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


The teaching of clinical skills has been assumed to occupy a central position in the curriculum of undergraduate medical education for generations. Axiomatic to the development of the practicing physician are the skills of interviewing a patient, performing and interpreting the results of a physical examination, and using this information to determine whether further investigations are required to make a diagnosis. Yet there has been increasing concern expressed both in Canada and in the United States that the teaching of both communication skills and physical examination skills has not received the emphasis in undergraduate medical school curricula that it deserves.

A number of reports from the Association of American Medical Colleges and others have highlighted concerns for the quality of clinical skills education (Barrows, 1986; Carraccio, 2002; Corbett, 2004). There are multiple potential reasons for the decline in clinical skills teaching. Current structure and function of academic health science centres result in junior medical students learning basic physical examination skills from specialists who are often more comfortable working in their own narrow field. Similarly, tertiary care facilities place increasing reliance on technicians to perform basic procedures and the emergence of ever-increasingly sophisticated medical technology has resulted in less reliance by physicians in practice on traditional clinical examination techniques.

In June 2003, the Association of American Medical Colleges convened a Task Force on Clinical Skills Teaching that included representatives from the seven national clerkship organizations, the Alliance for Clinical Education and the American Academy on Physician and Patient. This Task Force developed a national consensus regarding the clinical skills education of medical students and issued a report in 2005 (Barrows, 1986; Carraccio, 2002). This document outlined a number of recommendations for the structure of clinical skills curricula as well as outlining physical examination skills and procedural skills that undergraduate medical students should be taught.

In Canada, the impetus for change in the teaching of clinical skills developed from the AFMC UGME Deans’ meeting in Toronto in April 2001. While some issues that were voiced at this meeting were similar to those of the AAMC in the United States, the Canadian undergraduate Deans were equally concerned that one could not ignore the ongoing advances in medical technology that rendered some of the traditional physical examination manoeuvres outdated for the optimal care of patients. It was clear that several of the physical examination techniques that physicians currently practising were taught a generation ago in medical school have been found to be of little diagnostic value. The major thrust for the Canadian clinical skills initiative, therefore, was to develop a basic compendium of communication and physical examination skills and manoeuvres and annotate these techniques with the evidence for diagnostic utility where available. It was recognized that there are many areas of clinical examination for which evidence of diagnostic utility is still lacking.

In addition, the Undergraduate Deans believed that Canadian medical schools should establish an expected level of performance of clinical skills for different levels of training. Students travel widely around the country on elective and it was felt that there should be some statement of what skills would be expected by the time of entry to clerkship and subsequently, the competencies expected at the time of graduation upon completion of the undergraduate MD program.

A National Clinical Skills Working Group was formed under the auspices of the AFMC with representation from coast to coast across Canada. The Working Group, chaired by Dr. Alan Neville, Assistant Dean, Undergraduate MD Program, McMaster University, had its first meeting in Toronto in October 2002. For the past three years, this group has met on a semi-annual basis to reach consensus on the communication skills, physical examination skills and procedural skills expected of undergraduate medical students at the pre-clerkship and clerkship levels.