. Hutchison's clinical methods: An integrated approach to clinical practice–24th
ed. Edinburgh: Elsevier Publishers;2018.
Bickley L, Szilagyi P, Bates B. Bates' Guide to Physical Examination and History Taking. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2013.
Mehta G, & Iqbal B. (2010). The new MRCP PACES station 5. BMJ, c4273. doi: 10.1136/bmj.c4273.
Ericsson KA. Deliberate practice and acquisition of expert performance: A general overview. Acad Emerg Med 2008;15:988-94.
Alam U, Asghar O, Khan SQ, Hayat S, Malik RA. Cardiac auscultation: An essential clinical skill in decline. Br J Cardiol 2010;17:8-10.
Crumlish CM, Yialamas MA, McMahon GT. Quantification of bedside teaching by an academic hospitalist group. J Hosp Med 2009;4:304-7.
Qureshi Z. Back to the bedside: The role of bedside teaching in the modern era. Perspect Med Educ 2014;3:69-72.
Peters M, Ten Cate O. Bedside teaching in medical education: A literature review. Perspect Med Educ 2014;3:76-88.
Marel GM, Lyon PM, Field MJ, Barnsley L, Hibbert E, Parise A. Clinical skills in early postgraduate medical trainees: Patterns of acquisition of confidence and experience amongst junior doctors in a university teaching hospital. Med Educ 2000;34:1013-5.
Hales BM, Pronovost PJ. The checklist – A tool for error management and performance improvement. J Crit Care 2006;21:231-5.
Vargovich AM, Sperry JA, Spero RA, J Xiang J, Williams D. Use of checklists teaches communication skills utilized by specialties. MedEdPublish 2016;5:36.
Singh B, Saradananda S. Ethics and surgical training in ancient India – A cue for current practice. S Afr Med J 2008;98:218-21.
Rassie K. The apprenticeship model of clinical medical education: Time for structural change. N Z Med J 2017;130:66-72.
Jayakrishnan T, Honhar M, Jolly GP, Abraham J, T Jayakrishnan. Medical education in India: Time to make some changes. Natl Med J India 2012;25:164-7.
Matheson C, Matheson D. How well prepared are medical students for their first year as doctors? The views of consultants and specialist registrars in two teaching hospitals. Postgrad Med J 2009;85:582-9.
Ramani S, Orlander JD, Strunin L, Barber TW. Whither bedside teaching? A focus-group study of clinical teachers. Acad Med 2003;78:384-90.
Duffy FD, Gordon GH, Whelan G, Cole-Kelly K, Frankel R, Buffone N, et al
. Assessing competence in communication and interpersonal skills: The Kalamazoo II report. Acad Med 2004;79:495-507.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]