Introduction to Clinical skills
Khalil Ashkar MD
• “Knowing is not enough; we must apply.
• Willing is not enough; we must do.”
(Goethe)
Skill
• Is learned and not innate.
• Is able to be broken into explicit steps.
• Requires practice in order to improve
• Has a specific goal or outcome that is measurable
• There is no assumption in teaching clinical skills.
• Skills are demonstrated and not prescribed
Importance of Clinical skills
• “I hear and I forget…
• I see and I remember…
• I do and I understand…”
Chinese Proverb
SOAP
• S: Subjective
• O: Objective
• A: Assessment
• P: Plan
How to improve (Deliberate Practice)
• Well defined skill or task.
• Opportunities to practice and improve.
• Opportunities to repeat and reflect
• Regular feedback from the observer.
Pendleton’s feedback model
Case 1
• Mrs. Dina is a [Link] woman who has come to the office for the first time. She is experiencing
severe abdominal pain, looks pale, and is sweating profusely. Alice, the fourth year student on a family
medicine rotation, is assigned to take her history and to complete a physical examination. She enters
the room and begins the interview:
ALICE: Hi, Mrs. Dina. I'm Alice , a fourth-year medical student, and I will be taking care of you today.
MRS. Dina: Hi. I really feel bad.
ALICE: I can see that you're in pain. Is there anything I can do to help you be more comfortable while I
talk with you and examine you ? I need to find out some basic information before we can give you any
medication to help the pain.
Mrs. Dina: Yeah, if l curl up with a pillow against my stomach it helps a little.
ALICE: Then let me get a pillow for you before we begin...
Case 1
• Physical exam of acute abdomen:
1- Preceptor will introduce the manoeuver to examine the abdomen
2- will show how to examine the abdomen
3- Student will repeat the step and ask questions to the preceptor
4- student will perform himself the exam
Case 2
• 7 years old boy presenting with right knee swelling on daily basis.
SNAPP
S Obtains a history, performs a physical examination, "Eric is a 7-year-old male with a 3-month history of
and presents a summary of their findings to the right knee pain and swelling that occurs daily. No
Summarize briefly the history and findings preceptor. The summary should be brief and concise other joints are affected. He reports difficulty
and should not utilize more than 50% of the playing soccer. He denies current or previous
learning encounter (~3 minutes maximum to illnesses, recent travel, or injury. Daily ibuprofen
present) provides little benefit."
N • Provides two to three possibilities of what the "Given the length of the symptoms, my differential
diagnosis could be • Presents their list prior to the
Narrow the differential to two or three diagnosis includes: juvenile idiopathic arthritis,
preceptor revising the list
relevant possibilities reactive arthritis, and injury."
A • Discusses the possibilities and analyzes why the "I think juvenile idiopathic arthritis is highest on my
patient presentation supports or refutes the differential diagnosis given the age of the patient and
Analyze the differential comparing and differential diagnoses • Thinks out loud in front of the the length of the symptoms. Reactive arthritis is
contrasting the possibilities preceptor lower due to the length of symptoms and no history
of previous illness. Injury is low on the differential
due to no history of injury."
P Discusses areas of confusion and asks questions of "Is there anything else that you would include on
the preceptor your differential?" The preceptor may discuss the
Probe the preceptor by asking questions • Allows the preceptor to learn about their thinking importance of considering septic arthritis in the
about uncertainties, difficulties, or alternative and knowledge base differential diagnosis.
approaches • Prompts discussion from the preceptor on clinical
pearls or areas of importance
P • Discusses a management plan for the patient or "I would begin a prescription-strength anti-
outlines next steps inflammatory medication and order an ANA."
Plan management for the patient’s medical • Commits to their plan and utilizes the preceptor as
issues a source of knowledge
S • Identifies a learning issue related to the patient "I would like to understand the relationship of
encounter the ANA and the need for ophthalmology
Select a case-related issue for self-directed • Discusses the findings from the learning issue with
learning monitoring in juvenile idiopathic arthritis."
the preceptor
Case 2
• 30 years old lady presenting with right ear pain since two days.
• History.
• Physical exam.
• Summarize
• DD
CS 2 Module in UOB
• It is a module year long.
• Three hours session every week.
• Integrated with the organ system to highlight the link between basic
science and clinical practice
• Teaching Clinical skills in all it is aspect
• It promotes self learning
• Students are splitted in small groups.
• Each group is assigned to one preceptor
• Preceptor has to teach and supervise students during the CS module
• Learn how to compete a POMR using the appropraite terminology
• How to how to write a good history and document physical findings
• How to present the case verbally
• During the CS rotation students are asked to fill one POMR
Learning Outcomes
• Professional attitude in patieny- Physician relationship.
• Practice of ethical medicine.
• Art of listening.
• Learn the elements of good history and the presentation of diseases in
different patients
• Practice physical examintation skills
• Learn how to perfprm procedures from skilled people.
• How to approach the patient along the psychosial model taking into
consideration cultural diversities
• Health promotion and preventive skills
Grading
1- POMR
2- Attendance
3- Evaluation
4- OSCE
THANK YOU
Questions?