AFMC

1
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
Heckerlings Diagnostic Score

• Temperature gt 37.8? C
• Heart rate gt 100 /min
• Crackles
• Diminished breath sounds
• Absence of asthma in history
• Score of 4 or 5 argues for Pneumonia (LR8.2)
• 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 lt
  10, Heckerling score of 0 or 1 reduces the
  probability of Pneumonia to lt 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• Physical sign outdated capillary refill time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
19

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

22
(No Transcript)
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.