learning clinical skills as an MS1

[ohai]

What do people think about this?

It seems a little silly to learn practice before theory. What's the point of knowing any of these questions and exam methods if you don't know how to interpret the findings, or how to ask logical followup questions, or even why the question is asked in the first place? But maybe there is something to be said for going through the motions.

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[Mace1370]

What do people think about this?

It seems a little silly to learn practice before theory. What's the point of knowing any of these questions and exam methods if you don't know how to interpret the findings, or how to ask logical followup questions, or even why the question is asked in the first place? But maybe there is something to be said for going through the motions.

Learning clinical skills during M1 is an incredibly alluring carrot that schools can dangle in front of pre-meds during the interview to make them interested in the school. Other than that, there is little other point. Some people say that it breaks up the monotony of M1, which I suppose it does. I would rather have the time to just relax or study more if I needed to, however.

 

[Droopy Snoopy]

Learning clinical skills during M1 is an incredibly alluring carrot that schools can dangle in front of pre-meds during the interview to make them interested in the school. Other than that, there is little other point. Some people say that it breaks up the monotony of M1, which I suppose it does. I would rather have the time to just relax or study more if I needed to, however.

I agree with this for the most part, however there is also something to be said for developing confidence by learning these skills early and being able to do it routinely at the start of M3 year. Already knowing how to do some of the simple things (blood pressure, auscultate stuff, measure JVD, etc.) can help you start out on the right foot with the team, make you a effective/efficient data-gatherer, and enable you to concentrate on data interpretation and the clinical decision making process which are the keys to taking honors.

 

[namethatsmell]

Totally agree...learning clinical skills as an MS1 was a nice reminder of what the future holds. For whatever reason though, our skills workshops were typically a few days away from an exam, so must of us wanted to get outta there ASAP and get back to studying.

That being said, learning how to take a history (if that fits your definition of a clinical skill) as an first year has been helpful this year (MS2) when trying to think about how different diseases can present.

 

[Dwindlin]

I actually disagree. I think its better to know stone cold what a normal exam is before cluttering it with abnormals. Getting a lot of exposure M1/M2 of normal physical exams helps to solidify it, making abnormals easier to detect.

Just my opinion obviously. I think it would be fascinating to see if there is any actual data on the subject.

 

[unsung]

What do people think about this?

It seems a little silly to learn practice before theory. What's the point of knowing any of these questions and exam methods if you don't know how to interpret the findings, or how to ask logical followup questions, or even why the question is asked in the first place? But maybe there is something to be said for going through the motions.

Yeah, I agree. I found it a big time suck, and served to add stress to finding time to study for the "real" stuff.

Maybe towards the end of MSI, it's a little more relevant, but definitely not useful starting on day 1. Unfortunately, my classmates appeared to love the stuff, so I think the trend is here to stay.

 

[pingouin]

I dunno... we start learning physical exam during our second block of M1. This is because we have mandatory clinic time for the last 75% of our M1 year, which increases during our M2 year. Depending on the preceptor, you may or may not be practicing these skills starting in that second block.

Agreed- you need to practice to get used to the normals before being able to identify the abnormals.

 

[greatnt249]

Yeah, I agree. I found it a big time suck, and served to add stress to finding time to study for the "real" stuff.

Maybe towards the end of MSI, it's a little more relevant, but definitely not useful starting on day 1. Unfortunately, my classmates appeared to love the stuff, so I think the trend is here to stay.

Learning to take a history is probably more "real" in terms of being prepared for clinical medicine than knowing the exact mechanisms/pathway of the TCA cycle.

 

[Mace1370]

Ya, don't get me wrong there are definitely some very useful things you will learn in a clinical skills course. I found, however, that it was greatly outweighed by useless chaff. Example: 3 hour mandatory lecture about pediatrics followed by a 30 minute interview with a high school student.

 

[DeadCactus]

I hated it when we did it first year. Now in second year, I appreciate that we did it. Having learned how to do it in first year, second year gives us a chance to see some of the abnormal findings and more importantly makes it easier to translate pathology to presentation.

It seems like an unrelated distraction during first year, but like your other courses it's paving the way for second year material.

That's not to say a school administration can't make it a total waste of time through poor implementation...

 

[unsung]

Learning to take a history is probably more "real" in terms of being prepared for clinical medicine than knowing the exact mechanisms/pathway of the TCA cycle.

Sure, but does it take 50 hours of "fake" interviews with your classmates to learn the skill? Past a certain point (fairly early on), it was diminishing returns, honestly. (I'm sure once we all get out into the hospitals, it will still take some adjustment to learn to do it with real patients. It's inevitable.)

Also, in MSI, we don't really have the knowledge to know the right Qs to ask. Hence, it's like flailing around in the water, without anyone teaching you how to swim (or where to swim to). Does thrashing around for a long time actually prepare you to learn to swim for real, later on? I dunno, guys...

I admit, I may be a bit biased due to having a bit of clinical experience before med school. For someone without ANY experience of that sort, I can see how the early exposure might be seen as welcome, interesting, and even useful.

This is also why I'd rather schools require a certain amount of clinical contact before med school. (The way PA schools do it.) It would do a world of good for a lot of people, I think. Especially as immunization for 3rd yr, when ppl who have never worked a day in their lives whine about how miserable it is to actually work until 6pm every night... lol (Not to mention shaving off some of the classroom hours for this early patient contact stuff.)

 

[deuist]

There are plenty of other things that medical schools waste time teaching. Physical exam skills is very low down on the list. To some extent, knowing how to perform an H&P helps with learning certain diseases.

 

[Gabby]

It depends on your school. I go to a school with a systems-based curriculum so even as first years, physical exam skills was relevant. In the middle of the neuro block, we learned how to do a neuro exam. In the middle of the cardiovascular system, we learned how to do a cardio exam. We knew what we were looking/listening for even as first years because we were covering that particular system.

I'm glad my school set it up that way. I don't think it would have made sense to learn physical exam skills in second year for the blocks we did a year earlier.

 

[MilkmanAl]

I'm glad I learned all the physical exams during my first year. As someone said, it makes figuring out what's not supposed to be there a little easier, and that's nice for when you start pathology up. As far as actual clinical usefulness goes, though, that early exposure doesn't rate very high.

 

[Marcus Brody]

No one wants to believe part of their education is arbitrary and pointless. So we are seeing a lot of denial ITT. MS3s and 4s know the big picture a little better. A hands-on clinical class won't be very meaningful to an MS1 unless they've never touched patients before.

 

[Cruzinman]

MD, 1970-74. I don't care when you start seeing patients, put please lose the "standardized patient". I can promise you that when you get on the wards there will be no such thing. For example for every "textbook case" of acute appendicitis you will see three atypical presentations. You will feel very confident when you diagnose your first standardized patient presenting with cough, fever and pleuritic chest pain as lobar pneumonia until you see a similar presentation on the wards, tell your attending on morning rounds that everything is under control, and when you return for afternoon rounds your patient has died from a massive pulmonary embolism.

Think hard about that.

 

[Cruzinman]

Would someone also tell this old timer what "Problem Based Learning" is all about. I know the concept, but I don't understand the group approach to problem solving, the way they do it in law school. I promise you that when you're a resident on call at 2 AM you won't have your "group" around to help you come up with the DDX. The next "group" you encounter will be when the residents come in at 6AM and you have to present to them the diagnosis you reached on your own, usually after little sleep.

It's not like "House", like when Dr. House needs to brainstorm he calls his team in to the chalk talk room at any hour of the night. Medicine is a lonely business, and the best diagnosticians in my experience have not been the product of Group Think.

 

[Gabby]

Would someone also tell this old timer what "Problem Based Learning" is all about. I know the concept, but I don't understand the group approach to problem solving, the way they do it in law school. I promise you that when you're a resident on call at 2 AM you won't have your "group" around to help you come up with the DDX. The next "group" you encounter will be when the residents come in at 6AM and you have to present to them the diagnosis you reached on your own, usually after little sleep

Did you just compare the diagnostic skills of an MS1 with that of a resident's?

 

[Cruzinman]

Gabby, I was not making that comparison. I believe that group learning has an inhibitory effect on your ability to eventually learning how to think on your feet. Most older doctors use their internal mental computer to comb through differential diagnoses. That computer, at least mine is best "programmed" by the solitary activity of hard thinking and going over things in my head many times over. By the end of MI the blank pages in my textbooks were covered with the "lists" of diagnostic symptoms. Group learning is partly active (your part of the assignment) and mostly passive (everyone else's part). When you're forced to do it on your own it becomes 100% active, and more permanently ingrained in your brain. As a result I can go through the mental exercise of constructing a differential diagnosis without having to resort to my my PDA, while I see many of my younger colleagues sitting at the nurses station consulting their PDA when it's time to make the DDX.

 

[DeadCactus]

MD, 1970-74. I don't care when you start seeing patients, put please lose the "standardized patient". I can promise you that when you get on the wards there will be no such thing. For example for every "textbook case" of acute appendicitis you will see three atypical presentations. You will feel very confident when you diagnose your first standardized patient presenting with cough, fever and pleuritic chest pain as lobar pneumonia until you see a similar presentation on the wards, tell your attending on morning rounds that everything is under control, and when you return for afternoon rounds your patient has died from a massive pulmonary embolism.

Think hard about that.

Must be a damn terrible attending if his medical students are killing his patients.

The point is to teach students the basic process of doing an H&P, creating a differential diagnosis, and presenting a patient. The five plus years of training after second year will handle the diagnosis and treatment part.

You can argue the value of a head start in learning those skills, but it's asinine to condemn them for not properly teaching a skill that's only tangentially related to the task at hand.

Still, I bet it serves them a hell of a lot better in diagnosing a PE than sitting through lectures on not f--king the patient or how evil physicians are and how nurses are the benevolent Saints of the hospital...

 

[Isoprop]

Gabby, I was not making that comparison. I believe that group learning has an inhibitory effect on your ability to eventually learning how to think on your feet. Most older doctors use their internal mental computer to comb through differential diagnoses. That computer, at least mine is best "programmed" by the solitary activity of hard thinking and going over things in my head many times over. By the end of MI the blank pages in my textbooks were covered with the "lists" of diagnostic symptoms. Group learning is partly active (your part of the assignment) and mostly passive (everyone else's part). When you're forced to do it on your own it becomes 100% active, and more permanently ingrained in your brain. As a result I can go through the mental exercise of constructing a differential diagnosis without having to resort to my my PDA, while I see many of my younger colleagues sitting at the nurses station consulting their PDA when it's time to make the DDX.

PBL isn't 100% group work. Sure, there's some group collaboration, perhaps even more than traditional lecture/lab. But most PBL students are doing more "active" learning than lecture-based folks because they have to go home, hunt down which pages of robbins or xyz journal articles that pertains to their case. They're not being spoon-fed powerpoint slides and lecture notes. And trust me, the exams are administered independently.

PBL is just a different way of presenting the basic sciences.

 

[deuist]

PBL is just a different way of presenting the basic sciences.

Presenting the basic sciences? Don't kid yourself. There is little to no teaching that occurs during PBL. It's all self-driven learning at $30,000 a year. Students who advocate this learning method like to boast, "Look how much I've learned." The problem is that as a medical student you are too ignorant to know how much is out there, much less where to begin.

 

[Isoprop]

There is little to no teaching that occurs during PBL. It's all self-driven learning at $30,000 a year.

And how is this different from traditional based learning?

 

[Mace1370]

And how is this different from traditional based learning?

It's not, but to claim that PBL is something super special is rather silly.

 

[Isoprop]

It's not, but to claim that PBL is something super special is rather silly.

I agree. I wasn't saying PBL was a special, elite form of medical education, and all other med students are missing out. I was just trying to clear up the misunderstanding that PBL is just group work where lazy students depend on each other to think.