Clinical skills training in undergraduate medical education using a student-centered approach.

This thesis focuses on how to engage students in self-directed learning and in peer-learning activities to improve clinical skills training in undergraduate medical education. The first study examined the clinical skills teaching provided by student teachers compared to that provided by associate professors. This study showed that student teachers performed as good as or even better than associate professors when teaching simple clinical skills. The second study of this thesis examined how complex clinical skills--such as patient management skills--develop with increasing levels of competence. The Reporter-Interpreter-Manager-Educator framework was used to reflect this change and construct validity was explored for RIME-based evaluations of single-patient encounters. In the third study the effects of training in pairs--also known as dyad practice--examined. This study showed that the students practicing in pairs significantly out-performed those training alone using RIME-based assessments and that dyad training significantly improved students' confidence in managing future patient encounters. The final study examined students' use of self-directed clinical encounter cards (CECs) based on the RIME framework. Results from this study showed that self-directed CECs can have positive effects on participatory practice and clinical reasoning when implemented in a supporting environment but the chance of success depends on the context of use. Self-directed CECs can be successful but major faculty development initiatives are required before implementation in large and dispersed settings. In conclusion, this thesis demonstrated different aspects of student-centered approaches to clinical skills learning. Whereas self-directed learning is difficult in clinical clerkship, the experimental studies demonstrated remarkable advantages to peer-learning in skills-lab. Thus, peer-learning activities could be essential to providing high-quality medical training in the face of limited clinical teacher resources in future undergraduate medical education.