Do clinical skills matter?
During the past 150 years the advancement of medical science and technology coupled with an ever-changing clinical arena and demands has brought into question our continued passion for the teaching and learning of these ‘ancient arts’. So do we still need these ‘shaman-like’ skills? Why listen to a patient’s heart when you can get an echocardiogram? Why lay your hands on the patient’s abdomen or perform a complex set of neurological examinations when you can obtain a detailed view through an ultrasound or MRI scan? A chest radiograph will confirm pneumonia or a pneumothorax, a urine dipstick and full blood count will confirm or refute a urinary infection.
In fact, why bother with any examination at all?
Reviewing the limited evidence on the subject (see, for example, Sackett, 1992; Spiteri, 1988; Joshua, 2005) there does not appear to be any strong support for the retention of the teaching and learning of these skills. Reviews looking at inter-observer agreement (see Joshua et al., 2005) noted that inter-rater reliabilities and agreement were invariably low when doctors were asked to identify the presence or absence of many clinical signs, especially the more complex and difficult (or is that rarely performed?), e.g. whispering pectoriloquy (Spiteri et al., 1988). The sensitivity and specificity of clinical signs in many of the included studies are often called into question and would certainly exclude their use as ‘diagnostic’ if strict criteria were to be applied.
So how do we justify our continued devotion to these particular professional activities?
- Other than ‘confirming the diagnosis’ what other functions does physical examination serve in the modern consultation?
If we are humble enough and not dazzled by the skills of those 'master-clinicians' of the 19th and early 20th century, we may begin to answer these questions. There is no mention in the literature of how often clinicians agreed that a patient was ill and needed further investigation and treatment. To argue whether they failed to detect the ‘radiologically obvious‘ pleural effusion or that they missed a clinically insignificant heart murmur is probably unimportant. Being able to categorise patients as unwell or well and then using knowledge, skills and investigations to provide the cause and most beneficial treatment should be our goal, and the more we can arm our students and trainees in this pursuit the better.
In trying to divide the well from the unwell, clinical examination fulfils several other important roles.
- Examination is an integral part of the doctor–patient relationship. The simple ‘human effect’ of listening to and touching a patient can be intrinsically reassuring and comforting. Within this relationship, trust is essential, not only to be able to perform parts of the examination itself but also in subsequent decision making and management. It is very hard to convince a patient that they must undergo various, occasionally invasive and possibly painful, investigations if they have little trust in the clinician.
- The examination may provide important information about the diagnosis, prognosis and severity of the patient’s condition.
- The examination enables decisions to be made regarding appropriate investigations and therapy.
- Thorough, systematic examination may narrow or confirm a diagnosis where the patient gives little or no history, or presents with vague or non-specific symptoms.
- An ‘incidentaloma’ may be thrown up by systematic examination.
- And of course, examination allows us to gauge the success or otherwise of treatment.
Flegel (1999) suggests that clinical examination skills are the bridge between the patient’s history and the investigations required to make a diagnosis: an ‘adjunct to careful, technology-led investigations’. Thus clinical examination confirms diagnostic suspicion from the history, and directs the investigations and further management of the patient. In the NHS of the 21st century, with increasing economic consideration placed on everything we do, it may be argued that we should be increasing the teaching and learning of clinical skills, honing our skills to make expensive investigation focused and appropriate.
In the next section we will consider the different environments in which the teaching of clinical skills takes place.
- Before you begin the next section, list your main considerations when planning a teaching session involving clinical skills.
- How do you maximise the learning experience of the clinical environment for your students or trainees?
- What other clinical opportunities could you provide for the learners to practise their skills?