Learning Clinical Skills

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kl323

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So I'm a second year and my school has been having these mini sessions to teach us how to do various clinical exams.

Anyway, those sessions provide good exposure but is absolutely unable to help me learn the skill. I do realize that most of the clinical skills stuff are learned on the floors.

My concern is... will the residents /attendings/ upperclassmen be "teaching" those skills? Or are students left to do these exams over and over until it finally clicks?

Some stuff I have trouble with --- Heart sounds. I can't for the life of me hear the S1/S2 split on inspiration. Otoscopy. I can't find the tympanic membrane. I'm very nervous with putting the scope too deep. I've tried on my parents, but they've been very nervous with letting me try it out on them. My mom cringes even before I put the scope in. Fundoscope. Maybe I bought a cheap lousy scope, but I've only seen a vessel ONCE. Funny thing is, I saw the vessel using someone's Welch Allyn scope. My no brand name eBay scope was good for nothing.

Anyway... ideas? Suggestions?

I know I gotta keep doing it over and over and over and over again. I'm very tempted to get a decent scope for long term use. (Yes I know it's been debated over and over again about how much we'll actually use it after med school... but I think it's a worthwhile investment especially if I'm going to be a doctor...)
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You will learn the perfect your skills on the wards. By now you should know what normal sounds or looks like as well as the maneuvers to the physical exams. As you do more and consciously look for any pathology you gradually get better and faster.

Example: True you may have a hard time with heart sounds now but if you take the time to carefully listen and document what you heard you can easily confirm later with a resident or with an echo report. That is part of the learning process.

For the otoscope, you should NOT be putting in the otoscope deep at all. You just need to angle it properly (towards the eyes)! Practice on a friend.

and etc.

edit: the worse thing you can do is to go through the motions and not actively think about what you are trying to look for based on the history. That will lead to poor physical exam skills for sure.
 
kl323 said:
I know I gotta keep doing it over and over and over and over again. I'm very tempted to get a decent scope for long term use. (Yes I know it's been debated over and over again about how much we'll actually use it after med school... but I think it's a worthwhile investment especially if I'm going to be a doctor...)
Click to expand...

Practice does not make perfect. Perfect Practice makes Perfect.

In general, residents will not teach you and most will not even observe you doing a physical. Your exposure to the "right way" will be limited exposure to specific exam manuvers you get from residents and attendings. The temptation, then, is to copy what they do. Xeroxing a Xerox makes for a pretty crappy image. Since the educational structure has been set up for trainees to simply copy without explanation the physical exam manuvers of their superiors, you will be copying residents who copied their residents who copied their residents. This has prompted some training programs (Like Hopkins Bayview) incorporating a "physical diagnosis" course in their intern year for medicine, breaking old habits and actually telling people what the right way is.

If you are serious about clinical skills I suggest you invest in two books: Bate's Guide to Physical Examination and History and Sapira's Art and Science of Bedside Diagnosis. Bate's is a pirmer, perfect for an introduction to what needs ot be done. Sapira is DENSE. Like painfully dense, but will open your eyes. Honestly, how many people know how to do a Murphy's sign? (left hand along the costal margin, thumb perpindulcar to the axis of the patient and the ground? really knew it?)

I would also suggest you get a mentor. Likely, there is someone in charge of your physical diagnosis course. Ask them if there is a resident or attending who is particularly good at these skills, and get into their clinic or on their service. Even an upper level med student will do if they are good at it.

Finally, after mentorship and advanced reading, its time for perfect practice. What the hobbit was saying is absolutely true, but only after you know what you're doing for real. Not you THINK you know what you're doing, but ACTUALLY know what you're doing. The more time you take with your patients, the less "thumb-up-butt" time you'll have on the wards. Say you're interested in the physical exam, go around spending your free time practicing the physical exam. It will come.

And finally, Sam hit it right on the head. You must correlate what you find on actuall imaging. Thats how you know if you got it right or wrong. Correlation with imaging is best. Correlation with a mentor is often sufficient.

You will be amazed that what you find challenging now (heart sounds) becomes innate, allowing you to focus on heaptojulgular reflex and Grocco's triangle of pleural effusions.

1. Read (Bate's and Sapira)
2. Mentor (DO residents generally do the physical exam WAY better than MDs
3. Practice (Free Clinics, on the wards, many, many patients)
4. Correlate (Mentors, Imaging)
 
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I'm honestly not trying to be a douche, but what you will hear is the "splitting of S2." You should hear the aortic valve close first then the pulmonic valve, during inspiration.

I hope you can hear the splitting of S1 and S2.
 
dont waste your money or time on big bates, the baby bates is useful for quick reference, and also fits in your pocket!
 
kl323 said:
So I'm a second year and my school has been having these mini sessions to teach us how to do various clinical exams.

Anyway, those sessions provide good exposure but is absolutely unable to help me learn the skill. I do realize that most of the clinical skills stuff are learned on the floors.

My concern is... will the residents /attendings/ upperclassmen be "teaching" those skills? Or are students left to do these exams over and over until it finally clicks?

Some stuff I have trouble with --- Heart sounds. I can't for the life of me hear the S1/S2 split on inspiration. Otoscopy. I can't find the tympanic membrane. I'm very nervous with putting the scope too deep. I've tried on my parents, but they've been very nervous with letting me try it out on them. My mom cringes even before I put the scope in. Fundoscope. Maybe I bought a cheap lousy scope, but I've only seen a vessel ONCE. Funny thing is, I saw the vessel using someone's Welch Allyn scope. My no brand name eBay scope was good for nothing.

Anyway... ideas? Suggestions?

I know I gotta keep doing it over and over and over and over again. I'm very tempted to get a decent scope for long term use. (Yes I know it's been debated over and over again about how much we'll actually use it after med school... but I think it's a worthwhile investment especially if I'm going to be a doctor...)
Click to expand...

Ha! I'm glad I'm not the only one to feel this way. ;)

Especially re: otoscope. Truth is, I think a lot of your classmates "think" they see the tympanic membrane, when all they're really looking at is a patchy whitish piece of the ear canal. For realz. This is something an ENT doc said to me, btw, followed by "let's just be honest." :laugh:

I actually think it's one of the harder skills, despite seeming one of the easiest. This is 'cuz ppl's ear canal anatomy is different (curvature-wise), there's ear wax obstruction, and the membrane itself can look quite different from person to person.

With heart sounds-- actually I found that when I tilt my head forward a little, I end up hearing a TON better. Because the ear plug piece actually doesn't fit entirely properly if my head is at 90 degrees... but when I tilt my head, it occludes more & the sound is more clear. Until I figured this out, it was hard to hear much. These are the kinds of things you figure out for yourself about what works & doesn't... 'cuz no one would've told me that.

Fundoscope. I had a hard hard time too, until one day I got CLOSE (really close) and saw vessels. I've heard of 2 approaches: 1) come in at an angle from the side (this didn't work for me, even tho' this is what a lot of ppl say is "proper"). 2) come in more from the front-- but find the red reflex, then just follow the red reflex until you get in really really close... then all of a sudden, it works.

Btw... I'm really hoping that once we are on the wards and see the pathology, we'll be more certain about what "normal" looks like. I disagree with the above poster who said that by now we should know what normal looks like... Sometimes you really don't have a good handle on what's "normal" until you truly see an enlarged thyroid, or palpate a prostate cancer... then you can go back & think... ok, so That is what a hard cancer feels like... so everything else I was feeling was the texture of the normal prostate. Etc.
 
Some stuff I have trouble with --- Heart sounds. I can't for the life of me hear the S1/S2 split on inspiration.
Click to expand...

Dirty little secret is that there are brilliant cardiologist that can't auscultate these days
-old cardiology attending

but seriously

just know what normal is so you can put it in notes (modify of course according to reality)

NR, RR, good s1 and s2, no m/r/g, pulses +2 x4, no JVD, no edema
 
agree with above poster, you need to get Bates, it's one of the best books I've ever seen over physical exam.

Auscultation of the heart just takes ton of practice and hearing abnormal sounds vs normal sounds over and over again.

Seeing the tympanic membrane is quite easy, just put the external ear back, so the canal is relatively straight, hold the scope horizontally, make sure your 4th and 5th finger is touching the patients cheek (so that when you go further than they are comfortable, your hand dampens their jerk reaction so you dont poke thru!), and just look, you ll have to go in deeper than you would feel comfortable, but it's not that deep. The tympanic membrane has light reflex whereas wax does not.

Seeing the fundus is near impossible w a really cheap scope and undilated eye (but it can be done), like above poster said, go in from an angle, find the red reflex from far away, then just track that in, make sure patient is looking up a little and away! It really is hard to do though. Practice on someone with a big pupil if you can't dilate them.

It really is practice and muscle memory until you can get this all down, and practicing allows you to think about the logistics, ie how to remove the gown when you listen to heart etc, which you won't really get just from reading

Good luck!
 
OveractiveBrain said:
2. Mentor (DO residents generally do the physical exam WAY better than MDs
Click to expand...

Murphy Brown said:
Not to hijack the thread, but I found this interesting. Do you know why that is?
Click to expand...

So, this is a personal observation, not a grossly overarching statement. Ive seen the comfort level of the DOs with touching the patient versus the awkward tension of all but a few good MD residents. I've seen the "second year going through the motion" exam of MDs and actually took away something from the DOs. Have I had good MDs? Hell yeah. My best instructors have been MDs. But when it comes to some random 3rd year Med Student wanting to investigate the physical exam more thoroughly, the DO is the one I would turn to.

I think it is a product of two things:

(1) Selection: DOs who get allopathic spots are generally superior to their classmates, and also superior to other MD graduates. Its just harder to get an allopathic residency as a DO than it is as an MD, so getting an allopathic spot requires a stronger applicant.

(2) Training: DOs do OMM. They are trained to TOUCH, FEEL, and MANIPULATE the patient. MDs are trained in H+P--> LAbs. Sure we get talked at about the physical exam, but often its left as a followup to the laboratory, a cursory "i did it" or "see, physical exam correlates with the imaging." MD training just doesn't focus on the importance of the physical exam as much as DO training does.

As a followup Id say that a good MD is superior in management and working up a patient than a good DO. But I would, hands down any day, take a great DO over a Mediocre MD. The knowledge base is essentially the same with a different focus, a focus more on the being of the patient (DO) rather than the being of the disease (MD).

I am an Allopath, in case people are wondering.
 
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OveractiveBrain said:
So, this is a personal observation, not a grossly overarching statement. Ive seen the comfort level of the DOs with touching the patient versus the awkward tension of all but a few good MD residents. I've seen the "second year going through the motion" exam of MDs and actually took away something from the DOs. Have I had good MDs? Hell yeah. My best instructors have been MDs. But when it comes to some random 3rd year Med Student wanting to investigate the physical exam more thoroughly, the DO is the one I would turn to.

I think it is a product of two things:

(1) Selection: DOs who get allopathic spots are generally superior to their classmates, and also superior to other MD graduates. Its just harder to get an allopathic residency as a DO than it is as an MD, so getting an allopathic spot requires a stronger applicant.

(2) Training: DOs do OMM. They are trained to TOUCH, FEEL, and MANIPULATE the patient. MDs are trained in H+P--> LAbs. Sure we get talked at about the physical exam, but often its left as a followup to the laboratory, a cursory "i did it" or "see, physical exam correlates with the imaging." MD training just doesn't focus on the importance of the physical exam as much as DO training does.

As a followup Id say that a good MD is superior in management and working up a patient than a good DO. But I would, hands down any day, take a great DO over a Mediocre MD. The knowledge base is essentially the same with a different focus, a focus more on the being of the patient (DO) rather than the being of the disease (MD).

I am an Allopath, in case people are wondering.
Click to expand...

In my opinion, this is naive and grossly oversimplified.
 
nlax30 said:
+1 Agreed.
Click to expand...

Thank you for your input. It is meaningful and, in the context of our conversation, contributes significantly to the advancement of the practice of clinical skills.

As the human torch says "FLAME ON!"
 
To address the op we don't get to clerkships without being able to do an entire physical properly in under 10 minutes. Just takes practice.
 
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Upcoming 2nd year here. Should I get the big bates or pocket bates?
 
It is just doing it over and over again. Technique is obviously important, but I wouldn't get as bogged down in how you are holding something or approaching if you are getting the information needed without discomfort to the patient.

A huge chunk of docs hold the otoscope wrong.I tried doing it the right way for a long time and then one day I just said, "screw it" and did it with what was comfortable and visualized the TM right away on the next couple of people. I'm on the taller end of the spectrum and it was just too difficult to manipulate from such an odd angle while all hunched over for me.

I'm kind of surprised this is a second year thing though? We learn to do a (mostly) complete physical exam by the end of first year while having preceptors to make us do stuff. Then at the end we are with a primary care doc for a month seeing patients all day. Our second year clinical sessions are dedicated with the proper way to interact with a translator, pediatric exams, hostile or argumentative patients, internal gyn, etc. Then we have clinical skills sessions to learn IVs, catheters, suturing, ACLS and all that junk.
 
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