Windsor University School of Medicine has made it mandatory for all its students to learn History taking skills on a patient with physical diagnosis. These sessions will be scheduled once a week from the first semester and will be introduced in the master class schedule. it is mandatory that all students will be required to attend the session.

History and physical diagnosis sample is presented below

Clinical Competence SkillsClinical Competence Skillscapacity = requirement capacity = requirement

““the habitual and judicious use of the habitual and judicious use of communication, knowledge, communication, knowledge,

technical skills, clinical reasoning, technical skills, clinical reasoning, emotions, values, and reflection in emotions, values, and reflection in daily practice for the benefit of the daily practice for the benefit of the individuals and communities being individuals and communities being

served”. served”.

CompetenciesCompetencies

Effective Communication (asking, listening & responding)Effective Communication (asking, listening & responding) Basic clinical skillsBasic clinical skills Using science to guide DMTPUsing science to guide DMTP Life-long learningLife-long learning Self awareness, self-care & personal growthSelf awareness, self-care & personal growth Social & community context of health careSocial & community context of health care Moral reasoning &Ethical judgementMoral reasoning &Ethical judgement Problem-solvingProblem-solving ProfessionalismProfessionalism

ComponentsComponents

Identify: able to relate to people in Identify: able to relate to people in distress distress

Empathy: make them comfortable Empathy: make them comfortable Active listeningActive listening Communication skillsCommunication skills Patient safetyPatient safety Knowledge & Clinical reasoningKnowledge & Clinical reasoning Technical or procedural skillsTechnical or procedural skills

Diagnostic Skill Diagnostic Skill

First Impressions: First Impressions: Experienced Experienced clinicians make a short list of clinicians make a short list of differential diagnosis within the first differential diagnosis within the first few minutes of history-taking. few minutes of history-taking.

Keep an open mindKeep an open mind Open-ended questionsOpen-ended questions Detail orientedDetail oriented

ScenariosScenarios

Emergency roomEmergency room Inpatient unitInpatient unit Outpatient clinicOutpatient clinic Ambulatory careAmbulatory care Intensive care unit (CICU, NICU, PICU, Intensive care unit (CICU, NICU, PICU,

NSICU etc.)NSICU etc.) End-of-life care End-of-life care

ResidenciesResidencies Internal medicine: Internal medicine: Transitional year: Radiology, Neurology, Transitional year: Radiology, Neurology,

Anesthesiology Anesthesiology Family practice Family practice SurgerySurgery Orthopedics Orthopedics OphthalmologyOphthalmology Otolaryngology Otolaryngology Obstetrics & GynecologyObstetrics & Gynecology PsychiatryPsychiatry PediatricsPediatrics

Specialities: FellowshipsSpecialities: Fellowships

Cardiology, Gastroenterology, Cardiology, Gastroenterology, Nephrology, Pulmonology, Hematology & Nephrology, Pulmonology, Hematology & Oncology, Dermatology, Allergy & Oncology, Dermatology, Allergy & Immunology, Rheumatology, Toxicology, Immunology, Rheumatology, Toxicology, Endocrinology, Infectious diseases, Endocrinology, Infectious diseases, Genetics, GeriatricsGenetics, Geriatrics

Cardiothoracic, Vascular, Plastic, UrologyCardiothoracic, Vascular, Plastic, Urology NeonatologyNeonatology Sleep medicineSleep medicine

Phrases of wisdomPhrases of wisdom

““we are humans, we are not perfect”we are humans, we are not perfect” ““accidents do happen”accidents do happen” ““““Listen to the parents – They may know Listen to the parents – They may know

best” ” best” ” ““We have two ears and one tongue so we We have two ears and one tongue so we

may listen twice as long as we talk”! may listen twice as long as we talk”! Observe, absorb, and applyObserve, absorb, and apply Good humor is kind and compassionateGood humor is kind and compassionate Beware of medicalization!Beware of medicalization! Change is a processChange is a process

Family meetingsFamily meetings

VValuing and appreciating what the aluing and appreciating what the family members have to sayfamily members have to say

AAcknowledging the emotions cknowledging the emotions expressed by the family membersexpressed by the family members

LLISTENingISTENing UUnderstanding who the patient was as nderstanding who the patient was as

a person, by listening to family a person, by listening to family membersmembers

EEliciting questions from the family liciting questions from the family members.members.

Take home pointsTake home points

Focus has to be on the patientFocus has to be on the patient Physician must know the big picturePhysician must know the big picture Pay close attention to what the patients Pay close attention to what the patients

(and parents in pediatrics) have to say(and parents in pediatrics) have to say Describe what you see (not impressions and Describe what you see (not impressions and

interpretations)interpretations) Be clear and precise with the words you use Be clear and precise with the words you use

to describe (no euphemisms, vague to describe (no euphemisms, vague remarks)remarks)

Use the correct words to show the urgency Use the correct words to show the urgency of the situation of the situation

Sentinel events:Sentinel events:

surgery at wrong sites surgery at wrong sites perinatal injuries perinatal injuries deathsdeaths

GossipGossip

Genug syndrome: enoughGenug syndrome: enough ““Zahl Kam Rauf”: “number came up”Zahl Kam Rauf”: “number came up” ““I have the ticket. The train has’nt I have the ticket. The train has’nt

arrived”.arrived”. Beware of medicalizationBeware of medicalization

Fatigue = c f s/anemiaFatigue = c f s/anemia Shy = schizoidShy = schizoid RaceRace HIV treatmentHIV treatment

The Lancet (Vol 369: Number 9562: The Lancet (Vol 369: Number 9562: February 24-March 2, 2007) February 24-March 2, 2007)

Healthy Habits

A recent study from England A recent study from England examined the effects of four specific examined the effects of four specific health related behaviors – moderation health related behaviors – moderation in drinking, not smoking, regular in drinking, not smoking, regular exercise and plenty of fruits and exercise and plenty of fruits and vegetables in the diet. These health vegetables in the diet. These health behaviors added 14 more years to the behaviors added 14 more years to the life span of the individuals.life span of the individuals.

Electronic medical records:Electronic medical records:Drs.Pamela Hartzband and Jerome Groopman Drs.Pamela Hartzband and Jerome Groopman

(N Engl J Med 358: 1656-1658, 2008).(N Engl J Med 358: 1656-1658, 2008). The habit of cutting and pasting passages from other The habit of cutting and pasting passages from other

physician’s notes, instead of taking one’s own history, may physician’s notes, instead of taking one’s own history, may lead to errors in diagnosis and management.lead to errors in diagnosis and management.

Notes written on templates may be insufficient to document Notes written on templates may be insufficient to document some of the unique features of individual patients and may some of the unique features of individual patients and may interfere with critical thinking.interfere with critical thinking.

Automatic reproduction of ALL laboratory results may lead Automatic reproduction of ALL laboratory results may lead to errors and delay in identifying critically important data.to errors and delay in identifying critically important data.

New developments in the condition of the patient and New developments in the condition of the patient and sequences in change of status get buried in the mass of sequences in change of status get buried in the mass of data.data.

Physicians keep looking at the computer screen when the Physicians keep looking at the computer screen when the patient is talking thus missing important non-verbal cues.patient is talking thus missing important non-verbal cues.

Filling in boxes may help obtain and record important and Filling in boxes may help obtain and record important and critical data consistently, but does not allow entry of free critical data consistently, but does not allow entry of free texts on observations other than what the “pigeon-holes” texts on observations other than what the “pigeon-holes” require. (This is not the problem of the computer).require. (This is not the problem of the computer).

Physicians and Pharmaceutical Physicians and Pharmaceutical Industry Industry

How drug reps make friends and influence How drug reps make friends and influence doctors: Fugh-Berman A, Ahari S. PloS doctors: Fugh-Berman A, Ahari S. PloS Medicine April 2007; 4 (4): e 150 )Medicine April 2007; 4 (4): e 150 )

www.polsmedicine.org . www.polsmedicine.org .

A national survey of physician-industry A national survey of physician-industry relationship. Campbell EC, Gruen RL, relationship. Campbell EC, Gruen RL, Mountford J, Miller LG, Cleary PD, Mountford J, Miller LG, Cleary PD, Blumenthal D. N Engl J Med 2007: 356: Blumenthal D. N Engl J Med 2007: 356: 1742-50) 1742-50)

Resources for 3rd Year OSCE & Resources for 3rd Year OSCE & USMLE Step 2 CS Websites:USMLE Step 2 CS Websites:

USMLEUSMLE AAMCAAMC Prep4USMLEPrep4USMLE Studentdoc.comStudentdoc.com MDLinks.net MDLinks.net 

Publications:Publications: First Aid for the USMLE Step 2 CS, First Aid for the USMLE Step 2 CS, by Vikas by Vikas

Bhushan, Tae Le, L. David Martin, Fadi Abu Bhushan, Tae Le, L. David Martin, Fadi Abu Shahin, Mae Sheikh-Ali. ISBN: 007142184XShahin, Mae Sheikh-Ali. ISBN: 007142184X

CS Checklists: Portable Review for the CS Checklists: Portable Review for the USMLE 2 CS, USMLE 2 CS, by Jennifer K. Rooney. ISBN: by Jennifer K. Rooney. ISBN: 00714451530071445153

Blueprints USMLE Step 2 CS, Blueprints USMLE Step 2 CS, Carter E. Wahl. Carter E. Wahl. ISBN: 1405104384ISBN: 1405104384

Mastering the Objective Structured Clinical Mastering the Objective Structured Clinical Examination and the Clinical Skills Examination and the Clinical Skills Assessment, Assessment, by Jo-Ann Reteguiz and by Jo-Ann Reteguiz and Beverly Cornel-Avendano. ISBN: Beverly Cornel-Avendano. ISBN: 0071318135X 0071318135X