Mastering Clinical Medicine (Part 2)

See Part 1 here.

Deconstructing clinical skills

Any complex skill or activity can be broken down into parts. With more practice and experience, you become less conscious of the smaller parts and start to experience them as one whole integrated activity.

For example, when someone learns to play the piano they may start with one hand on the keyboard playing the five notes that rest under each finger. They may then learn to move their hand up and down to play notes of higher or lower pitches. Initially, they will learn both hands separately and later will play with both hands at the same time. In comparison, an experienced pianist playing a Beethoven sonata will not be consciously thinking about any of this. By that stage, the subcomponents of the skill have coalesced into one fluid process.

This is true also in medicine. When someone starts learning medicine, they must learn the key subcomponents, such as ‘history-taking’ (asking the patient questions about what’s wrong) and the ‘physical examination’ (inspecting the patient’s body for signs related to disease). These subcomponents can be further broken down; a history includes exploring the patient’s main complaint, screening for other symptoms, exploring the patient’s medical background, their social situation and other elements. An experienced doctor has the ability to integrate these skills and draw on the appropriate combinations as required.

When learning these skills, a useful approach is to deconstruct them into their smallest parts, analyse the best ways to learn each component and then re-integrate them. This is an approach that Tim Ferriss used to become world champion in Chinese kickboxing and set a World Record in Argentine tango. He even deconstructed how to make a good podcast, then used the principles to make a podcast asking world-class performers to deconstruct their performance. (Meta or what.)

I will use the example of mastering the ‘physical examination’ to demonstrate how I used these principles, although it can be applied to many aspects of learning medicine. While the specifics may be useful, I want to demonstrate the process which you can then apply in different ways and to different things.

I applied the same approach to history-taking, physical examination, practical skills such as taking bloods and cannulation, and interpreting investigations such as ECGs and X-rays. I also applied this principle outside of medicine. For example, I credit it with the fact that I went from being a beginner at basketball to representing my university within fifteen months.

Mastering the physical examination

At medical school, you must learn the ‘formal’ way to perform physical examinations which is rarely followed fully in clinical practice. Assessment is usually in an ‘OSCE’ format (Objective, Structured Clinical Examinations), which involves examining a patient’s specific body system (for example, Cardiovascular, Respiratory, Neurological), then summarising the signs that you found and answering questions about it (the ‘viva’).

I divided OSCE-style physical examinations into four components:

  • The examination schema: The specific sequence used and signs looked for. For the major systems (cardiovascular, respiratory and abdominal examinations), you usually start in the hands, work up the arms to the face, then down the body via the chest and abdomen to the legs).
  • Recognition of signs: In every patient, the schema followed is the same but different patients will have different patterns of signs present. A skilled clinician recognises these signs in combination to point towards a diagnosis, for example the combination of (i) nail clubbing, (ii) reduced chest expansion and (iii) fine crackles in the lungs is suggest of pulmonary fibrosis.
  • Presenting the findings: After the examination, you must briefly summarise the signs (both positive signs and important negatives) and the possible diagnoses that they point towards.
  • Viva: The examiner then asks follow-up questions about the possible conditions, distinguishing features and other information.

For each of these aspects of the examinations, I devised a plan for practising them until they became second nature.

The examination schema

As early as possible, create your own specific sequence for the examination. My advice is to look at multiple sources, decide on a logical structure and then create a central guide which you follow every time. You can make minor modifications based on feedback and teaching, but get as much practice as possible performing the same sequence in the same way until it becomes second nature.

Useful resources for creating your initial schema include websites such geekymedics.com and oscestop.co.uk or clinical examinations books such as Macleod’s or Talley and O’Connor’s.

In terms of the structure, it is useful to create ‘hooks’ that you can hang different parts of the examination off. For example, for the inspection part of the hand examination I have five hooks: (i) skin, (ii) nails, (iii) soft tissues, (iv) bones and (v) joints. Within each of these five there are a number of things to look for: e.g. when inspecting the (i) skin I’ll look for rashes, nodules, scars, etc.; then, when looking at the (ii) nails I’ll look for pitting, onycholysis, clubbing, etc. It is much easier to remember things in these domains than as a long separate list.

Think of as many useful ways for remembering different parts of the examination (rather than rote learning it all). For example, for the palpating and percussing part of the abdominal exam there are:

  • Two things you palpate AND percuss (the liver and spleen)
  • Two things you only palpate (the kidneys and the aorta)
  • Two things you only percuss for (shifting dullness and bladder)
  • Two things you auscultate (bowel sounds and bruits)

Once you have created the schema and thought of useful ways to remember it, the more practice, the better to make the examination as automatic as possible. As the old adage goes “One examination a day keeps finals at bay”. Not having patients is no excuse; practise with your friends, on a teddy bear or even on your pillow!

Recognition of signs

The key to getting good at recognising patterns of signs is to see as many patients as possible on the wards and trying to figure out what is wrong with them – there is no real substitute. Initially, it is okay to know what condition the patient has before you see them so that you can see it and register “so that’s what spider naevi look like”. However, once you have a little experience you want to avoid as much as possible knowing what the patient’s condition is before you meet them. This way you actively have to try and work out what they have and you will learn much more.

Another useful technique is to visualise the combination of signs you would expect to see in certain conditions. For example, choose a disease like Cushing’s Disease or someone who had a renal transplant following renal failure – travel from head to toe imagining the signs you may see. When you run through practice examinations with your teddy bear/pillow/friends, choose a particular condition and imagine what signs you would pick up as you go along.

Presenting the findings

There is no ‘right’ way to present findings after an examination, although certain approaches are more effective than others. My advice is to experiment with different ways and find what works for you. The two most popular approaches are as follows.

  1. Following the rough order of the examination

As an example, a patient with aortic stenosis:

“On examination of Mr Jones’ cardiovascular system, I found him comfortable at rest with no evidence of oedema, cyanosis or anaemia and no peripheral stigmata of cardiovascular disease. His pulse is slow rising in character, the rate is 70 and regular and blood pressure is 120/95. The JVP is not raised. The apex beat is sustained and in the 5th inter-costal space. Heart sounds 1 and 2 were normal, with an added ejection systolic murmur hear loudest in the aortic region with radiation to the carotids.

In conclusion, Mr Smith has a narrow pulse pressure, a sustained apex beat and an ESM which is in keeping with aortic stenosis.”

This is the easier method of the two. In advance, decide the ‘hooks’ you will use for each examination as it will make it much easier to remember. For example, using this method for the cardiovascular presentation, I would always have the opening sentence above, then mention pulse, JVP, apex beat and heart sounds in that precise order.

2. Present only the main positive findings then important negative findings.

For example, in a patient with aortic stenosis:

“On examination of Mr Jones’ cardiovascular system, the main positive findings were a slow-rising pulse, narrow pulse pressure, displaced apex beat and ejection systolic murmur heard loudest in the aortic region with radiation to the carotids. This would be in keeping with aortic stenosis.

Notable negatives included no diastolic murmurs, no metallic heart sounds, no evidence of heart failure, including no peripheral oedema or crackles in the lungs, and no evidence of infective endocarditis, including no clubbing, Osler’s nodes or Janeway lesions.”

The notable negatives mentioned should be tailored to rule out other possible causes and possible consequences of the condition you concluded. For the above example, heart failure and infective endocarditis are both possible consequences of aortic stenosis.

This is a slightly more difficult method of presentation but if executed well can make you stand out.

My approach was to practise both methods and then select the one I was most comfortable with in the exam. If an examination went well and I was confident of the diagnosis, I would use the second method. If I was less confident, the first method was nice to fall back onto. A friend of mine, who did not want to have to decide during the exam, selected a preferred method and used it every time.Again, practise as much as possible so that it becomes second nature. It can also be useful to practise presenting with different conditions in mind, to further reinforce your ability to recognise patterns of signs.

Viva

Common questions in the viva include “what is the differential diagnosis for X?” (for example, a systolic murmur, jaundice, hepatomegaly), “what investigations would you like to perform?” and “what would your management be?”.

I prepared answers based on the most likely examination findings and the most common questions asked. For each, I thought of a logical structure for an answer and aimed for a top three or groups of three where possible. I created recordings where I would ask the question then leave a pause for me to answer before the recording gave the model answer that I prepared. I would listen to these recordings when I had free moments, such as when I was running errands in town or travelling somewhere, until they became second nature.

Click here for two examples of the answers I prepared and then recorded. If you would like access to the full set of recordings, contact me at: hi@chrislovejoy.me.

Integration

As well as practising separate components, it is important to continually practise integrating them together. This can be done by finding a colleague and practising on each other or on patients, each time following the full schema, presenting findings and giving each other a viva. Examinations in pairs or threes are always best; you can take it in turns to examine and give each other feedback. It can be useful to keep a list of patients with signs which you can also share with colleagues

CHAPTER 3 SUMMARY

• Hospitals are designed for treating patients and not training students so it is important to be proactive and confident.

• Make the most of your time by having an objective, not being afraid to leave, tagging on to good teachers and linking your experiences to reading.

• Doctors must learn separate skills, such as history-taking, examinations, practical skills and interpreting investigations, and combine them in order to look after patients.

• These skills can be learnt effectively by deconstructing them into subcomponents, mastering them individually and practising their integration

Continued in Chapter 4.

status: No status —

This is a chapter from The Modern Medical Student Manual. A full list of chapters are below:

  • Introduction: From That Day To This Book
  • Chapter 1: Medicine from Fifty Thousand Feet: Perspective, Targets and Limits
  • Chapter 2: The Fundamentals of Fast Learning - Part 1 and Part 2
  • Chapter 3: Mastering Clinical Medicine - Part 1 and Part 2
  • Chapter 4: Increasing our Impact (and the power of Self-Education) - Part 1 and Part 2
  • Chapter 5: A Scientific Approach to Research - Part 1 and Part 2
  • Chapter 6: Commanding Clearer Communication - Part 1 and Part 2
  • Conclusion

Plus Bonus Chapters:

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The full book is also available as an eBook or Paperback.