How to improve on clinical exams?

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ololona

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I just had a practice clinical exam today where I had to do a history and physical examination and I failed. How can I improve? How can I make the patients feel at ease and ask more open ended questions without prompting them? What are some resources to learn these materials?
 
Where are you at in your training?

I’m an M2 but since we have Clinical Skills Exams in COMLEX-PE style for school, and should be gaining some competency for rotations, I read/refer to First Aid for Step 2-CS and Step 2-CK.

Also, your school should be incorporating these things into your curriculum when you’re being tested on them.
 
I just had a practice clinical exam today where I had to do a history and physical examination and I failed. How can I improve? How can I make the patients feel at ease and ask more open ended questions without prompting them? What are some resources to learn these materials?
Usually when you get vague feedback like 'ask more open ended questions' it just means you didn't start with one. Just throw the old 'what brings you in today' at them as soon as you walk in the door. Then say 'anything else' or 'tell me more,' while staring at them in silence. Follow that with a 'I'm sorry, it must really suck to have *insert problem*.' Then move on to focused questions from then on.

The other thing it could mean is that the actor thought your ROS was too broad (i.e. you asked too many). This is counter-intuitive and stupid, but I certainly had that happen to me in the past. Don't take that open-ended thing to heart. At one point I was following up tons of questions with 'tell me more' and it was screwing with my timing. At that point I really went over the rubrics I was graded on very closely. My school would change them every semester (stuff always got added), but I had an idea what they were actually giving points for. This allowed me to focus on what I actually needed to do to pass, rather than chasing useless ambivalent advice like 'ask more open ended questions.' I never 'failed' a OSCE again even when many of my class did. I suggest you do the same.
 
Look up active listening skills on youtube. Using things like reflections and summarizations, you'll really help the patient understand that you care. Making a patient feel heard and understood will go a long way for you in your clinicals and future practice.
 
Start with open ended questions, and let the patient speak initially - try not to interrupt. It should be like a funnel. Open initially, and then more closed once you're starting to get an idea of what's going on and you can ask more probing questions or clarifying questions as you go along. The other poster that mentioned summarizing is also a really good idea. Periodically, you can summarize what you've heard from the patient, like "it sounds like you're telling me that you've had this intermittent dull pain in your side for two weeks, it's better with x, worse with y, and ibuprofen seems to help. Does that sound about right?"

Also it's important to be systematic in how you take a history so you don't forget something, e.g. CC/HPI, ROS, PMH, PSH, FH, TobEtOH & Drug Use, Social History. You may not do the order the same way every time, because not every conversation is going to be the same - there will be some variation. You probably have a rubric of some kind that you're being graded with, so use that to your benefit to know what you must ask about. If you're systematic about it though, you'll be less likely to forget something.

There are a few textbooks on history taking and physical examination skills. Bates is pretty solid for physical exam - also check out the Stanford 25. They have a YouTube channel I think where they show how to do different physical examination skills. I think the most important thing to do is practice, practice, practice. How do you get better at auscultation? Listen to as many hearts and lungs as you can. How do you get better at doing an abdominal exam? Examine as many abdomens as you can. You're the one ultimately responsible for your education, so make the most of it.
 
I just had a practice clinical exam today where I had to do a history and physical examination and I failed. How can I improve? How can I make the patients feel at ease and ask more open ended questions without prompting them? What are some resources to learn these materials?
For some the PE comes naturally, but for most it doesn’t. Best way to improve is to practice with someone who you trust will be blunt.
 
you need to have a flow. Know the soap note format, and ask questions tailored to it

before every standardized patient i write the same thing on my paper down so i dont forget anything important. You should come up with your own. A checklist so you dont get off track

CC:

HPI:
why specifically did you chose to come in today and not another day
O
P
Q
R
S
T
associated symptoms

PMH:
diagnoses
medications
hospitalizations
surgeries
allergies
childhood illness

maintenance:
immunizations
last checkup/visit to specialist related to CC
pap/colon/mamm/etc

SH: smoke
drink
drug
caffeine
living arrangement
occupation
diet
exercise

FH: 1st degree

ROS: ALWAYS ask general (fever, night sweats, fatigue, weight changes, orthopnea, paroxysmal nocturnal dyspnea, etc)
then go from top of the body down, hitting each system in your differential


come up with your own system and stick to it.
 
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