Clinical skills is sort of an interesting experience. On one hand, it is clearly a teaching tool for necessary skills that will be needed in actual practice. It’s a place to learn and develop these skills with experienced tutors, in a safe learning environment, with simulated patients.
On the other hand, it is artificial as can be.
Clinical skills is to practice, as this is to practice:
Clinical skills is a lot like a medical drama series: they sound and look like medicine, but in reality, they are both just a performance. Skills and medical shows both feature scripted scenarios: medicine practiced on healthy patients, with pretend findings announced out loud to the unseen observer. In tv this is the audience, in clinical skills this is the preceptor.
There’s this thing that tv and movies does, where a certain character explains something that everyone they are talking to already knows: “The patient’s BP is dropping, and as you know that means we have to____.” This is called exposition, and it is for the sole benefit of the observer – it’s information that the observer isn’t expected to know already, but needs to know to follow the plot. It’s usually a bit of a clunky thing: it feels artificial and strange, because you, as the observer, know that the characters knows this, that it’s for your benefit, and it can take you out of the drama if it is done too bluntly.
Clinical skills is basically 1-2 hours of exposition.
Skills is saying, “Ok, now I am going to…” and “If this patient has this, I would expect…” and “I’m observing for…” over and over again. It’s narrating your every action for the benefit of the observer, and yes, it definitely takes you out of the scenario of this being a “patient focused” encounter. The most you can really do is make sure you ask the patient if it is ok, and explain it to them, but even that can be recommended to be “toned down a bit” because you have limited time to complete your examination.
Now, this isn’t to say that clinical skills isn’t useful at what it is intended to do: teach us the mechanics of physical examinations. I think it definitely is useful in this, as a way to teach us skills to put in our “toolbox” for practice. But, an experience like I had this week – a one hour witnessed physical, where you just do an entire physical for an hour, narrating and performing for your preceptor (who acts unseen and doesn’t speak) – does make me wonder how these experiences are going to affect my interactions with real patients. This unseen narration style is also 100% not what will be used in clinical practice, and as I mentioned, not very patient focused.
I suppose clerkship will teach me how to apply these skills in a “real” way, but I definitely have noticed that clerks I’ve spoken to mention that there really is a cognitive dissonance in the way that skills are done once they come out of 2nd year and into clerkship. One clerk mentioned that she was observing a doctor do some MSK procedure and was trying to identify the special tests and their functions. The doctor she was observing just said “forget the specifics of skills, just think of what you need to examine on this patient based on function.” That sort of stuck with me as a clear example of how the way that we are taught these skills is not quite suited to practice. Sure, I can do a full MSK physical exam, but the likelihood of every doing that on one patient is pretty low. I hope clerkship – which is approaching uncomfortably fast! – does teach me how to streamline these skills, and bring the encounter back towards the patient.
Until then, I suppose I’ll just have to keep performing: the understudy, waiting for her chance at the real part 😉