AFMC

1. Jasper, May 10, 2007 AFMC National Clinical Skills Working Group Evidence-Based Clinical Skills

2. Quote from Verghese “It is ironic that the ready availability of diagnostic technology has not, it seems, enhanced bedside skills, but instead has encouraged atrophy” Verghese A et al. Ludwig Traube: the man and his space. Arch. Int. Med. 1992; 152: 701-703

3. A 28 year old man with no significant previous medical history went to his family doctor complaining that for the past three days he had experienced an unproductive cough and a fever of 37.5?C and mild shortness of breath on exertion. He has no history of respiratory disease such as asthma. Physical examination: Temp 37ºC. Pulse 72/mm, regular. Chest exam: Air entry was symmetrical in all areas, with no crackles. What is the probability this patient has pneumonia? Does he need a CXR?

4. Heckerling’s Diagnostic Score Temperature > 37.8? C Heart rate > 100 /min Crackles Diminished breath sounds Absence of asthma in history Score of 4 or 5 argues for Pneumonia (LR=8.2) Score of 0 or 1 argues against Pneumonia (LR -= 0.3)

5. In patients presenting with cough in the community, where probability of Pneumonia is < 10%, Heckerling score of 0 or 1 reduces the probability of Pneumonia to < 3%. ? CXR?

6. Patient may not need CXR BUT Was the patient asked about history of asthma? How do you detect diminished breath sounds or crackles? OR Can you take a pulse?!!!!

7. Clinical SkillsDebate Position 1: All traditional physical signs remain accurate and diagnostically useful today. Position 2: Physical diagnosis has little to offer the modern physician, since traditional signs cannot compete with the technology of modern diagnostic tools.

8. Useful or Useless Physical sign outdated – capillary refill time Physical sign accurate – early diastolic murmur for A.R. Physical sign as diagnostic standard – systolic murmur and click for mitral prolapse

9. Identifying the Issue Accepting the diagnostic value of many physical signs, what are the barriers to teaching them to medical students?

10. Identified Barriers for Teaching Clinical Skills Changes in clinical environments – busy clinicians – institutional environment limits faculty willingness and time to teach clinical skills. Hospital residents have fewer hours available to teach Physician specialization in tertiary care environments – leads to “discomfort” teaching physical examination outside the “specialty” area. Specialty technicians in hospitals reduce opportunity for medical students to learn practical skills.

11. Identified Barriers for Teaching Clinical Skills Reliance on written examinations to assess professional development. In the USA, increasing regulatory and pay or influences constrain clinical teaching activities and exclude students from active participation in patient care. Lack of “curricular explicitness” regarding what students should be learning to do as clinicians.

12. Overcoming the barriers USA The AAMC Project on the Clinical Education of Medical Students – Clinical Skills Education AAMC 2005

13. Canada AFMC UGME Deans meeting, Toronto, April 2001 Decision to form a working group to develop a basic compendium of communication and physical examination skills and maneuvers, annotated with the evidence for diagnostic utility, where available Secondly, the working group should identify the expected level of performance for a) entry to clerkship b) graduation

14. National Clinical Skills Working Group Representation from most of the 17 Canadian Medical Schools First meeting, Toronto, October 2002

15. Levels of Performance Level 1: Describe the physical sign or maneuver but not elicit it. Level 2: Perform the maneuver, and explain the rationale for the test. Elicit the physical sign. Level 3: Perform the maneuver or recognize the physical sign and interpret the findings in terms of pathophysiology. Level 4: Perform the maneuver or recognize the physical sign and may know the evidence justifying the use of the test; interpret the findings.

16. Levels of Evidence Grade A: Independent, blind comparison of sign or symptom with a “gold standard” of diagnosis among a large number of consecutive patients suspected of having the target condition. Grade B: Independent, blind comparison of sign or symptom with a gold standard of diagnosis among a small number of consecutive patients suspected of having the target condition. Grade C: Independent, blind comparison of sign or symptom, with a gold standard of diagnosis among non-consecutive patients suspected of having the target condition; or non-independent comparison of sign or symptom with a gold standard of diagnosis among samples of patients who obviously have the target condition plus, perhaps, normal individuals; or non-independent comparison of sign or symptom with a standard of uncertain validity. Sacket and Goldsmith

17. Design of Skills Document Introduction, Rationale and Guide Communication Skills Mental Status Examination Examination by Body System Pediatric Examination Procedural Skills

18. Communication Skills and Medical Interviewing

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20. Respiratory Exam

21. Procedural Skills Level of Competence Level 1: Describe the indications, contraindications, risks, common complications and the process of the procedure Level 2: Perform the procedure under supervision in a non-clinical setting (e.g. simulated set-up) Level 3: Perform the procedure in a stable patient under supervision in a controlled clinical setting Level 4: Perform the procedure in a stable patient without supervision in a controlled clinical setting

23. National Clinical Skills Working Group Next Steps

24. ?Align Clinical Presentations (MCC) with Evidence-Based Clinical Skills ?Development of “Master Clinician Teacher” role through Faculty Development Initiatives. ?Collaborative OSCE development Make the document available on the AFMC website.