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19.02.2013

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Background: For more than 20 years, medical literature has increasingly documented the need for students to learn, practice and demonstrate competence in basic clinical knowledge and skills. Methods: Since 2002, an annual longitudinal evaluation questionnaire was distributed to all medical students targeting the skills taught in the CSL. Teaching and assuring medical students’ competence in fundamental clinical skills have been persistent challenges in curriculum development for decades. For more than 20 years the medical literature has increasingly documented the need for standardized curriculum components in which students can learn, practice, and demonstrate competence in basic clinical knowledge and skills. Prior to each CSL session, students must complete two self-directed learning and assessment activities to ensure readiness and effective use of time in the focused, structured, fast-paced, problem-solving, interactive activities. Once stations are completed, the instructor conducts a large group debriefing discussion to reinforce core content and skills, facilitate learning through questioning, promote student input, and utilize reflective critique. Following review and approval by the LSUHSC-New Orleans Institutional Review Board, a paper-based form of the CSLQ was administered to all LSUHSC-NO medical students (Years 1–4) in May 2002, immediately following completion of the first year-long implementation of the CSL sessions. A longitudinal study of students’ evolving self-efficacy and engagement in performing clinical skills and procedures prior to and following the CSL was originally planned.
The first dataset (pre-Hurricane Katrina) included responses of second-year students collected in May 2002, reflecting the last medical student class that did not experience the CSL curriculum (pre-CLSQ), and responses of second-year students collected via the CLSQ in May 2003 and 2004, representing the first two classes who completed both years of the CSL curriculum.
For the second dataset (post-Hurricane Katrina), entering first-year medical students completed the CSL in August 2005, just prior to starting classes. Like so many medical schools, the LSU-New Orleans faculty responded to public calls for curriculum reform and revised its undergraduate medical education, particularly with the introduction of SPM in Years 1 and 2 and the construction of a state-of-the-art school-wide learning center in 2001. Encouraging were the results for those clinical skills where increased self-confidence immediately following completion of the CSL was further increased by the end of the third-year clerkships, offering evidence of the desired scaffolding effect for learning in medical school. In 2001, the Louisiana State University Health Science Centers (LSUHSC) School of Medicine – New Orleans replaced its traditional Introduction in to Clinical Medicine (ICM) course with the Science and Practice of Medicine (SPM) course.
The clinical forums component has small group sessions with faculty, senior students, and peers regarding doctor-patient interactions and communication, case-based presentations and discussions, and application of medical ethics and professionalism principles. MD Student Learning Center, a centralized educational resource situated organizationally within the Offices of the Dean, School of Medicine.
For example, in Year 1 students conduct ECGs and apply content of electrophysiology to human patient simulation scenarios in the CSL session targeting cardiac rhythms at the same time as they are learning cardiac rhythms in their physiology course (Year 1 – Human Physiology).
Upon entering a CSL session, each student is assigned immediately to a small group of two or three members. For example, in a lumbar puncture station, students use an anatomical model, an actual patient kit, and a standardized performance checklist for self-instruction and peer evaluation.


Direct observations and informal feedback from students enrolled in the CSL have consistently revealed positive reactions.
At the time of this administration, only first-year students had used the CSL and students in Years 2–4 provided baseline data on those who had not experienced the new CSL curriculum. However, the impact of Hurricane Katrina altered the study context significantly before and after 2005, particularly in terms of the population and patient census in New Orleans, and correspondingly the overall clinical environment and opportunities for students to engage in direct patient care (substantially reduced patient access and volume).
Second, data collected after 2005 and through 2009, representing a cohort of medical students across their four years of medical school, were analyzed to examine differences in medical students’ self-reported practice of clinical skills and procedures in the second year prior to and after the CSL training sessions. The chi-square test was used to compare self-efficacy ratings and number of procedures performed (practice) for students without (2002 data) and with the CSL.
Examining the self-efficacy scores for the completed cohort across their four years of medical school, Figure 1 shows that students’ self-efficacy scores increased after completing CSL training. While a higher and more consistent response rate across all four years would have facilitated a more conclusive interpretation, one possible explanation is that students’ reported self-efficacy and preparedness achieved through the CSL did facilitate their pursuit of and active engagement in opportunities to perform the identified clinical skills and procedures, thus further increasing their self-efficacy and abilities to perform. The changing landscapes of healthcare, program accreditation, and medical education have become increasingly more complex and less conducive to such heavy reliance on apprentice-type teaching and learning. Direct observations of students during CSL sessions and unsolicited comments from clinical faculty members who work with students have provided some evidence, albeit anecdotal, suggesting that students are learning targeted knowledge and skills. Consequently, the opportunities for students to practice the targeted clinical skills and procedures were substantially different before and after Hurricane Katrina. Spearman's correlation coefficient was computed to measure the correlation between students’ self-efficacy and number of procedures performed.
For some procedures, the self-confidence gained as a result of the CSL simulation experiences decreased slightly by the end of their third-year clerkships (CPR, IV, lumbar puncture, and intubation).
An equally important goal was to engage students from the beginning of medical school in the practices of mastery learning and a focus on developing competency in knowledge, technical and non-technical skills, and professionalism.
The decrease in confidence after full-time learning in clinical clerkships shown in Figure 1 was not surprising, and may reflect either inflated self-confidence that was calibrated as a result of real-life experiences, realizing limited real-life opportunities to perform skills and procedures (particularly in the altered post-Katrina environment), or both.
Although we report effectiveness evidence for implementation at only one school, the overwhelming interest and feedback from colleagues who have examined and used our model and experiences to pursue developments at their own schools provide additional support for the feasibility and potential contribution to enhance students’ clinical competence. Today's patients and providers are sometimes less tolerant of students’ inexperience and novice abilities. Weekly large group discussions are co-facilitated by clinical and basic science faculty members to debrief, provide feedback on responses, and help students integrate important basic sciences into clinical practice for the assigned DxR case. For the remainder of the session, students rotate with their assigned small groups to each of five or six stations every five to 15 minutes and practice the targeted skills and behaviors.


When a student completes the assigned exercise, they switch roles and repeat the process until each one has completed the learning cycle for the station. For all CSL stations, students are expected to demonstrate professionalism, good hand hygiene, universal precautions, and maintaining a sterile field when indicated. Results of the annual student evaluations of the course have been consistently very positive. In addition, the CSL and students’ clinical learning were temporarily displaced to other locations. However, as shown in Figure 1, confidence levels were sustained (mask ventilation) or increased (GUC, pelvic exam, and skin suturing) by the end of the third-year clerkships. The premise was that standardized early exposure would strengthen students’ pre-clinical preparation and self-confidence, which in turn would facilitate their future efforts to pursue and succeed in performing such core clinical skills and procedures correctly and safely. With increased outpatient care, shorter hospital stays, and less time for teaching in clinical settings, students’ access to sufficient and appropriate patient situations has decreased and their opportunities for learning and practice can vary considerably. For the CSL, students complete a series of hands-on, situation-based learning and assessment sessions targeting 36 core clinical skills and procedures, starting the first week of medical school and continuing until the end of Year 2. Thus each student learns, performs, observes, assesses, and provides feedback using the standardized performance checklist as a guide. First-year students complete a total of 12 hours in face-to-face sessions, while second-year students complete 10 hours. From the onset, a key premise of the CSL curriculum was that active learning and deliberate practice in these sessions would increase students’ confidence in engaging in core clinical skills and procedures, and in turn result in increased student participation and practice in subsequent opportunities (actual and simulated) as they progress through medical school.
More interestingly, Table 3 shows that the number of procedures performed by the end of the second year was significantly greater for the students who completed CSL training than for those who did not have the CSL in the curriculum.
Finally, as shown in Table 4, the correlation between students’ self-efficacy level and the number of procedures performed in the second year was positive and statistically significant. After completing a station, the students rotate together to the next station to perform new tasks, and continue in this fashion until all the stations have been completed.



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