It has been said that students do not respect what you expect, they respect what you inspect. In the internal medicine clerkship, what should our students expect us to inspect? To put it another way, what are the core clinical competencies of the medicine clerkship? Recently, medical educators have focused on defining the core learning objectives of the medicine clerkship. One curriculum, developed by representatives of the Society of General Internal Medicine and the Clerkship Directors in Internal Medicine, proposes that students should demonstrate competence in the skills of diagnostic decision making, case presentation, history taking, physical examination, communication, test interpretation, therapeutic decision making, ethical medical care, self-directed learning, and preventive care.
Another task for the student is to learn how to become an effective member of the health care team. This requires that the student learn how to interact with nurses and other health professionals, learn how physicians use diagnostic reasoning, learn what is expected of him or her by the other team members, learn the managerial tasks of gathering test information, learn how to write admitting notes and progress notes, and learn how to give oral presentations in a variety of settings.
Traditionally, many of these expectations were not made explicit, and students were more or less sent onto the wards and expected to “figure it out.” Although much learning occurs through role modeling and immersion, there is an increasing sense that these learning tasks and competencies should be made explicit. This helps the student by making the expectations clear from the outset and also makes it easier to design clinical performance examinations, which have become increasingly important evaluation tools in the third year of medical school.
Although there is no shortage of texts in which students can find discussions of core internal medicine topics such as the differential diagnosis of chest pain, the resources are far fewer for advice about how a student should function in the hospital, clinic, or office. Charles L. Bardes has given third-year medical students a very helpful guide to clinical effectiveness in his book, Essential Skills in Clinical Medicine.
The first section of the book, “The Clinics,” presents a basic introduction to the settings in which students work and learn. Bardes makes no assumptions and defines terms such as fellow, consultant, and attending rounds. A chapter on writing notes gives specific guidelines for admission notes, progress notes, procedure notes, and outpatient notes. The advice is concrete, and student-friendly: “Make your own plan and show your reasoning. You are not a robot, not a transparent scribe, and not a dope.” The author provides detailed examples of each type of note. Chapters on rounds, oral presentations, orders, procedures, and prevention of nosocomial infection contain information that is basic, specific, and likely to be highly useful for beginning third-year students. The second section, “Assimilating Information,” provides advice about accessing the medical literature and applying it to clinical problems. The author also gives simple, systematic approaches to interpreting electrocardiograms and chest x-rays. In the last section, “The Diagnostic Process,” he demonstrates the pitfalls of techniques often used by beginners, such as “what crossed my mind” or the “brilliant guess.” He does not hold out one method as superior in all situations, but advises that the “simple list,” the “mnemonic device,” the “diagnostic template,” “cluster recognition,” and the “systems approach” are all strategies that can be useful. He illustrates the importance of creating a problem list through the use of numerous clinical case problems.
The great strength of this book is that it gathers together in one place practical information that students beginning their clinical years want and need. It fills a niche that is different from textbooks, pocket minitexts, or manuals of therapy. The information is well organized, numerous helpful examples are given, and the author writes in a tone that demonstrates concern and care for medical students. The major weakness of the book is inevitable; that is, it treats a large number of important topics rather superficially. One hopes the annotated bibliography will stimulate students to read more.
Who should read this book? Certainly medical students beginning their clinical years will find this book a valuable guide to becoming a successful clinical clerk. Clerkship directors may find it useful for defining standards for basic clinical skills. As medical education increasingly emphasizes the importance of defined clinical competencies, students will turn to books such as this one to find out what skills they can expect us to inspect.