My clinical skills suck

[Jabbed]

I have zero confidence in my clinical exam skills. What to do?

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[Psai]

What year are you

 

[Serous Demilune]

Find a PDF of Bates Guide to Physical Exam and History Taking

 

[ACSurgeon]

I have zero confidence in my clinical exam skills. What to do?

How do you define clinical skills? What field do you think you're going into?

 

[Doctor Bob]

Patients will very easily pick up on your lack of confidence. If nothing else, you need to develop confidence in what little you do have.

 

[Jwalker]

Practice?

 

[PL198]

neither does anyone else

 

[Jabbed]

How do you define clinical skills? What field do you think you're going into?

Physical exam proficiency and basic procedures. Looking at CCM as an endpoint, not sure about the residency yet.

 

[Jabbed]

Find a PDF of Bates Guide to Physical Exam and History Taking

Tried and failed. I'm very much a textbook learner, but I hated Bates.

 

[qw098]

Tried and failed. I'm very much a textbook learner, but I hated Bates.

I'm not a huge fan of Bates either. The following website is SUPERB!

http://meded.ucsd.edu/clinicalmed/abbreviation.htm

 

[VisionaryTics]

The trick is practice. Do thorough exams as much as possible, and actively seek out positive findings and procedures. Really pays dividends in developing your confidence and skills.

 

[Mass Effect]

Telling us what year you are in school would be beneficial to answering this question.

 

[caffeinemia]

My clinical exam skills are at my finger tips. Click click - order EKG, CXR, Abdominal CT, Echo. Boom.

 

[Jabbed]

Telling us what year you are in school would be beneficial to answering this question.

M2.

 

[tiedyeddog]

M2.

Don't sweat it. Once you hit the clinical years your exam skills will start to blossom. It is something learned through repetition. No one is born with it, you get it with experience. Those who act like they are born with it are great at faking it.

 

[cbrons]

I feel like my exam skills are pretty terribad as well, but I think I have enough confidence that things usually are not awkward for the patient. I notice I am improving the more I do. One thing I really want to improve is my presentation skills, though. Haven't really found a good resource to help with that.

 

[Jabbed]

Don't sweat it. Once you hit the clinical years your exam skills will start to blossom. It is something learned through repetition. No one is born with it, you get it with experience. Those who act like they are born with it are great at faking it.

Is there anything that I can do now before the clinical years? I feel that I haven't been properly instructed, so something in the way of a video instructional would be ideal.

 

[Ismet]

Is there anything that I can do now before the clinical years? I feel that I haven't been properly instructed, so something in the way of a video instructional would be ideal.

You'll need to be a bit more detailed about what your weaknesses are. Were you not taught the parts of a basic physical exam? Can you do the parts of a focused cardiac (or lung or abd or MSK etc) exam? Or do you just have trouble putting it all together? If it's the latter, 3rd year will solve that quickly. You'll be doing so many H&Ps on several rotations that it will become second nature. The key is to practice in the same order each time so that order becomes ingrained and you're sure to not miss a step.

Bates has videos, that'll probably be your best bet: https://batesvisualguide.com/

 

[Mass Effect]

Is there anything that I can do now before the clinical years? I feel that I haven't been properly instructed, so something in the way of a video instructional would be ideal.

What, specifically, do you feel weak in? As an M2, you SHOULD feel your exam skills are weak because they likely are. This will improve dramatically within a few months of third year. But is there anything in particular you felt you weren't taught well? Do you know where to put the stethoscope to listen to the heart? Lungs? Abdomen? Do you know how to test for range of motion of the neck, the arms, the hips, and the knees? Do you know how to check the cranial nerves? Really, that's all that's expected of you at this point (and the cranial nerve thing is borderline).

 

[Mad Jack]

Tried and failed. I'm very much a textbook learner, but I hated Bates.

Weird, I really like Bates. It's a solid book, physically and information-wise.

 

[tiedyeddog]

Is there anything that I can do now before the clinical years? I feel that I haven't been properly instructed, so something in the way of a video instructional would be ideal.

You absolutely don't need to do this but you can:
1. do some time in a free clinic. Ask the preceptors there to show you a proper exam
2. find a preceptor/mentor in IM or family med. Ask them to show you proper exam during clinic.

 

[Armadillos]

As an MS4 I honestly feel like 99.99% of diagnostic clinical skills are history taking, then just looking at the patient and ordering labs/imaging. Ironically, surgeon's abdominal exams seem to be about the only physical exam maneuver from the standard exam that consistently influences treatment. Obviously im exaggerating before everyone gets on my back. But that being said, medstudents get so excited about physical exam maneuvers, but of the whole exam just looking at the patient has to consistently provide the most clinically relevant information.

 

[Jabbed]

You'll need to be a bit more detailed about what your weaknesses are. Were you not taught the parts of a basic physical exam? Can you do the parts of a focused cardiac (or lung or abd or MSK etc) exam? Or do you just have trouble putting it all together? If it's the latter, 3rd year will solve that quickly. You'll be doing so many H&Ps on several rotations that it will become second nature. The key is to practice in the same order each time so that order becomes ingrained and you're sure to not miss a step.

Bates has videos, that'll probably be your best bet: https://batesvisualguide.com/

Those videos are exactly what I'm looking for, thank you.

I was instructed on how to perform the basic and focused exams, but I honestly feel that I'm just going through the motions more so than actually examining the patient. I frequently wonder "what am I even looking for?" as I palpate. Heart/lung sounds are hit or miss for me. Anything that requires actual technique, like thyroid palpation or a fundoscopic exam, completely escapes me.

Overall my exam is also very disjointed and I'm frequently forgetting things. I mostly chalk this up to my poor understanding of the maneuvers and their relevance in the first place.

 

[Ismet]

Those videos are exactly what I'm looking for, thank you.

I was instructed on how to perform the basic and focused exams, but I honestly feel that I'm just going through the motions more so than actually examining the patient. I frequently wonder "what am I even looking for?" as I palpate. Heart/lung sounds are hit or miss for me. Anything that requires actual technique, like thyroid palpation or a fundoscopic exam, completely escapes me.

Overall my exam is also very disjointed and I'm frequently forgetting things. I mostly chalk this up to my poor understanding of the maneuvers and their relevance in the first place.

What you are describing is pretty much what every other MS2 feels. You are at the right stage. Physical exam in pre-clinical is understanding the motions, physical exam in 3rd year is applying the exam to the patient's complaints. Heart/lung sounds are hit or miss for every MS2. If you mastered those skills, you wouldn't need a physical exam course. It takes practice to train your ear to listen for murmurs/gallops. Thyroid palpation escapes many people much farther along in training unless there's something obvious or unless there's something in the patient's history that makes you suspect something might be wrong. And you really can't do a fundoscopic exam unless the pupils are dilated, which you'll do if you have to do an eye exam in the ED or something.

I think you'd especially benefit from coming up with an order and always doing it in that order. You need a strong and broad foundation before you can start narrowing your exam down for a focused physical. Because most exams you do in 3rd year and the rest of your life are not this all-inclusive exam they teach you in pre-clinical (I've talked to 1st and 2nd years who were surprised to find out that, no, you do not percuss the liver in every patient. lol). You tailor the exam to the patients' complaints.

 

[tiedyeddog]

What you are describing is pretty much what every other MS2 feels. You are at the right stage. Physical exam in pre-clinical is understanding the motions, physical exam in 3rd year is applying the exam to the patient's complaints. Heart/lung sounds are hit or miss for every MS2. If you mastered those skills, you wouldn't need a physical exam course. It takes practice to train your ear to listen for murmurs/gallops. Thyroid palpation escapes many people much farther along in training unless there's something obvious or unless there's something in the patient's history that makes you suspect something might be wrong. And you really can't do a fundoscopic exam unless the pupils are dilated, which you'll do if you have to do an eye exam in the ED or something.

I think you'd especially benefit from coming up with an order and always doing it in that order. You need a strong and broad foundation before you can start narrowing your exam down for a focused physical. Because most exams you do in 3rd year and the rest of your life are not this all-inclusive exam they teach you in pre-clinical (I've talked to 1st and 2nd years who were surprised to find out that, no, you do not percuss the liver in every patient. lol). You tailor the exam to the patients' complaints.

excellent advice. The targeted physical exam is also good advice. Attendings love to see that.

 

[JP2740]

You are year 2. Worry about step 1 and only step 1. Relax, breathe, don't even think about this **** right now. Step 1 only.

 

[jdh71]

Looking at CCM as an endpoint, not sure about the residency yet.

Oh. This is just treating numbers and images anyway. All you really need to know how to do is order labs and films. Practice mouse clicks.

 

[NontradCA]

I'm an M1. We do H & Ps out in clinic and I feel like an absolute idiot. It doesn't help that the resident pimps me on systems we haven't even covered yet. It's just a mess

 

[Ismet]

I'm an M1. We do H & Ps out in clinic and I feel like an absolute idiot. It doesn't help that the resident pimps me on systems we haven't even covered yet. It's just a mess

You'll be fine. Gotta start somewhere.

 

[PL198]

As an MS4 I honestly feel like 99.99% of diagnostic clinical skills are history taking, then just looking at the patient and ordering labs/imaging. Ironically, surgeon's abdominal exams seem to be about the only physical exam maneuver from the standard exam that consistently influences treatment. Obviously im exaggerating before everyone gets on my back. But that being said, medstudents get so excited about physical exam maneuvers, but of the whole exam just looking at the patient has to consistently provide the most clinically relevant information.

so much this. physical exams are so subjective and they're just going to mean less and less clinically over time.

 

[JP2740]

Basically, you'll figure it out during 3rd year. It isn't worth taking a moment of your brain to think about anything other than step 1 unless it is something you do to naturally take a break from medical school. Don't let anyone tell you otherwise.

By the way, surprise surprise, other med students have been in your shoes before. I was one of them. It didn't matter a single damn bit. You're good.

 

[ACSurgeon]

Physical exam proficiency and basic procedures. Looking at CCM as an endpoint, not sure about the residency yet.

You'll learn all this during your clinical rotations and residency/fellowship. It's good that you have enough insight to realize you need more practice. Take advantage of rotations to get as much exposure as possible. Ultimately, you will become very good at examining patients within your field (e.g. I'm very good at abdominal exams, less so with complicated neuro exams).

 

[Nephronlearner]

Keep in mind that what I am telling you here may not be the perfect solution for you since the emphasis put on clinical examination over here may be greater than in the US, but I will try to help regardless.

Anyway, the purpose of the clinical examination course in pre-clinical years is to familiarise you with the basic examination techniques. You can't become proficient at it until you have spent a considerable amount of time on the wards. Until then, you can't know what to look for. That's why I believe the best resource for you would be a good video collection. You can find lots of excellent videos on youtube.
Swartz or Bates videos are probably good enough. If you want more details, consider Macleod.
Also, try to look at the typical H&P form used at the hospital you were assigned and try to memorise how it's structured, what is written on it, etc.

Then later on, when you already know the clinical presentation of diseases, you should (if you have the time) try to read an actual physical exam book to review common presentations and signs to look for. Also, those books will generally tell you the important questions to ask depending on the presenting symptom.
Choice of the book will depend on how much detail you want and how proficient you want to be. I have Swartz, Talley & O'Connor (Australian book I believe, I may be wrong, though), little Bates and Oxford handbook. Given that your time is probably very limited, Swartz is probably a better choice than Talley (or Sapira, I have heard good things of that book too, but, again, it seems quite long). I found Oxford handbook more readable than little Bates (as pocket reference).

There is also a website "practicalclinicalskills" with plenty of recordings of different heart and lung sounds. I believe the University of Michigan website also has a free online auscultation module.

Your history taking skills will also probably improve with time. As you learn clinical features of diseases, you will also learn what to ask the patient.
Finding good history taking videos is trickier. I know that the University of Bristol (UK university) has a history taking video course, I am not sure about others.

To give you an example: in your second year, you are probably expected to perform a basic cardiovascular exam, involving palpation and auscultation and just writing down whatever you notice. You can't be proficient at listing all the "important negatives" and minor findings that senior doctors do.
If your patient has congestive cardiac failure, you should ask about dyspnoea, paroxysmal nocturnal dyspnoea, cough, etc. In order to do so, you need to be very familiar with the symptoms of cardiac failure. Then when examining the patient, you should look for oedemas, jugular venous distension, heave on palpation, displaced apex beat, cyanosis, etc. And finally you learn what tests to order. But I doubt that is expected before you actually start clinical rotations.
Videos should be adequate for now!
(hint: alternative solution - just perform echo and see the big lazy heart)

I hope I have helped

 

[PikminOC]

M2.

If you were a midlevel, youd be done with your education right now.

 

[dextor2003]

So all of you guys say don't worry about it for now, and that we'll get better with practice during clinicals, which definitely is a huge relief. But then I guess I'm also concerned how preceptors perceive this during those initial months when we're just starting to pick up the skills. If they don't expect perfection from the very beginning (hopefully at least), then just how forgiving/understanding have preceptors been from your guys' experience in regard to your not-so-great clinical skills during those early months? Obviously no one wants a bad letter or grade, so then is improvement the biggest thing they base them on as opposed to competence?

 

[tiedyeddog]

So all of you guys say don't worry about it for now, and that we'll get better with practice during clinicals, which definitely is a huge relief. But then I guess I'm also concerned how preceptors perceive this during those initial months when we're just starting to pick up the skills. If they don't expect perfection from the very beginning (hopefully at least), then just how forgiving/understanding have preceptors been from your guys' experience in regard to your not-so-great clinical skills during those early months? Obviously no one wants a bad letter or grade, so then is improvement the biggest thing they base them on as opposed to competence?

They perceive you as a brand new MS3 who doesn't know jack, just like all of your classmates.

 

[MTCS]

you're not supposed to be good yet. you're only expectation is that you actually know how to do an exam.

 

[The new guy]

I have zero confidence in my clinical exam skills. What to do?

I'm with you, Op. I am a first year and we haven't had any lessons on how to do a physical exam. But we shadow physicians and sometimes they tell us to roll up our sleeves. Some of my classmates are really good at faking confidence even if they have no idea what's going on. I am not one of those. From what I've seen, there is no correlation between confidence and actual medical knowledge, some of my most confident classmates are the ones who are barely passing. For those of us without this natural gift, I think (hope) it will get easier with practice.

 

[PL198]

2nd year was a big jump in physical exam skills IMO even though we didn't spend a ton of time on it. things just start clicking more and making sense. memorize the order you go through things now and it'll stick with you forever. then once you understand the reasons behind everything, it'll be 2nd nature and you can do them like its nothing and actually look for stuff

 

[Ismet]

I'm with you, Op. I am a first year and we haven't had any lessons on how to do a physical exam. But we shadow physicians and sometimes they tell us to roll up our sleeves. Some of my classmates are really good at faking confidence even if they have no idea what's going on. I am not one of those. From what I've seen, there is no correlation between confidence and actual medical knowledge, some of my most confident classmates are the ones who are barely passing. For those of us without this natural gift, I think (hope) it will get easier with practice.

You're almost done with first year and they haven't taught you the physical exam yet??? Usually by this time of the year you're starting to do H&Ps

 

[The new guy]

You're almost done with first year and they haven't taught you the physical exam yet??? Usually by this time of the year you're starting to do H&Ps

We know how to do histories but not physicals. I think we do physicals next year.

 

[Ismet]

We know how to do histories but not physicals. I think we do physicals next year.

That sucks :/ Sorry. If you want to teach yourself the basics so you can be more confident when you're with docs, check out the Bates videos posted above!

 

[TheWorldWarrior]

H&P classes before clinicals were basically guidelines for me. I realized quickly during 3rd year, one rarely gets to do a complete H&P on a patient [they may say OK, but then you can see the annoyance after the first 30 minutes hahaha]. Best way to get better is to do exams, on real people, with real findings.

The NEJM had an excellent overview of breath sounds this past year; "The Fundamentals of Lung Auscultation";

http://www.nejm.org/doi/full/10.1056/NEJMra1302901

I suggest all read this article; it will help you not sound like an idiot, saying things like "course crackles"; i mean WTH are course crackles [got chewed out by a critical care attending during rounds; fixed myself and now we're cool]. Ask your residents to go over physical exams [just one system or parts of a system at a time, and focus on doing them correctly].

Other examples: I used to be terrible at heart sounds until a resident told me to use the peripheral pulse as a guide for S1; now heart sounds are easy. You only need to know whether something is systolic or diastolic [if it's new they're gonna get an echo anyway; everything is usually grade 3]; systolic is meh though sometimes serious; diastolic always pathologic.

Neuro exams may take the longest for some people; try to get a good neuro rotation; ask your attending or senior resident to go over one part of the neuro exam each day e.g. reflexes, proprioception, cranial nerves 1-5, 6-12 etc, cerebellar, sensation etc. I fortunately had a great neuro rotation, which gave me enough freedom to see consults on my own; i floundered several times but as a result, am now super comfortable with a neuro exam.

Last: Never say you did an exam when you didn't. Whenever you admit someone with abdominal pain, always do a rectal/guiac; you'll look good.

If you haven't realized, the key to all of the above is to do exams, and tell people about them; part of being a student, and even a resident is to make some mistakes and learn from them; no one is perfect. If you think you hear a heart murmur, speak up. If you hear crackles, rales, rhonchi; speak up. If you think a patient has cerebellar findings speak up. No one expects any student/resident at the very least to be perfect; they expect you to try and [study, of course].