Clinical skills day : preparing third year medical students for their rural rotation

Introduction: In order to prepare third year medical students in the Rural Physician Associate Program for a nine-month community-based continuity care experience in rural Minnesota, USA, a clinical skills day that featured human patient simulators and standardized patients was developed. Patients presenting with common urgent and routine primary-care problems were developed and presented using the objective structured clinical examination for teaching. The goals of the day were to: (1) distinguish urgent from non-urgent clinical presentation; (2) use clinical guidelines for making decisions; (3) communicate effectively in stressful situations; and (4) uncover a significant clinical issue with a different presenting complaint. Methods: Case scenarios were written for a variety of diagnoses in patients with differing ages. Scenarios were both urgent and non-urgent and typical of what might be encountered in primary care. They included: chest pain with bradycardia and pulseless electrical activity; major trauma from an all-terrain vehicle; labor and delivery; acute abdomen (acute appendicitis in a 20 year old and diverticulitis in a 70 year old); anaphylaxis after an influenza vaccination; pediatric upper respiratory infection in which the


Orientation
Prior to the day, faculty received an on-line presentation orienting them to the IERC, and the teaching model and the scenario assigned to them. Evidence-based guidelines were provided for context and to share with the students as resources to utilize during their RPAP experiences. A brief face-to-face orientation session was held before the students arrived.
Students reviewed an on-line audio-visual presentation orienting them to the IERC and outlining the learning expectations for the day. Otherwise, students were not expected to prepare for the day because this was an immersion learning experience.

Evaluation
Evaluations were completed at the end of the day by both students and faculty. The final evaluation completed by students at the end of the 9 month RPAP experience also enquired about the value of the clinical skills day. Analyses of these data included simple descriptive statistics (quantitative) and written comments organized into representative themes (qualitative). The University of Minnesota Institutional Review Board granted exemption from formal review.

Case scenarios
Cases scenarios were written for a variety of diagnoses in patients of differing ages. Less complex primary care problems were given 20 min. Complex problems including acute abdomen, labor and delivery management, and two Students were randomly assigned to small groups of three to four students that rotated through the stations as a unit.
Groups were combined for the longer cases. The students were encouraged to take turns leading the interview among Knee injury A middle-aged man presented with knee pain after a weekend of playing football. The objectives of this station included the ability to gather information about the nature of the injury and to make a decision about whether or not to order an X-ray with the assistance of the Ottawa guidelines, and to inform the patient on basic assessment and plan 8 . was discussed as tool for assessing depression 10 . The standardized patient played a critical role in providing feedback to the students about which interviewing skills were productive in eliciting her information.

Heartburn and depression
Radiology This station was the only one without role-play by a standardized patient. Instead, a series of different X-rays were presented based on brief case scenarios with the following objectives: to review an X-ray in an organized approach and to find basic abnormalities on X-ray assisted by clinical details.  Table 1 shows the overall mean for each station. Table 2 presents the day's evaluation immediately after the event.
Students rated the stations and overall day positively, with means well above four on the 5 point scale. Table 3  On the evaluation 9 months later, the majority (71%) thought the orientation was very helpful (15%) or helpful (56%). A quarter rated the experience as adequate (24%) and 5% did not think the experience was helpful. Table 4 summarizes the written comments 9 months later about how to improve the day and how the learning was applied. A few could not remember the specifics of the day, but had retained a positive impression of it. Table 5

Discussion
Student feedback about the limited usefulness of resuscitation skills training as orientation to a rural longitudinal clerkship encouraged faculty to develop an active, learner-centered experience with broader and more appropriate objectives. Using the OSCE format for teaching as opposed to testing has been done by others and, as our evaluations suggest, it was well received by the students 15 .
Students learned eagerly in a non-competitive and supportive environment. The increased content and the intensity of the urgent care stations may have led to the complaints about the length of the day. In the future, RPAP faculty will continue to use student and faculty feedback to make improvements for the following year. While evaluations immediately after the event are essential, enhanced longitudinal assessment following the students' RPAP community experiences will impact the design and support of the teaching experience.
The RPAP students are immersed in their settings, working with 'experts', physicians who have been in practice for several years 16 . They can use intuition where empirical knowledge does not yet exist. 'Learning for mastery' or outcome-focused and competency-based teaching objectives that encourage students to acquire skills at the level of a practicing physician, enables students to put all their skills together 17 . Introducing them to this early in a realistic, facilitated experience is the value of the OSCE format 5 .

Conclusions
The clinical skills day experience immersed students into situations that they would be facing in their settings. This provided them with opportunities to begin to understand the complex skills that they would need before they learned them step by step. Building a bridge between skillslaboratory learning and real-life communities of practice using faculty-assisted simulated clinical learning is valuable 18 . Evaluations were positive both immediately after the experience and 9 months later. As we ponder how to improve medical education 19 , the evaluations for this clinical skills day support the value of learning that is realistic, active and faculty facilitated.      • Used guidelines all the time.
• Once my preceptor knew that I knew how to find guidelines, she started asking me to find the answers to many evidence based medicine questions.

Objective 3 Communication under stress
• It helped me practice…I had many patients with depression, loss of one's spouse, sexual orientation and this let me work out some of the bugs and be more aware of what they might be needing. • I dealt with upset and crying patients, dying patients and developed more comfort with time. Objective 4 Uncover a hidden issue • I found myself asking patients if there was anything else the wanted to discuss…many had other issues that they might not have brought up.

Suggestions for improvement
• More time • More cases • Sessions should help us be more succinct with our presentation skills.
Doctors don't have time to listen to an entire H&P. • Small group work does not encourage the participation of all students. ER, Emergency room; H&P, history and physical.