Performance Medicine

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:


I stopped watching this show after a few seasons, but still…I miss McDreamy.

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 😉


11 thoughts on “Performance Medicine

  1. Great post! I like how you’ve compared clinical skills to a performance. So true! I do get tired of reciting my introductory soliloquy to the “patient” in the same tone of voice every time. But what’s odd is that they encourage us to stick to this script in skills, yet when put in hospital, the senior doctors tell you not to waste time going through everything. Ahh show business! Hopefully you are able to streamline and adapt the skills taught, as you said!

  2. Clinical skills and the ability to do a comprehensive physical will help you more than you know when you’re in the big bad world of hospital medicine. It’s so much easier to see the signs of the disease process when you don’t have to worry about where to find this pulse/ what the next part of the cranial nerve exam is… It will all be worthwhile soon I promise. The fact that you’re even worried about how it will translate to an interaction with a real patient means that you’re on the right track! Just keep swimming!

  3. It helps! 🙂 don’t worry, I used to comolain to but then again, how else would you learn to be thorough and systematic. The quick and concise way will definitely come out after you’ve practiced what you think is your script.
    Moreover I’ve encountered patients who asked me questions about almosr every move I made haha

  4. I feel you 1000% on this. For this reason I am much more nervous for the OSCE’s than I am for the actual assignments we have where we will be seeing and doing PE on actual patients. And same as you, I hope third year fills in the gaps and makes things more clear.

    • Surprisingly, I found the OSCE a bit awful to study for (mostly because I wasn’t quite sure how to, and live alone so I had no one to practice on) but really pretty good to do 🙂 And in terms of information I’ve actually retained long term, the OSCE and clinical skills exams are definitely the things I remember more than any lecture. But yes, it is super artificial, and I agree with you in the hope that with the ‘real’ patients in third year, those gaps can disappear! Thanks for dropping by 🙂

  5. Happy to see fellow med student bloggers. Great post. It’s interesting how we perform a full physical exam as an MS1 or MS2 and how that gets broken down into focused exams during third year. People will say you should always do a full exam as an MS3 with your patients, but then you’ll have attendings or residents who question why you performed a funduscopic exam on… almost any patient (without head or vision issues that is).

    • Thanks 🙂 Yes, it is an interesting contrast from skills to practice I think. I understand that the full physical is a very important skill, but so to are focused exams, which I hope clerkship will clarify for me. I was volunteering at a refugee clinic this weekend and the doctor asked me to do a “head and neck” exam, and I was like – eyes, hears, thyroid, lymph? – what does that mean? So it’s that kind of thing I hope MS3 will help with! 🙂

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