Writer's Workshop: Teaching Preclinical Medical Students the Art of the Patient “Write-Up”

Abstract

Abstract Introduction Documenting the full history and physical examination as a write-up is required in clinical rotations. The majority of students and faculty feel that despite the effort required, this exercise is essential to clinical learning. The process helps the student organize thoughts. The final product can be a useful tool in the assessment of a student's ability to interpret and synthesize data. Given evidence that student notes can be improved with feedback, we sought to develop a set of educational tools that would aid in the teaching and assessment of this important skill. Methods Using the Bates' Guide to the Physical Examination and History Taking and a validated write-up assessment form for third-year medical students, we developed a guide to the comprehensive write-up and a grading rubric. We created a videotaped encounter with a standardized physician and standardized patient that 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. Results For the academic year 2012-2013, we had 180 second-year medical students complete a write-up using the comprehensive guide and grading rubric. We scored all write ups using the grading rubric and found that many students were struggling still with completing this exercise. The average score was 75 out of 100 points with a standard deviation of 17. Discussion For the academic year 2013-2014, we used the same guide and grading rubric, but also conducted this session with all 180 students. We are planning on repeating the write-up exercise and will have data to see if there is an improvement in overall scores since introducing this Writer's Workshop experience.

Keywords

• Clinical Skills
• Write Up
• Clinical Note
• Preclinical Student