Patient records

Teaching medical students the art of the ‘write-up’ Debra Bynum1, Cristin Colford1 and Kenneth Royal2 1

Department of Internal Medicine, University of North Carolina, North Carolina, USA Department of Family Medicine, University of North Carolina, North Carolina, USA

2

The ability to document a clinical encounter is a key communication skill ... for entering residency

SUMMARY Background: The creation of a complete ‘write–up’ continues to be essential to the clinical learning experience for medical students. The ability to document a clinical encounter is a key communication skill and Core Entrustable Professional Activity for entering residency. Methods: We developed a guide to the comprehensive write–up, a grading rubric, and a videotaped encounter with a standardised doctor and patient. Second-year medical students created a write–up based upon this encounter, which was then

peer-reviewed in a small group writer’s workshop session. The students were later required to submit a write–up, based upon a real patient encounter, to the course directors for a grade. All write–ups (n = 185) were graded by the course director. Fifty-one were independently graded by a second course director. These grades were compared with the 175 student write-ups from the previous year. Results: The average grade for student write-ups was 86 with a standard deviation of 9, compared with an average of 75 with a standard deviation of 17 for the

year prior to the introduction of this session (p < 0.001). The average score given by a second rater was 83 with a standard deviation of 11, indicating a high level of agreement and internal consistency. Discussion: These tools were easy to use and well received by faculty members and students, and the quality of student write-ups significantly improved after the introduction of the session. The grading rubric demonstrated high inter-rater reliability, indicating that this can be adapted and used by others for instruction and assessment.

246 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 246–249

tct_12304.indd 246

6/29/2015 10:26:47 AM

All students were required to view the video and to create a write-up based upon the case scenario

INTRODUCTION

I

n this age of electronic health records with template-based notes and billing-focused documentation, one might question the utility of teaching medical students the skills needed to create a formal ‘write-up’. Documenting the full history and physical examination in the format of a write-up is a core component of clinical rotations for multiple reasons. The majority of students and faculty members feel that despite the time and effort required, this exercise is essential to the clinical learning experience.1 More frequent feedback on write-ups is directly correlated with a student’s perception of the quality of teaching in the clinical setting.2 The writing process helps the student organise thoughts and develop a differential diagnosis and a plan. The final product can be a useful tool in the assessment of a student’s ability to not only gather but also to interpret and synthesise data.3 Finally, the ability to communicate and document a clinical encounter is not only a key skill that all medical students must have,4 but is also a Core Entrustable Professional Activity for entering residency according to a recent position statement made by the Association of American Medical Colleges (AAMC).5 Despite the importance of this activity, many students struggle to create a write-up that is comprehensive and clear. The complexity of the real-life patient encounter is often confusing, and interferes with the student’s ability to understand the basic components of a thoughtful, thorough and organised note. Given this observation and evidence that student notes can be improved with frequent and high-quality feedback,6,7 we sought to develop a set of educational tools that would aid in the teaching and assessment of this important skill.

METHODS Second-year medical students in the Clinical Skills Integration (CSI) course at the University of North Carolina are expected to be able to create high-quality write-ups before they begin the clinical clerkships of the third year. Using Bates’ Guide to the Physical Examination and History Taking,8 and an assessment form that had been validated for use with third-year medical students,9 we developed a guide to the comprehensive write–up and a grading rubric. Similar to the scoring rubric for student notes in the United States Medical Licensing Examination (USMLE) step–2 clinical skills examination, more credit was assigned to the differential diagnosis and to the clinical reasoning than to other components of the write–up.10 For the 2012–2013 academic year, students were required to submit several write-ups to their small group faculty member for formative feedback. Faculty members and students used the guide for a reference both to create the write-up and for feedback. At the end of the year, all students (n = 175) submitted a write-up of their choosing to be graded by one of the course directors. Given the variable student performances with this

assignment, we determined that there was a need for more structured instruction, leading to the development of the writer’s workshop. We created a videotaped encounter with a standardised doctor and a standardised patient. The videotaped encounter is less than 15 minutes in length, includes enough information to create a complete note and focuses on a single chief complaint that is straightforward yet conducive to the development of a differential diagnosis. A sample write-up for this encounter, using the guide and grading rubric, was written by the course directors with feedback from the small group faculty members involved with this class. For the 2013–2014 academic year, the CSI course for secondyear medical students was essentially unchanged, with the exception of adding this writer’s workshop session to the fall semester. For the writer’s workshop, all students were required to view the video and to create a write-up based upon the case scenario. They brought these write-ups to a small group session in which they worked together with approximately six other students and their faculty leader to edit and perfect their notes. At the end of the session, students and faculty members were able to compare their notes with the comprehensive sample write–up.

© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 246–249 247

tct_12304.indd 247

6/29/2015 10:26:48 AM

The quality of the student write- ups was improved.

As was the case previously, students were expected to submit several subsequent write-ups throughout the year to their small group faculty member for formative feedback. In April of 2014, all 185 students submitted a write-up to be graded, based upon a real patient encounter and with the same instructions given to the students in the previous year. All write-ups were graded by the same course director, who had also graded all of the write-ups from the previous year. The same grading rubric was applied to both student cohorts. Permission to conduct this study was sought from the University of North Carolina Institutional Review Board, who declared the study exempt from review. Data were analysed using SPSS 21.

RESULTS For the 2012–2013 academic year, the average score of student write-ups was 75, with a standard deviation of 17. The following academic year, after the introduction of the writer’s workshop session, the average grade for student write-ups was 86, with a standard deviation of 9. Results using the Mann–Whitney U–test indicated that the scores over the 2 years statistically differed (p < 0.05) at the 95 per cent confidence level. In addition, a Cohen’s effect size of d = 0.751 indicated a significant practical difference between the two sets of scores. In order to assess the reliability of the grading rubric, the second course director independently graded 51 writeups. The average score on those was 83, with a standard deviation of 11. The Cronbach’s alpha reliability estimate for the sets of scores was 0.901, indicating a high level of internal consistency. Intra-class correlation estimates were computed to determine the extent to which the two course directors provided consistent

ratings. The intra-class correlation for consistency was 0.82, and the correlation for absolute agreement was 0.79, indicating a high level of agreement between the two raters.

CONCLUSION The ability to create a write-up of a history and physical examination has long been considered one of the most important writing skills for a medical student.11 The introduction of a session focused on how to construct an organised and complete write–up was successfully implemented, and the quality of the student write-ups was improved. In addition, there was less variability in quality, as noted by a decrease in the standard deviation between student scores. There are a number of factors that could explain the improvement in student performance. First, the students were able to focus on a common symptom using a standardised encounter when first learning how to do the write–up. This reduced the variables that occur when interviewing and examining real-life, hospitalised patients, and allowed students to focus on the components and organisation of a comprehensive write–up. In addition, there was faculty member development involved in the preparation for the writer’s workshop session. Each of the small group facilitators practised grading sample write-ups with the rubric, and then used the same rubric when assessing and giving feedback on write-ups that the students completed during the academic year. There is validated concern that the grading of write-ups can be subjective unless a standardised and systematic tool is used.12,13 In this study, there was strong evidence of inter-rater reliability, suggesting that the

rubric functioned as a reliable tool and could be used for not only feedback but also for assessment. There are limitations to the development and use of this rubric and session. Some faculty members debated how the different components of the write-up should be weighted. There was significant reliability between the two course directors in their use of the grading rubric, but it is not yet known if this high degree of reliability would persist with the use of the rubric by other faculty members who are less involved in medical student education. In addition, the fact that the course directors who were grading the write-ups were involved in this study is a potential source of bias. To address some of these concerns, we plan on repeating the session and grading assignment with the next cohort of second-year students. An independent faculty member not involved with the course will grade a subset of these students, and therefore the reliability of the system will be assessed. Despite these limitations, this session was well received overall by faculty members and students, resulted in a documented improvement in student performance, and could easily be adapted for use in other courses and at other institutions. REFERENCES 1. McLeod PJ. Assessing the value of student case write-ups and write-up evaluations. Acad Med 1989;64:273–274. 2. Torre DM, Simpson D, Sebastian JL, Elnicki DM. Learning/feedback activities and high-quality teaching: perceptions of thirdyear medical students during an inpatient rotation. Acad Med 2005;80:950–954. 3. Woolliscroft JO, Calhoun JG, Beauchamp C, Wolf FM, Maxim BR. Evaluating the medical history: observation versus write-up review. J Med Educ 1984;59:19–23.

248 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 246–249

tct_12304.indd 248

6/29/2015 10:26:49 AM

4. Association of American Medical Colleges (AAMC). Learning Objectives for Medical Student Education: Guidelines for Medical Schools. Washington, D.C.: AAMC;1998. 5. Association of American Medical Colleges (AAMC). CEPAER Drafting Panel Report: Core Entrustable Professional Activities for Entering Residency. MedEdPortal: AAMC; 2014. Available at https://www.mededportal.org/icollaborative/resource/887. Accessed on 20 May 2014. 6. Spickard A, 3rd, Gigante J, Stein G, Denny JC. Automatic capture of student notes to augment mentor feedback and student performance on patient write-ups. JGIM 2008;23:979–984.

7. McCarty T, Parkes MV, Anderson TT, Mines J, Skipper BJ, Grebosky J. Improved patient notes from medical students during web-based teaching using faculty-calibrated peer review and self-assessment. Acad Med 2005;80:S67–S70. 8. Bickley LS, ed. Bates’ Guide to the Physical Examination and History Taking, 11th edn. Philadelphia, PA: Lippincott Williams and Wilkins; 2012. 9. Kogan JR, Shea JA. Psychometric characteristics of a write-up assessment form in a medicine core clerkship. Teach Learn Med 2005;17:101–106. 10. Park YS, Lineberry M, Hyderi A, Bordage G, Riddle J, Yudkowsky R.

Validity evidence for a patient note scoring rubric based on the new patient note format of the United States Medical Licensing Examination. Acad Med 2013;88:1552–1557. 11. Yanoff KL, Burg FD. Types of medical writing and teaching of writing in U.S. medical schools. J Med Educ 1988;63:30–37.

This session was well received ...and resulted in a documented improvement in student performance.

12. Middleman AB, Sunder PK, Yen AG. Reliability of the history and physical assessment (HAPA) form. Clin Teach 2011;8:192–195. 13. Baker E, Riddle J. IDEA in evolution: An attempt to use RIME to more accurately assess medical student write-ups. JGIM 2005; 20(suppl 1):157.

Corresponding author’s contact details: Debra Bynum, Department of Internal Medicine, University of North Carolina, 126 MacNider Building, 101 Manning Drive, Chapel Hill, NC 27514, USA. E-mail: [email protected]

Funding: None. Conflict of interest: None. Acknowledgements: None. Ethical approval: This work was submitted to the Institutional Review Board at the University of North Carolina, School of Medicine, and was declared exempt from further review. doi: 10.1111/tct.12304

© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 246–249 249

tct_12304.indd 249

6/29/2015 10:26:49 AM

Teaching medical students the art of the 'write-up'.

The creation of a complete 'write-up' continues to be essential to the clinical learning experience for medical students. The ability to document a cl...
246KB Sizes 0 Downloads 11 Views