clinical skills education

The AAMC Project on the ClinicalEducation of Medical Students

Clinical Skills EducationEugene C. Corbett, Jr., M.D., FACPRobert G Petersdorf Scholar-in-ResidenceAssociation of American Medical Colleges andBrodie Associate Professor of Medicine University of Virginia School of Medicine

Michael Whitcomb, M.D.Senior Vice President for Medical Education Association of American Medical Colleges

For more information about this publication contact:Michael E. Whitcomb, M.D.

Senior Vice President for Medical EducationAAMC

2450 N Street, NWWashington, DC 20037-1127

(202) 828-0505

Copyright 2004 by the Association of American Medical Colleges. All rights reserved.

Several years ago, the AAMC was presented witha great opportunity when Don Nutter, vice dean atNorthwestern University School of Medicine andAAMC secretary for the LCME, indicated that hewould like to spend a year as a PetersdorfScholar-in-Residence studying the state of the clin-ical education of medical students in this country.Don’s work during that year set in motion a seriesof activities that have resulted in both institution-specific and national efforts to improve medicalstudents’ clinical education. The study describedin this report is one example of the kinds of activi-ties that were stimulated by Don’s work.

Gene Corbett, the author of this report, spent the2002-03 academic year as a Petersdorf Scholar-in-Residence studying how clinical skills are beingtaught. His findings extend in important ways theobservations made during the course of Don’sproject. In so doing, they highlight the need formedical schools to do a better job in developingand implementing an organized approach forteaching fundamental clinical skills during themedical school experience.

Gene’s work has already had an impact. TheAAMC Task Force on Clinical Skills Teaching – atask force that includes representatives from all ofthe major organizations representing clerkshipdirectors – was formed by Gene during his time atthe AAMC. The task force is at work developing aconsensus statement on the teaching of clinicalskills. His work is also responsible in part for the

involvement of the AAMC in a collaborativeproject with The New York Academy of Medicine,which has been designed to enhance educationfor the clinical transaction. The project, which isfunded by the Josiah Macy, Jr. Foundation and theArthur Vining Davis Foundation, has awardedgrants to six medical schools to assist them withtheir efforts to develop and implement innovativeapproaches for the teaching of fundamental clin-ical skills.

Gene’s report is important not only for what ittells us about the current state of the teaching ofclinical skills in medical schools, but also for whatit tells us about the failure of medical schools tofocus sufficient attention on this issue over theyears. His message is particularly importantbecause of the perspective he brings to the issue.His views reflect not only the experience of afaculty member who has been teaching clinicalmedicine for many years, but also the experienceof a physician who practiced general medicine inthe community for eleven years after completinghis formal education. It is clear that both experi-ences shaped his judgment that medical schoolsneed to do a better job in teaching clinical skills. I have no doubt that Gene’s work, like Don’s, willhave an important affect on how clinical medicineis taught in the future.

Michael E.Whitcomb, M.D.Senior Vice President for Medical Education

The AAMC Project on the Clinical Education of Medical Students

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“On the pedagogic side, modern medicine, likeall scientific teaching, is characterized byactivity. The student no longer merely watches,listens, memorizes: he does. His own activitiesin the laboratory and in the clinic are the mainfactors in his instruction and discipline. Aneducation in medicine nowadays involves bothlearning and learning how; the student cannoteffectively know, unless he knows how.”

Abraham Flexner, 1910

Patients expect physicians to be knowledgeableand to use their knowledge skillfully to providemedical care in a professionally competentmanner. The mandate for medical education is toeducate and train physicians who can meet thoseexpectations. To that end, undergraduatemedical education programs are expected toprovide learning experiences that will allow eachaspiring physician to acquire the knowledge,skills, and attitudes deemed appropriate formedical school graduates. Ideally, those programswill ensure that students have the opportunity tobegin to develop that set of basic clinical skillsthey will need to care for patients throughouttheir professional careers.

I have been interested in the quality of the clinicalskills education provided by medical schoolssince the earliest years of my medical practice.Shortly after I entered general practice, I recog-nized that I needed to learn on my own many ofthe basic skills that were required to provide careefficiently and effectively to patients seeking myhelp. Although I felt reasonably book-smart, Ibecame aware that I did not have the skillsrequired to engage and build relationships withmany kinds of people, and that I had to learn andrelearn important aspects of the physical exami-

nation. I especially struggled with placing my clin-ical decisions in the context of my patients’personal lives, financial limitations, and familyrelated constraints.

After being in practice for a while, I realized thatthe clinical skills education I received in medicalschool had been unstructured and unspecified.Rather than stating explicitly the clinical skills Ineeded to acquire and providing opportunities forme to learn them, it was assumed that I wouldacquire them during the course of my clinical rota-tions. As a consequence, I, like most studentsboth then and now, set about trying to learn all ofthe facts I could learn about the diseases Iencountered, rather than focusing on acquiringthe elementary clinical skills necessary to interactwith and manage the care of patients. I clearly didnot approach developing clinical skills proficiencywith the same intensity and developmental rigor Idid in acquiring clinical knowledge. I wonderedwhy the clinical skills education I received in theformative years of my medical education hadn’tbeen conducted in a way that would have betterprepared me for the challenges of clinical prac-tice. It seemed to me that there must be a way ofteaching these basic skills that would be moreeffective from a developmental educationalperspective.

I became more concerned about clinical skillseducation when I returned to the academic envi-ronment after eleven years of community practice.I observed that the clinical skills education ofstudents had remained unstructured and unspeci-fied. I noted the dominating influence thatacquiring knowledge was having on the educationof students, and I could not help but note thatmedical students were becoming increasinglymarginalized in the clinical care environment. Theopportunities for students to participate at ameaningful skill-learning level in ongoing clinicalcare in both hospital and clinic settings seemed to

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be becoming more limited with each passing year.Coupled with the fact that much of the fourth yearhad become elective, it seemed to me that theopportunities students had to develop basic clin-ical skills proficiency were becoming quite limited.

I do not believe things have improved to anyconsiderable degree during the ensuing years.Indeed, a recent survey at my own institutionrevealed that fourth year students perceive majorgaps in their preparedness for residency trainingbecause of deficiencies in their clinical skillseducation. A similar observation is contained inthe recent AAMC report on the Clinical Educationof Medical Students and in a number of otherrecent publications about students’ clinical skillability. These observations are noteworthy, sincefive major reports focusing on the quality ofundergraduate medical education, which wereissued in the 1980s and the early 1990s – three bythe AAMC, one by the AMA, and one by the MacyFoundation – commented on the need to improvethe clinical skills education of medical students.

Fortunately, there are a number of changes occur-ring in response to growing concerns both in thiscountry and abroad about the quality of students’clinical skills education. Medical educators atsome institutions are developing alternativemethods to teach and assess clinical skills, toinclude the use of standardized patients, computersimulations, and body models. Schools in Europein particular are implementing explicit anddetailed clinical skills curricula. There is also agrowing effort on the part of both licensure andcertification bodies to incorporate measurementof clinical skills competency in their examinationsof students and residents.

When the opportunity presented itself for me tospend a sabbatical year studying clinical skillseducation at the Association of American MedicalColleges as a part of the AAMC Project on theClinical Education of Medical Students, Iembraced the idea enthusiastically. In thiscapacity, I set about to study and inspect in oneyear all that I might in order to document as best I

could the state of clinical skills education inmedical schools. I wanted to learn about the clin-ical skills curricula that were offered by medicalschools and use that information to help me betterdefine and organize the domain of skills to belearned in medical school. I also wanted toconceptualize what a four-year developmental clin-ical skills curriculum might look like and how bestto implement it. This experience provided me anopportunity to participate in a variety of medicaleducation activities both here and abroad, and tointeract with literally hundreds of thoughtful andcommitted educators who struggle with theseissues each day in their own institutions.

The project I pursued was exploratory and itera-tive in nature. There was no investigative hypoth-esis beyond my own concern that the clinicalskills education of students may be the weakestlink in our formative medical education process.The basic intent was to investigate what is knownabout the clinical skills education of students andto learn what is occurring in institutions in thiscountry and abroad to improve the education ofmedical students in the realm of clinical skillsdevelopment. What I learned has led me toconclude that there is much that needs to be doneto improve the teaching and learning of clinicalskills in the medical school curriculum. I havealso discovered that the traditional implicitness ofskills education in the undergraduate medicaleducation process makes it difficult to fully appre-ciate what is actually occurring in the day to dayclinical activities that medical students experi-ence. Nonetheless, it seems to me that Flexner’sadmonition to medical educators is as applicabletoday as it was a century ago. I hope this report,which focuses only on the state of clinical skillseducation, will increase the attention paid to thisfundamental educational responsibility.

The overall project I designed was intended toserve the goal of the AAMC Project on the ClinicalEducation of Medical Students by focusing on theclinical skills education of medical students. Thespecific objectives of the project were to:

to document the status of clinical skillseducation in U.S. medical schools

to identify model approaches for teachingclinical skills

to develop and set forth principles that mightguide the design of an ideal clinical skillscurriculum

to make recommendations for improvingclinical skills education in undergraduatemedical education

In addition, I anticipated that the project wouldaccomplish the following:

Disseminate information about the state ofclinical skills education

Promote a national dialogue about evaluatingand improving clinical skills education

Assist individual medical schools in theirefforts to improve the quality of the skillseducation of students

Promote a national dialogue on how toachieve a fully integrated and developmentalclinical skills curriculum across thecontinuum of undergraduate and graduatemedical education

In order to document the status of clinical skillseducation, I conducted the following activitiesbetween July 2002 and June 2003:

A comprehensive review of the literature onthe clinical skills education of medicalstudents

A review of existing databases pertaining toundergraduate medical education (CurrMIT,AAMC Graduation Questionnaire, LCMEsurveys of medical schools)

A review of historical reports pertaining tothe clinical skills education of students

An e-mail survey of the curricular deans of allU.S. and Canadian medical schools to gaininformation on clinical skills curricula andfacilities

Site visits to ten clinical skills centers (six inthe U.S. and four in Europe)

Attendance at medical education meetings(seven in the U.S. and three in Europe) toparticipate in discussions with medical educa-tors and students about clinical skills education

The establishment of a collaborative effortwith national clerkship organizations for thepurpose of developing consensus regardingclinical skills education in U.S. medicalschools

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Based on the results of the project activities listedabove, it is possible to draw some general conclu-sions about the state of clinical skills education, toinclude the assessment of students’ performance, inU.S. medical schools. The observations made duringthe course of the project are presented in threesections: the state of the clinical skills curriculum,the assessment of clinical skills, and the develop-ment of clinical skills centers.

Clinical Skills CurriculumIt is clear that there is no curricular standard andmuch variability within the medical educationcommunity regarding the clinical skills education ofmedical students (see Fact Sheet, p. 5). Very fewschools appear to approach clinical skills educationas an explicit developmental process throughout thefour years of the curriculum. Only a minority of U.S.medical schools have explicit clinical educationobjectives that guide the clinical skills education ofstudents. For those that do, there is wide variationin the skills specified. Most medical schoolsprovide some formal clinical skills education,primarily during the first and second years of thecurriculum. There is substantial variation in thedegree to which clerkship disciplines participate inan organized way in teaching and assessing clinicalskills. There continues to be an assumption thatstudents acquire the clinical skills required for post-graduate training during clerkships, but mostschools do not determine if this is in facthappening. There also is no explicit clinical skillsdevelopmental process that formally bridges thecontinuum of undergraduate and graduate medicaleducation.

Clinical Skills AssessmentFew schools have an organized approach forassessing clinical skills in a developmentally explicitmanner. While the majority of schools assess clin-ical skills ability at some time in the curriculum, theassessment exercises do not systematically andcomprehensively relate to a clear set of objectivesfor clinical skills education. Standardized patientprograms, which are becoming a popular method of

assessment, exist in more than three-quarters ofU.S. medical schools, primarily for the purpose ofteaching and/or assessment of communication,history-taking, and some physical examinationskills. For schools with these programs, themajority report that they use the information fromthese exercises for making decisions about studentprogress. Schools employ standardized patients(SPs) to assess certain clinical skills at differenttimes during the clinical curriculum. In the majorityof schools, students are required to pass an exami-nation that includes the assessment of selected clin-ical skills before they can graduate. The number ofschools employing SPs for final assessmentpurposes increased greatly (n=26 to 67) during thepast decade. However, the use of paper and pencilexaminations for the assessment of clinical skillsability remains in place in about one-fifth of medicalschools. Many fewer schools (n=25) formallyassess student clinical skills using direct facultyobservation of student performances.

Overall, clerkships use standardized patients andobjective structured clinical examinations (OSCE)for student evaluation about half of the time. Somediscrepancies exist between students and medicalschools in the reporting of the methods used andthe frequency of clinical skills evaluation in the clin-ical years. Students report direct observation byfaculty as occurring less often than medical schoolsreport the same information. According to studentsthe frequency of faculty participation in both obser-vation and feedback about physical examinationranges between 40 percent and 80 percent. It isnoteworthy that over a quarter of graduatingstudents have reported that they have never beenobserved taking a history and performing a physicalexamination by a faculty member. A minority ofstudents report having been required to successfullypass an OSCE at the completion of any of therequired clinical clerkships. On the other hand,schools with established skills programs assessstudents more often and with a wider range ofassessment methods including faculty observation,OSCE, computer case simulation and peer evalua-tion.

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The Fact Sheet below provides informationpertaining to the status of clinical skills educationin U.S. medical schools. The data depicted in thetable are drawn from a variety of sources – LCMEAnnual Medical School Questionnaire (2002),AAMC Graduating Students Questionnaire (2002),Curriculum Directory (2002), and a survey of asso-

ciate deans for medical education (2002). In somecases, data from more than one source were avail-able for one item. Variation in the denominator isa reflection of each dataset sample size. In someinstances, the denominator includes both U.S. andCanadian medical schools.

No. (%)U.S. medical schools with explicit competency-based learning objectives 17/62 (25)

15/59 (27)

U.S. and Canadian medical schools with any formal clinical skills curricula 34/142 (24) 32/62 (52)

U.S. and Canadian medical schools with formal skills curricula in the clinical years 5/142 (4) 8/62 (13)

U.S. medical schools with an explicit list of clinical skills to be learned 27/62 (44)

Specified categories of clinical skills to be learned: CommunicationHistory-taking

Physical ExaminationBasic Clinical Testing

Basic Procedures

12/62 (19) 13/62 (21)11/62 (17)14/62 (23)16/62 (26)

U.S. and Canadian medical schools with a clinical skills education facility: Yes

Planning34/62 (59) 9/62 (15)

U.S. medical schools with standardized patient programs for instruction: Communication skill

History-takingGeneral physical exam

Specialized physical exam

104 (83)109 (87)98 (78)116 (93)

U.S. medical schools with standardized patient programs for assessment:Basic courses

One or more clerkshipsFinal comprehensive

100 (80)82 (66)58 (46)

U.S. medical schools with any form of final clinical skills assessment: 36/53 (68) 71 (57)

Forms of final clinical skills assessment: Direct observation

Paper & pencilSP/OSCE

Computer SimulationOral examination

25 (20) 20 (16) 67 (54) 8 (6) 5 (4)

Students’ report of being observed by clerkship faculty in the performance of physical examination: Family medicine

PsychiatryInternal medicine

PediatricsOb/GynSurgery

(71)(69)(65)(64)(51)(40)

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The establishment of clinical skills centers or labo-ratories to facilitate the teaching and assessmentof clinical skills is one of the more recent develop-ments occurring in medical schools. Thirty-fourU.S. and Canadian medical schools indicated inresponse to an e-mail query that they had estab-lished a clinical skills center for teaching andassessing students’ clinical skills. Nine additionalschools indicated that they were in the process ofestablishing such centers. Clinical skills centers inthe United States generally focus upon theteaching and/or assessment of communication andhistory-taking skills as well as some physicalexamination skills. Centers in Europe also consis-tently focus on physical and mental examinationas well as basic clinical testing and procedureskills. Detailed review of established clinical skillscenter programs reveals significant variations inteaching and assessment activities, and in the waysthat these activities are conducted from aprogrammatic and curriculum perspective.Observations made during the site visits (six U.S.sites, three U.K. sites, and one site in theNetherlands) revealed the following:

While some centers continuously coordinatethe teaching of clinical skills within themedical school curriculum (n=6), others func-tion primarily as a resource for departmentswishing to conduct an assessment activity(n=4)There is substantial variation in the frequencywith which students participate in centeractivities during the course of their education(range 2 to 140). The more frequently astudent is involved in center activities, themore likely this involves repetitive opportuni-ties for skills learning and assessmentthroughout all the years of the curriculum.

Although most programs provide formal feed-back to the student, the composition and formof the feedback varies from school to school.At three centers, clinical faculty do not partici-pate in the student feedback process. At onecenter, feedback to the student is optional.Most centers have a medical director who isresponsible for overseeing the use of the facilityfor teaching and/or assessment activities.The degree to which members of the clinicalfaculty participate in the assessment exercisesconducted in the center is highly variable fromschool to school and from department todepartment within schools. At most centers,clinical faculty participation is sparse andlimited to a few selected or interested faculty.The most common use of centers is for theconduct of summative assessment exercises.A minority of centers conduct customizedprograms to address individual student’s reme-diation needs.As a general rule, students participate incenter assessment exercises more frequentlyduring the early years of the curriculum thanthey do during the clerkship years.Communication and history-taking skills areuniformly a part of center activities. There is substantial variation in the degree towhich physical examination skills are repre-sented in center activities. A few centers allow students to use the facilityfor self-directed learning.With some exception, there is generally noeffort to use the center as a resource forfaculty development. Although program evaluation is a uniform partof the conduct of center activities, there isconsiderable variation in the ability to accessand observe skill performance databases.

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Overall, from the data that are available, it appearsthat contemporary clinical skills education in theU.S. undergraduate medical curriculum continuesto remain a largely implicit process with wide vari-ability among schools in the attention and detailgiven to this essential educational activity. Thisimplicitness, lack of comprehensiveness, and widecontent variability is the norm within schools andclinical disciplines. Despite the fact that medicalstudents in the United States can continue theirpostgraduate education almost anywhere in thecountry, it is noteworthy that there is no nationalconsensus on what comprises basic clinical skillseducation. This situation contrasts to the uniformmanner in which clinical knowledge standards areupheld in curricular, licensing, and certificationprocesses. Formal attention to students’ skilldevelopment seems under standardized andperhaps substandard. From a historical perspective,it appears that emphasis upon clinical skills educa-tion has diminished to a level that requires thefocused attention of medical educators everywhere.

Educating about clinical skills involves a distinctset of teaching and learning behaviors. At the one-on-one education level, the most essentialelements required for effective clinical skillseducation are:

A skilled and willing teacher An appropriately prepared and motivatedstudent An informed and willing patientTime and opportunity for repeated skills prac-tice, including exposure to a sufficient numberand diverse group of patientsAn attitude of shared professional responsi-bility toward the patient by the student andteacherTime and opportunity for effective feedbackbetween teacher and student

From an overall educational perspective, two keyconditions are necessary for guaranteeing thatsuch teaching and learning activities are embeddedin the curriculum. First, guiding and improving theclinical skills development of students requires athorough delineation of the clinical skills thatshould be taught during the medical school experi-ence so that both students and faculty are awareof their responsibilities in ensuring that these arelearned. Second, there is a need to delineate howand when those skills should be learned asstudents progress through the curriculum. It isdoubtful that students can acquire the clinicalskills needed if these two conditions are not met.

In addition, there are at present two major obsta-cles that must be addressed if medical schoolshope to improve the clinical skills education oftheir students. First, they must recognize the time-intensive nature of skills education and adopt poli-cies and procedures for supporting and rewardingmembers of the clinical faculty who are respon-sible for the teaching of clinical skills. There is noquestion that in order to teach skills effectively, aconsiderable commitment on the part of theresponsible faculty members is required. Serviceproductivity demands now placed on faculty in theclinical environment are an obstacle to this occur-ring. It is also clear that many members of theclinical faculty are not willing or able to make thecommitment required to teach clinical skills effec-tively because they are not rewarded for doing so.Medical schools must therefore adopt policies thatwill reward and financially compensate facultymembers for the time they commit to teachingmedical students the essential clinical skills theyshould acquire prior to progressing into their resi-dency programs.

Second, medical schools must recognize thatincreasing specialization in medicine is making itprogressively more difficult to identify facultymembers who have both the interest and confi-dence required to teach basic clinical skills. Most


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members of a specialized clinical faculty prefer toteach primarily within their immediate area ofexpertise. Thus, it can no longer be assumed thatany member of the clinical faculty who is assignedclinical teaching responsibilities can and willconsistently teach generic clinical skills tostudents. Given this reality, medical schools mustidentify a core group of clinical faculty who willaccept responsibility for teaching clinical skills tostudents. In our current service-oriented climate,for example, a teaching faculty member may notbe the same as the attending of record on the clin-ical services to which clerkship students areassigned.

In order to achieve clinical skills proficiency inmedical school, the opportunity to learn and prac-tice skills needs to be an integral and continuingpart of the undergraduate medical curriculum.Because of existing barriers to optimal clinicalskills education, a more explicit educationalprocess is needed to achieve this goal. Specificclinical skills curricula are necessary to helpensure that the continuing opportunity to learnand practice skills exists throughout the under-graduate medical school years. Schools that haveformal skills education programs appear to haveimproved educational experiences and engenderbetter clinical skills educational outcomes. In thedesign of a clinical skills education curriculum,institutions should develop:

A set of overall clinical skills education objectivesSpecified levels of clinical skills developmentthroughout the four-year curriculumA list of specific skills to be learned beforegraduationDesignated experiences for clinical skillslearning throughout the curriculumA developmental clinical skills-assessmentprocess which includes both formative andsummative elementsA system for providing continuing and individ-ualized feedback to students about their clin-ical skills development

Opportunities for clinical skills remediationand self-directed learningA system for assisting faculty in the develop-ment of the teaching and assessment abilitiesrequired for implementing effective clinicalskills education.

Because of the national context within whichstudents may progress in their undergraduate andpostgraduate career development, the apparentunderdevelopment of clinical skills curriculagenerally, and the multiple barriers whichcurrently exist toward achieving this basic under-graduate medical education goal, it would behelpful if a number of things occurred nationally.

A national consensus on the clinical skillseducation of medical students which includes:• a set of recommended clinical skill educa-

tion objectives including a set of specificclinical skills to be learned during the under-graduate medical experience

• principles for guiding the teaching andassessment of clinical skills

• guidelines for the development and imple-mentation of an explicit four-year develop-mental clinical skills curriculum.

Resources and recommendations regarding thedesign, development, and use of clinical skillsteaching and assessment facilitiesRecommendations regarding the use of stan-dardized patients, computer simulations, andrelated instructional techniques in the overallteaching and assessment of clinical skillsA national program for providing resources,advisement, review, and evaluation of clinicalskills education programsA national effort to involve both undergrad-uate medical and postgraduate clinicaltraining organizations in the development of ashared perspective on clinical skills education.

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I am grateful to many for providing me the opportunity to spend a sabbatical year at the Association ofAmerican Medical Colleges. This includes many colleagues at the University of Virginia, particularly Dr.Sarah Corley, for taking care of my patients in my absence. Dr. Evan Heald deserves a special word ofthanks for his careful and exemplary role as acting Ambulatory Clerkship Director. I owe a special apprecia-tion to the many faculty at visited institutions both here and abroad who offered their time, ideas andexpertise to this project, and to the even greater number who exchanged ideas and conversation over theInternet. I am also grateful to Jan Thomas who consistently undertook the challenge of coordinating mycomplex schedule at the University of Virginia, and to the wonderfully helpful staff in the Division of MedicalEducation at the AAMC who shared in a supporting role. A very special appreciation is due MichaelWhitcomb, Deborah Danoff and Brownie Anderson for their limitless help and guidance, and for creatingsuch an engaging and stimulating environment within which to work. I also wish to acknowledge thesupport of the Anne L. and Bernard B. Brodie Endowment for financial support during my sabbatical year.


Book and Reports1) Flexner A. Medical Education in the United

States and Canada. Boston, MA: MerrymountPress, 1910.

2) Nutter D, Whitcomb M. Report on the AAMCProject on the Clinical Education of MedicalStudents. Washington, DC: Association ofAmerican Medical Colleges, 2001.

3) Future Directions for Medical Education.Chicago, IL: American Medical Association,1982.

4) Physicians for the Twenty-first Century. Reportof the Panel on the General ProfessionalEducation of the Physician. Washington, DC:Association of American Medical Colleges,1984.

5) Clinical Education and the Doctor ofTomorrow. Proceedings of the Josiah Macy, Jr.Foundation National Seminar on MedicalEducation. New York, NY: Josiah Macy Jr.Foundation, 1989.

6) Educating Medical Students. Assessing Changein Medical Education. The Road toImplementation. Washington, DC: Associationof American Medical Colleges, 1992.

7) The Education of Medical Students. Ten Storiesof Curriculum Change. New York, NY: MilbankMemorial Fund, 2000.

8) Contemporary Issues in Medical Education.The Role of Faculty Observation in AssessingStudents’ Clinical Skills. Washington, DC:Association of American Medical Colleges,1997.

Journal Publications9) Kassebaum DG, Eaglen RH, Cutler ER. The

objectives of medical education: Reflections onaccreditation looking glass. Academic Medicine1997: 72:648-666.

10) Milan FB, Goldstein MG, Novak DH, et al. Aremedical schools neglecting clinical skills? Asurvey of U.S. medical schools. Ann Behav Socand Med Educ 1998; 5: 3-12.

11) Kassebaum DG, Eaglen RH. Shortcomings inthe evaluation of students’ clinical skills andbehaviors in medical school. AcademicMedicine 1999; 74: 842-849.

12) Fox RA, Ingham Clark CL, Scotland AD, DacreJE. A study of pre-registration house officers’clinical skills. Med Educ 2000;34: 1007-1012.

13) Moercke AM, Eika B. What are the clinicalskills levels of newly graduated physicians?Self assessment study of intended curriculumidentified by a Delphi Process. Med Educ2000;36: 472-478.

14) Tekian A. Have newly graduated physiciansmastered essential clinical skills? A commen-tary. Med Educ 2000; 36: 406-407,

15) Carraccio C, Wolfsthal SD, Englander R, et al.Shifting paradigms: From Flexner to competen-cies. Academic Medicine 2002; 77: 361-367.

16) Smith MA, Gertler T, Freeman K. Medicalstudents’ perceptions of their housestaff’sability to teach physical examination skills.Academic Medicine 2003; 78: 80-83.

17) Langdale LA, Schaad D, Wipf J, et al. Preparinggraduates for the first year of residency: Aremedical schools meeting the need? AcademicMedicine 2003; 78: 39-44.

18) Holmboe ES. Faculty and the observation oftrainees’ clinical skills: Problems and opportu-nities. Academic Medicine 2004; 79: 16-22.

19) Howley LD, Wilson WG. Direct observation ofstudents during clerkship rotations: A multi-year descriptive study. Academic Medicine2004: 79: 276-280.

20) Remmen R, Scherpbier A, Van der Vleuten C,et al. Effectiveness of basic clinical skillstraining programs: A cross-sectional compar-ison of four medical schools. Med Educ 2001;35: 121-128.

21) Preiffer CA, Ardolino AJ, Madray H. Theimpact of a curriculum renewal project onstudents’ performances on a fourth-year clin-ical skills assessment. Academic Medicine2001; 76: 173-175.

22) Corbett EC. Improving clinical skills educationin the undergraduate medical curriculum.Medical Encounter 2004; 18: 5-7.


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