Guidelines: The do’s, don’ts and don’t knows of direct observation of clinical skills in medical education

Abstract

IntroductionDirect observation of clinical skills is a key assessment strategy in competency-based medical education. The guidelines presented in this paper synthesize the literature on direct observation of clinical skills. The goal is to provide a practical list of Do’s, Don’ts and Don’t Knows about direct observation for supervisors who teach learners in the clinical setting and for educational leaders who are responsible for clinical training programs.MethodsWe built consensus through an iterative approach in which each author, based on their medical education and research knowledge and expertise, independently developed a list of Do’s, Don’ts, and Don’t Knows about direct observation of clinical skills. Lists were compiled, discussed and revised. We then sought and compiled evidence to support each guideline and determine the strength of each guideline.ResultsA final set of 33 Do’s, Don’ts and Don’t Knows is presented along with a summary of evidence for each guideline. Guidelines focus on two groups: individual supervisors and the educational leaders responsible for clinical training programs. Guidelines address recommendations for how to focus direct observation, select an assessment tool, promote high quality assessments, conduct rater training, and create a learning culture conducive to direct observation.ConclusionsHigh frequency, high quality direct observation of clinical skills can be challenging. These guidelines offer important evidence-based Do’s and Don’ts that can help improve the frequency and quality of direct observation. Improving direct observation requires focus not just on individual supervisors and their learners, but also on the organizations and cultures in which they work and train. Additional research to address the Don’t Knows can help educators realize the full potential of direct observation in competency-based education.

Things We Do for No Reason™: Card Flipping Rounds

“…The direct observation of trainees with patients allows highlevel impactful clinical feedback and provides a basis for calibrating how much autonomy to allow. 16 Trainees also indicate that teaching is more impactful during BSR than during walk rounding or card flipping, and clinical skill training during BSR is superior to a discussion in a conference room or a hallway context. 2,3,15,17,18 One study has even suggested that the education of bedside rounds may help improve clinical skills in comparison with traditional models.…”

“…9 This initiative starts by preparing ahead of time, which allows the mental energy during encounters to be directly observed by learners in action. 16 Preparation also allows the presentation to focus more on clinical reasoning rather than data gathering. 20 Faculty members should also consider ways to foster resident autonomy and establish the role of a supervising resident as the team leader.…”

Good educators and orphans: the case of direct observation and feedback

“…Yet, as Kogan et al. also state, direct observation in medical education is often infrequent and of poor quality . We first discuss how recent research on optimising direct observation and feedback aligns with what we know about being a good clinical educator.…”

“…We elaborate on this by zooming in on direct observation and feedback as central constituents of supervision. Direct observation is crucial for the purposes of feedback and assessment, as Kogan and colleagues describe in their guidelines on direct observation . Yet, as Kogan et al.…”

“…Residents struggle with unclear stakes, fears of assessment, credibility judgements regarding the observer, and issues around authenticity, autonomy and efficiency . In this literature, longitudinal training relationships are mentioned as providing a way forward . Moreover, new perspectives on feedback suggest the importance of a longitudinal educational alliance between the resident and supervisor in which the resident likes and values the supervisor, and both agree on learning goals and the ways these can be achieved .…”