DOI: 10.5068/d1sx1w
title: Student comments on Advanced Clinical Skills Course

description: Proficiency in clinical examination skills upon graduation from medical
 school is a core competency. Over the last few decades, the ability and
 confidence in this fundamental and crucial skill set have declined. The
 motivation and interest in meticulous physical examination by recently
 graduated residents have also eroded. In this case study, we describe a
 comprehensive, innovative, and immersive advanced clinical skills elective
 taken during the second half of the final year of medical school for
 students at the David Geffen School of Medicine. The course utilizes novel
 approaches to inspire, refresh and consolidate essential bedside
 observation skills and examination techniques. This approach gives senior
 students the confidence and fundamental understanding of how dedication to
 the patient exam can improve the doctor-patient relationship, core
 clinical reasoning and the practice of cost-effective and evidence-based
 care through their careers. We describe how the integration of fine art
 appreciation and introductory biding techniques are used to help students
 hone their visual diagnostic skills. We show how this is solidified
 through a longitudinal series of clinical image review sessions with
 diagnostic reasoning principles to formulate a clear differential.
 Point-of-care ultrasound, EKG analysis, advanced cardiac auscultation and
 diagnostic imaging skills are integrated in a comprehensive and memorable
 fashion. We present this case study to inspire clinical skills teachers
 everywhere to replicate our methods in resurrecting the importance of
 physical exams for their learners. Opening their trainees’ eyes to new
 methods of honing their visual intelligence and developing healthy habits
 for stress and burnout reduction will aid the rest of their professional
 careers.
description: <strong>Methods</strong> All
 students rotate through all of these sessions and field trips over the 15
 days of the course. <strong>Visual
 Diagnosis</strong> This key component of the
 course occurs each morning from 9:00am to 10:30am. In our medical school,
 we have a large classroom equipped with 24 benches, each of which has two
 flat-screen monitors. The 50 students are randomly assigned to small
 groups of 4–5 students, who share a bench. At the control screen, the
 three course chairs reveal up to ten high-resolution clinical images on
 each group monitor per session.  These clinical images were obtained and
 curated by the course chairs over their combined 70 years of inpatient and
 outpatient clinical practice in academic teaching hospital departments:
 general internal medicine, neurology, ophthalmology, emergency medicine,
 pulmonary and critical care settings. All images were obtained with
 patient permission or were de-identified. Most are of actual clinical
 signs but where appropriate, images are augmented with radiologic and
 micro and macro pathologic slides as a means to narrow the differential
 diagnosis or to clarify the clinical findings shown during the discussion.
 The small groups of students at each table are given 3–5 minutes to view
 and discuss the image, and on the second attached screen at each table,
 they generate a differential diagnosis of up to five conditions. After all
 groups post their differential, the course chairs choose the best
 differential to share with the groups on each of their screens. Each table
 then votes on which of the five is the most likely diagnosis. One of the
 course chairs then discusses the options starting with the least likely
 and provides confirmation of the answer. The other educators present add
 additional details such as clinical anecdotes, prevalence, positive and
 negative likelihood ratios or an interesting or amusing commentary
 (clinical tangent) which all help clarify and solidify the material for
 the learners. A running tally of which table contributed the most correct
 differential lists is kept and the teams/tables with the top three correct
 lists receive a small prize at the end of the course (usually a
 second-hand copy of a book from an essential reading list from the course,
 covering broad medical and non-medical topics). As the course progresses,
 the goal is to show more challenging images and common conditions with
 more unusual presentations as well as reducing the time allowed for
 discussion of the differential at each table to encourage efficiency and
 mastery of the subject matter. <strong>Highly
 meticulous physical exam technique demonstration and prioritization of
 signs by likelihood ratios</strong> From 11am to
 12pm, a faculty master clinician demonstrates a physical exam to the
 entire group of students. These sessions are traditionally organ-system
 based covering cardiovascular, pulmonary, abdominal and neurologic exams.
 The goal of these sessions is to act as a refresher for the students from
 what they learnt earlier in medical school as well as to give an
 opportunity to provide tips on higher yield maneuvers that are supported
 by the literature, with high sensitivity and specificity and positive and
 negative likelihood ratios. The <em>Journal of the American Medical
 Association (JAMA) Rational Clinical Exam</em> series is referenced
 as well as the book Evidenced Based Physical Exam, fifth edition by Steven
 McGee.  <strong>Real patient encounters (clinic
 and hospital)</strong> Each afternoon of the
 course begins with clinical encounters, which consist of 90-minute
 inpatient and outpatient sessions that run concurrently; groups of
 students participate in the inpatient session while other groups attend
 the outpatient session. These sessions offer a core clinical experience of
 encounters with real patients who have pertinent histories and
 educationally valuable physical findings. Session one runs from 1pm-2:30pm
 and the second session from 2:30pm-4:00pm. Outpatient sessions take place
 in the medical school. Tutorial rooms are equipped with a standard
 outpatient exam bed, a sink, a privacy curtain, internet access and a dry
 erase board. The course chairs have cultivated a group of patients with
 chronic stable medical conditions who were identified either after
 admission to the inpatient teaching service, being recommended to one of
 the course chairs by a colleague or who are existing outpatients of the
 course chairs. This group of clinical teaching partners (CTP) have classic
 clinical exam findings such as crescendo-decrescendo systolic murmurs of
 aortic stenosis, the classic cutaneous signs of systemic sclerosis, or
 chronic stable rheumatoid arthritis. These patients are also adept at
 presenting their clinical histories in a concise and logical order and are
 comfortable interacting with, and being examined by, medical students.
 They are compensated at an hourly rate for their time and in some cases
 for travel expenses. They are also provided lunch each day and parking
 validation. Some CTPs will bring hard copies of their old x-rays, images
 of acute exacerbations of their condition (Raynaud’s Phenomenon) or their
 medical devices like portable oxygen canisters with oximizer pendants.
 Each group of students will see at least three CTPs during their 90-minute
 afternoon session. Every student has the opportunity to examine the CTPs
 in a quiet space and receive instruction from a seasoned clinician
 educator every day. While these sessions are proceeding, the inpatient
 sessions are taking place across the street in the teaching hospital for
 the rest of the students. A clinician educator meets 4-5 students in the
 lobby and proceeds to the Emergency Department (ED), medicine ward or
 Intensive Care Unit (ICU). A daily list of patients with interesting
 clinical findings is supplied by on-service hospitalists or chief
 residents. Patients are similarly selected for their clinical signs and
 willingness to be seen by a small group of students. Some examples of
 patients would include those with pericardial friction rubs, neurologic
 signs like hemiparesis, cranial nerve lesions, clonus, muscle wasting or
 skin rashes, purpura and petechiae. Sometimes patients may not be in their
 rooms and faculty preceptors will then usually pivot to discussion of
 interesting radiologic findings such as the patient’s echocardiogram,
 electrocardiogram (EKG) or chest x-ray until the
 patient returns or move down their list to the next patient.
 <strong>Advanced EKG interpretation and cardiac murmur
 review</strong> Three one-hour sessions
 from 11am-12pm are devoted to advanced electrocardiogram analysis and
 auscultation of common cardiac murmurs on a simulator provided by a
 senior, teaching award-winning cardiologist. 
 <strong>Advanced clinical imaging</strong>
 This thread of this part of the course consists of three review
 lectures on plain radiologic film reading, reviewing computational
 tomography scans (CT) and a session on analyzing Magnetic resonance
 imaging (MRI) films by a senior radiology faculty member. Each session is
 based on being able to detect common radiologic findings seen in clinical
 medicine and emergency medicine settings. To solidify these concepts and
 to correlate clinical exam findings with radiologic images, the course
 chairs have curated a set of over 100 slides that show a physical exam
 finding with a radiographic image or microbiologic/pathology slide.
 Examples of this include images of the hands of a patient with
 sclerodactyly, juxtaposed with the associated radiologic features of
 calcinosis, flexion contractures and acro-osteolysis. These sessions take
 place during the afternoon for students not assigned to the clinic or
 inpatient rounds and are given by one of the course chairs for 90 minutes.
 Each student attends 2–3 of these sessions per course.
 <strong>Clinical Reasoning Session</strong>
 Clinical reasoning is a topic that fits naturally into our
 course. Given that we review and expand upon many of the fundamentals of
 clinical medicine, we felt that adding a few sessions on this topic was
 essential. In the final week of the course when the students have
 refreshed and honed the clinical skills of history taking, physical exam
 and differential diagnosis formulation, we provide two sessions on
 clinical reasoning. We teach them how to integrate all of the information
 obtained into a problem representation, revising the information they
 gleaned from the patient with the goal of an ordered differential. In
 these sessions, we make the students aware of all the biases that may
 affect their thinking and how to critically appraise their own reasoning
 processes. Dual process theory and metacognition principles are reviewed
 and expanded upon in these sessions.
 <strong>Point of Care Ultrasound (POCUS) workshop and hands
 on practice</strong> This thread consists of
 small group Point of Care Ultrasound (POCUS) sessions where students scan
 ultrasound simulators and each other with faculty preceptors to build on
 their skills of image acquisition and interpretation. Students complete
 assigned videos prior to the session in order to maximize hands-on time.
 Two lectures, <em>Tropical</em> <em>medicine</em>
 <em>ultrasound</em> and <em>Pulmonary</em>
 <em>ultrasound</em>, are given that focus on image
 interpretation and clinical integration. POCUS has been demonstrated to
 improve diagnostic accuracy, decrease time to diagnosis, improve patient
 satisfaction and reduce healthcare costs, among other benefits. Over the
 last three years, we have trained our students in POCUS to further build
 upon their diagnostic capabilities. This imaging technology is unique in
 that it brings the clinician back to the bedside and strengthens the
 patient-physician relationship, a value that is core to this course. POCUS
 not only augments the physical exam, it also refines a clinician’s exam,
 creating more astute clinicians even in the absence of ultrasound. An
 example of this is evaluating the jugular venous pressure (JVP), a skill
 that many find elusive. When students are asked to first estimate the JVP
 on a patient by exam and then they are able to visually confirm the JVP,
 see the course of the internal jugular vein and witness hepatojugular
 reflux by ultrasound, their comprehension of this exam maneuver
 grows.  <strong>Enhancing observational
 skills</strong> <em>Fine art appreciation
 at a local museum</em> Teaching visual literacy
 and taking students out of the clinical setting was the basis for using
 fine art principles to develop observational skills. One of the
 recommended texts for the course is Visual Intelligence by noted art
 historian, Amy Herman. She utilized her degree in fine art to create the
 successful, “Art of Perception” program and trains
 thousands of professionals from Secret Service agents to medical students.
 We were fortunate to recruit a senior clinician educator to the course who
 had fine art training as an undergraduate before participating in a
 landmark study: “Training the Eye: Improving the Art of Physical
 Diagnosis” while in medical school14. This study conducted at Harvard
 School of Medicine and the Boston Museum of Fine Art, consisted of eight
 paired sessions of art observation exercises with didactics that integrate
 fine arts concepts with physical diagnosis topics and an elective life
 drawing session for 24 pre-clinical students who were then compared to 34
 classmates at a similar stage who did not do this training. The frequency
 of accurate observations on a visual skills examination was used to
 evaluate pre- <em>versus</em> post-course descriptions of
 patient photographs and art imagery. Those participants who were
 randomized to the art appreciation arm of the study performed
 significantly better than their peers in their ability to make clinical
 observations and in terms of their level of sophistication when describing
 both art and clinical images. During our course, the students receive a
 talk given by the lead author of the above study on fine art concepts and
 correlation with clinical observations. On two Friday mornings of the
 course, field trips are organized to the UCLA Hammer Museum of Art, just a
 short walk from the School of Medicine. This gallery with a permanent
 collection of historical works and special exhibits that include local and
 national artists of edgier contemporary art has collaborated with us for
 over seven years. The morning sessions begin in the permanent collection
 with pairs of students describing a work of art to a fellow student who
 creates a drawing based on their description. Subsequent activities during
 the two-hour outing, include sessions in the contemporary exhibits which
 explore themes such as structural racism, empathy and unconscious bias;
 all highly relevant themes to current clinical practice.
 <strong>Bird identification at the University Botanical
 Garden</strong> Another novel addition to the
 course is birding. Five years ago, after a close family member of one of
 the course chairs discovered birding and pulled the entire family into
 this activity, it become apparent that the skill set of the bird
 enthusiast is very useful for training one’s eye and cultivating visual
 intelligence. In birding, one uses all one’s senses to spot birds in the
 field. Plumage or field marks, bird sounds, behavior and the location you
 encounter the bird in, are all essential for identifying it in a natural
 environment that can be complex and dynamic. Birding can also provide a
 focal point for noticing, reconsidering, and understanding everyday spaces
 that may go unobserved, despite a high frequency of visitation. For
 example, features of an office courtyard or parking lot may become visible
 – and take on new significance – when used as birding locations. The head
 of educational programming for Los Angeles Audubon Society was contacted
 and so began a lasting collaboration with our course. She now provides an
 hour-long introduction to birding to the class with an emphasis on
 drawing. Basic bird shapes and sizes are reviewed to get the students in
 the mood for the Friday activity. To maintain a more manageable teaching
 experience, one-third of the students then join her on three separate
 hour-long walks through the UCLA Mildred Mathias Botanical Garden starting
 at 8:30am. This activity usually takes place on the midpoint of the course
 and also serves as an opportunity to get out into nature and address how
 wellbeing and healthy habits can foster a long career in clinical
 practice. This experience was validated recently in an editorial in the
 <em>New England Journal of Medicine</em> where the author, who
 came to birding late in life, describes the cognitive requirements of
 birding and correlates them with the diagnostic skill required for
 clinical neurology. The use of birding skills to enhance clinical practice
 is not well studied in the medical literature but its recent increase in
 popularity as a pandemic pastime has led to more articles being written
 including a recent publication by Koontz et al. in the radiology
 literature. Our conviction is that birding enhances observational and
 clinical diagnostic skills in two important ways: 1)    Frequent observation of what
 is common enables quicker recognition leading to faster and more accurate
 clinical diagnosis. 2)    Frequent observation of what
 is common enables recognition of features that are out-of-the-ordinary,
 and this equates to advanced clinical diagnosis.
 Furthermore, the act of disengaging from work and getting out
 into nature is the perfect antidotes to the stresses of the hospital and
 clinic. Burnout mitigation, while still actively honing our visual
 intelligence, has been an incredible addition to the curriculum. We now
 receive just as many birding images as we do clinical images from our
 course alumni. <strong>Sample
 schedules</strong> The scheduling of CTPs for
 outpatient encounters is based on the premise that the students never see
 the same patient during the course twice. CTPs are chosen to provide
 variety, but in some instances, a few recurring physical exam features
 appear, such as aortic stenosis murmurs, Heberden's nodes of
 osteoarthritis, corneal arcus, rosacea, and onychomycosis. Owing to the
 presence of a busy and active lung and liver transplant population at our
 institution, the signs of pulmonary fibrosis, spider angoimata,
 gynecomastia, and Dupuyren’s contractures are also more frequently
 encountered. The faculty preceptors for our course are seasoned and gifted
 teachers a large number of whom have won teaching awards in the medical
 school. While the outpatient teaching environment is relatively calm and
 predictable, the faculty member who does the inpatient rounds need to be
 efficient and pragmatic. Acute medical emergencies, code-blues, emergent
 testing and procedures will derail even the best planned inpatient
 sessions. Having the flexibility and experience to pivot on the fly is a
 key feature of our hospitalist faculty who often will utilize their entire
 inpatient list in a given afternoon. Having prior knowledge of the patient
 details reduces the stress or a brief teaching script is provided by
 course organizers. <strong>Modifications for
 distance learning during the pandemic of 2020</strong>
 The course is usually offered in the last two weeks of February
 through the first week of March each year. In 2020, as the global Covid-19
 pandemic was beginning we were able to successfully complete the course in
 person. We then had the luxury of an entire year to plan the 2021 course
 virtually. The move to all virtual instruction was seamless. The physical
 exam technique demonstrations were filmed and edited to maximize
 visualization of highly meticulous and accurate technique and also serve
 as a course library to be used in perpetuity. Most of our seasoned
 clinical teaching partners were able to master zoom, either on their own
 or with the aid of family members. Eighteen encounters were filmed
 remotely during which key history was provided to a course chair
 interviewer. Where possible obvious clinical exam findings were
 demonstrated by zooming the camera onto the relevant area. For example,
 sclerodactyly, digital clubbing, facial asymmetry, and arachnodactyly and
 hyperextensible digits in a patient with Marfans syndrome. During the
 course, the filmed 20-minute encounter is viewed by the group and
 preceptor and the CTP from the video then answers students’ questions in
 real-time. Although not as educationally rewarding as the real thing, it
 is still a good teaching experience. Teaching visual
 diagnosis remotely using our clinical images bank was also highly
 effective and students could be placed into ‘virtual breakout rooms’ in
 small groups to view and discuss the images and develop a differential
 diagnosis list. Each group's list is visible to the course chairs via
 a Google docs format in the main ‘zoom room’. The best differential is
 chosen, and students vote virtually on the best single diagnosis and
 faculty members provide discussion and teaching points as they would in
 person. Despite no hands-on instruction, the course remained highly rated
 by students as a valuable learning exercise. The overall course score and
 positive comments were not significantly different to in-person courses of
 prior years. <strong>Assessments, evaluations and
 learner feedback</strong> In its early
 incarnations, the students were expected to identify abnormal physical
 exam findings on hospitalized patients and were graded by faculty on
 examination technique. This has given way over the past two decades to the
 far less stressful and time-consuming visual diagnosis quiz. On the first
 Thursday morning of the course, a 20-question test consisting of 20
 clinical images is administered. Students have two minutes to answer a
 specific question such as “what is the diagnosis?” or ‘what is this
 clinical finding? At the end of the quiz, the faculty review the answers
 with the class, and they selfgrade. They are requested to note their
 scores as on the final Thursday of the course a 30-question quiz, which is
 more challenging, is held and again self-graded. Students overwhelmingly
 do better on the second quiz. For students, it is tangible evidence that
 their visual intelligence has improved in three short weeks. 
 Course evaluations over the last 15 years have been based on
 50–60 students providing a rating of 1–5 with 1 being poor and 5 being
 extremely effective. The overall course evaluation during this time period
 is 4.92/5. The most frequent, recurring comments that students have made
 about this course over the years are (a) this is the best clinical
 teaching in the whole of medical school, and (b) it should be made
 available to all students throughout their years in medical
 school.
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