A brief history of clinical skills
Clinical is derived from the Greek ‘klinikos’, which means ‘pertaining to or around the sick bed’. Throughout this module the term ‘clinical skills’ refers to those clinical examination and procedural skills commonly performed in real or simulated clinical environments.
Clinical examination developed from several sources from 2000BC, including the practice of the Ancient Egyptians and Ayurvedic practitioners. The basic examination procedures were developed further by the schools of Hippocrates (450BC) and Galen (200AD), who introduced the concept of ‘taking a history’ or more pertinently, listening to the patient’s story, progressing to a ‘focused’ examination of the patient. These ancient scholars gave us the concept of using the five senses (tasting, observing, touching, listening and smelling) to diagnose what was wrong with the patient. With the exception of tasting (!), they still form the basis of a physical examination.
Over the next 1,000 years, influenced by the great Islamic physicians Avicenna and Razi in Baghdad (900–1000AD), today’s approach developed: taking a history followed by a systematic clinical examination. The examination procedures in use today have changed little since the formalisation of medical education in Europe and North America in the 19th century, although during the past 50 years clinical procedures and investigations have become increasingly augmented by the various technologies involved.
Until recently, the teaching and learning of clinical skills invariably occurred at the patients’ bedside or other clinical areas, augmented by small and large group teaching in the classroom and lecture theatre. This ‘apprenticeship model’ (Hays, 1999) allowed direct observation and performance of skills overseen by senior clinicians. This was not always ideal. Patients were often talked about or over, rather than talked to or with, and the guiding principle of ‘see one, do one, teach one’ was not always the easiest (or safest) method for the patient.
The past 20 years has seen a changing clinical environment and working practices, the introduction of ‘clinical skills labs’ and the dominance of the objective structured clinical examination (OSCE) as the main clinical assessment tool. Students have been encouraged to seek other methods of acquiring clinical skills and we now have a generation of young doctors who have increasingly substituted rather than augmented clinical experience. In doing so, we have removed some key elements of the clinical experience that cannot be replicated by the safety and protection that simulation offers. This is particularly true of intimate examinations including breast, external genitalia and rectal examination.
Think of your own preferences as to when and where you teach clinical skills. How does your practice reinforce the needs to examine ‘real patients’ as well as ensuring students/trainees are competent and safe before doing so? How do you assess this learning?