AFMC National Clinical Skills Working Group Evidence-Based Clinical Skills Document

What this document is - What this document is not

Much of this document consists of a series of tables which, for the physical examination skills, is laid out by body system. The tables outline the communication skills and physical examination manoeuvres required to assess a patient as part of a general examination. Specialist physical manoeuvres and techniques (for example, the clinical procedures in the delivery room of an obstetrical unit) are not included in this document. Specific reference is made, however, to certain clinical skills issues pertinent to the pediatric setting. For each of the physical signs or manoeuvres, a rationale is given, followed by a brief reference to the technique employed to demonstrate the manoeuvre, then its interpretation, then the evidence for its clinical or diagnostic utility. Each table then identifies whether or not this physical sign or manoeuvre should be demonstrated at the pre-clerkship or clerkship level, or both.

"Pre-clerkship" means "prior to beginning to function as a daily member of a clinical health-care team". "Link" or "transitional" rotations that prepare students for clerkship have been included as "pre-clerkship", recognizing that in individual universities those rotations by convention might be considered as part of clerkship. Students would normally be expected to have achieved the pre-clerkship competencies before going to another centre for a rotation.

The distinction between pre-clerkship and clerkship appeared to the National Clinical Skills Working Group to be a useful division in the continuum of competencies across an undergraduate medical school curriculum. This is entirely consistent with the recommendation #5 from the recent AAMC Report alluded to above: "The Task Force recommends that medical schools adopt an explicit developmental approach to the design of clinical skills education curricula, including the designation of expected levels of skill performance proficiency throughout the four year curriculum."

This document does not represent a clinical skills curriculum. Each medical school has its own individual curriculum and this current document does not prescribe how the competencies required to detect the physical signs should be taught or evaluated.

Some caution is also required in considering the word "evidence". For many, evidence conjures up randomized clinical trials in therapeutics. This type of evidence is not available in relation to clinical skills but many manoeuvres or skills have in fact been subjected to some kind of critical scrutiny and where that has been done, we have tried to address this in this document. Here and there, contributors have identified manoeuvres or skills which clinicians do seem to find useful as gauged by the consensus of members of the Working Group, but which do in fact have little evidence to support their diagnostic utility upon review of the literature. Clinical teachers should be aware not only of the evidence for clinically useful tests and manoeuvres but also widely used and accepted manoeuvres or clinical skills which do not seem to have much evidence to support them. One further consideration is that diagnostic utility of a single manoeuvre may not be very impressive in terms of its clinical performance in isolation, but in clinical practice, it may need to be evaluated in the context of the patient’s presenting complaint or other demonstrable clinical signs. The impact of further research, as well as the ongoing development of medical technology, will continue to impact upon what undergraduate medical students should be taught in their communications and physical examination skills courses.