Seeing is Believing: Using Direct Observation to Teach Clinical Skills

4-5 Minute Read

Author: Julpohng “JP” Vilai, MD, FAAP

Purpose

To encourage clinician educators to incorporate direct observation of learners, even in a busy clinic.

Learning Objective

1. Discuss the significance and benefits of direct observation in medical education.

2. Describe an example of a direct observation tool.

3. Recall two tips and strategies for incorporating direct observation in clinical teaching.

The value of direct observation paired with actionable feedback in undergraduate medical education cannot be understated; direct observation may be the best way to assess competency in clinical skills and professional attitudes.(1,2) In the Preceptor article, Direct Observation, Perfection, and Imposter Syndrome, the author gives the analogy of sending someone to practice piano in a quiet room, then returning to tell the instructor how it went.(3) This analogy highlights the importance of observation and feedback and the problems with not including direct observation as a clinical teaching tool: what does the learner truly gain from an experience where they are never observed taking a history or doing a physical exam, except, perhaps during an Observed Structured Clinical Examination (OSCE)?

Observation for Assessment

To be clear, it is not that learners are never observed. In fact, direct observation has been broadly utilized in graduate medical education, although residents have mixed feelings about its usefulness.(4,5) The Liaison Committee on Medical Education (LCME) requires that clerkships provide direct observation of clinical skills,(6) and, in the 2021 Association of American Medical Colleges (AAMC) Medical School Graduation Questionnaire (GQ), the vast majority of medical students reported being observed performing a patient history or physical exam.(7) However, the quality and utility of medical student direct observation experiences has been shown to be inconsistent: Alex et al found that medical students may not be assessed for clinical skills as often as suggested by GQ data and that the value varies widely.(8)

While the LCME mandates that all medical schools use OSCEs to evaluate clinical competency of graduates, knowing that you are being tested for a grade—often a significant portion of it—can undermine psychological safety, encourage stylized performances rather than authentic interactions, and create suboptimal conditions for helpful feedback.(5) Additionally, the United States Medical Licensing Examination Step 2 clinical skills examination, once required for medical licensure to help ensure students met a minimum clinical skill standard, has been discontinued. As a result, there appears to be an opportunity for direct observation as a frequent, low-stakes method to provide helpful feedback and develop learners’ clinical skills and attitudes.

Clinical Teaching Methods

When we consider some precepting strategies in medical education such as shadowing, traditional precepting, and the triangle method, it becomes apparent that the focus tends to be more on the preceptor’s efficiency and the patient’s experience rather than ensuring the learner’s competency.

Many direct observation tools exist, and most have similar elements. I would like to highlight the Structured Clinical Observation (SCO); an example is given here.(9) Students and faculty rated the SCO highly as a way to provide practical, immediate, and actionable feedback that was not overly time- or cost-prohibitive. One might have expected that learners could feel a sense of lost autonomy or lack of trust by not seeing patients independently, but they actually appreciated being able to demonstrate what they were capable of, receiving specific, actionable feedback, and feeling validated that they were doing things correctly and that preceptors were actively invested in their education.(8,10)

Incorporating Structured Clinical Observation into Clinical Teaching

I must acknowledge that I sometimes dread the thought of being stuck in a room with a learner who takes a lot longer to do something that I could accomplish rather quickly, especially when I have a packed schedule.

Practice Tips

• Appreciate the importance of observation and make it valuable for the learner.

• Make the observations brief and focused on portions of the encounter instead of its entirety; high-quality DO including feedback can be accomplished in about 5 minutes.

• Repeat the observation frequently with the same learner and concentrate on common themes.

Additionally, I sometimes struggle to give feedback that is better than “great job.” I can convince myself that a learner has a strong fund of knowledge based on their performance on formative and summative assessments (e.g., using the One-Minute Preceptor method and multiple-choice tests, respectively) while ignoring the importance of clinical skills.

Practice Tips

Use an existing, validated direct observation tool that fits your setting and goals; no need to reinvent the wheel.

Center on 2-3 major points of feedback and ensure the learner receives it immediately after the observation.

Seek resources, continuing medical education, and faculty or resident development and training in direct observation.■

References

1. Fromme HB, Karani R, Downing SM. Direct observation in medical education: A review of the literature and evidence for validity. Mt Sinai J Med. 2009;76(4):365-71. 

2. Holmboe ES, Sherbino J, Long DM et al. The role of assessment in competency-based medical education. Med Teach. 2010;32(8):676-82. 

3. Morgenstern B. Direct Observation, Perfection, and Imposter Syndrome. Preceptor: Ideas & Inspiration for Clinical Educators. Published: April 17, 2024. https://preceptor.substack.com/p/the-triangle-method-for-clinical. Accessed June 5, 2024. 

4. Holmboe ES, Hawkins RE, Huot SJ. Effect of training in direct observation of medical residents’ clinical competence: A randomized trial. Ann Intern Med. 2004;140(11):874-81. 

5. LaDonna KA, Hatala R, Lingard L et al. Staging a performance: Learners’ perceptions about direct observation during residency. Med Educ. 2017;51(5):498-510. 

6. Liaison Committee on Medical Education. Liaison Committee on Medical Education. Standard 9.4: Assessment System. Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. Published October 2021. http://lcme.org/directory. Accessed June 5, 2024. 

7. Association of American Medical Colleges. Medical School Graduation Questionnaire. 2021 All Schools Summary Report. https://www.aamc.org/media/55736/download. Accessed June 5, 2024. 

8. Alex CP, Fromme HB, Greenberg L et al. Exploring medical student experiences with direct observation during the pediatric clerkship. Acad Med. 2024 May 1. Epub ahead of print. PMID: 38696720. 

9. Lane JL, Gottlieb RP. Structured clinical observations: a method to teach clinical skills with limited time and financial resources. Pediatrics. 2000;105(4 Pt 2):973-7. 

10. Kuo AK, Irby DI, Loeser H. Does direct observation improve medical students’ clerkship experiences? Med Educ. 2005;39(5):518.