Clinical Skills Introduction - Macleod’s Clinical Examination Audiobook​

hello my name is James Gill and this is a trial that I'm doing the moment with LC via about McLeod's clinical examination as some of you may know I have over the past recorded some YouTube videos for Oracle medical school about the clinical examinations students and doctors at large are normally required to perform on patients those videos were designed as revision tools to augment the clinical skills teaching at warrant medical school the one problem with videos such as that is that they require quiet they require you to sit down and actually watch the thing and if you've got some understanding about what's going on all the better the thing that they're not particularly useful is original learning I if you've never done a clinical examination before they don't really show you what and more importantly why I was doing those particular examinations those particular movements on a patient so I've looked at what podcasts and things are available for medical students and the area of clinical skills is one area that hasn't had a lot of things taught to it yet so I thought I'd attempt it and then it comes the question what are you going to do how are you going to deal with what is a huge topic how do you examine the human body and then I thought actually I do the same as I've been doing with the clinical skills videos I'd use McLeod's clinical examinations as my baseline as it was when I was at medical school myself and essentially trying to record it I listened to vast numbers of audio books when I'm in the driving seat when I'm going for a run when I'm sliding the bike in dorset is and I thought fine let's record MacLeod clinical examination but I do appreciate that having some dodgy doctor just reading a textbook at a computer screen to be honest is probably gonna be a good way to put people to sleep whilst I am going to read cloud clinical examination I'm going to throw my 6 penneth in as it were talk about my examples clinically my methods of learning some of the things in there and I just thought the actual textbook itself would give a very good structure to a series of podcasts as with all such things in life just because I've had an idea and I do have a few of them doesn't necessarily mean it's going to be any good so what I need to do is a favor from yourself dear listener drop me a comment in the feedback tell me am I completely wasting my and they're more importantly your time is this something that you'd find useful is this something that you'd prefer less of James and more of the people who've written the clouds ultimately this is going to be chapter one which as I look at the book here covers four pages so it's not going to be a particularly long exercise in listening but it should provide a nice introduction and give us something to work with over the next few weeks so without further ado here we go McLeod clinical examination chapter 1 probably should have some music here or something like that but imagine that this is a music going on at this point ok so chapter one approach to the patient being a good doctor from your first day as a student you have professional obligations placed upon you by the public the law and your colleagues which will continue throughout your working life I know that it doesn't make any comment about your parents and friends but hey patients want more than merely intellectual and technical proficiency to be a good doctor or nurse is much easier if you genuinely like and are interested in people most patients want a doctor who listens to them and the over 70 separate qualities have been listed as being important fundamentally though we all want doctors who are is the first list knowledgable respect people healthy or ill regard of who they are support patients and their loved ones when and where needed are always courteous ask us questions let's people talk and listens to them carefully I think that's probably one of the most important things so far not there's been much so so far the reason being is that 90% of all complaints in the clinical setting are actually due to communication issues I'll return to the listener promote health as well as treat disease give unbiased advice letting people participate actively in all decisions related to the health and health care assessing each situation carefully and help whatever the situation may be use evidence as a tool not as a determinant of practice now that's a really crucial one and it comes back frequently to when you've got the patient in front of you even if you've got a slight lead range blood level that you're talking about who are you treating are you treating the patient or are you treating the computer and I think it's very important that sometimes like using evidence as a tool we don't forget that we're not treating a disease but we're actually treating the patient part of that as the next bullet point says is humbly accept death as an important part of life and help people make the best possible arrangements when death is close work cooperatively with other members of health care teams and finally our proactive advocates for their patients mentors for other health professionals and are ready to learn from others regardless of their age role or status sound sleep planner you'll be doctors a doctor also needs a balanced life and to care for themselves and their families this is something that we're seeing more and more in the healthcare profession the issues with burnout and people need to find their own ways both at medical school and in their career overall of how to survive and how to be able to deal with the rigors that are the job the learning that you have to do and the pressures the patient put on you in short we want doctors who are happy and healthy caring and competent and to care for people throughout their life one way to reconcile these expectations with your inexperienced and incomplete knowledge or skills is to put yourself in the situation of the patient and all the relatives we're going to call that empathy consider how you would wish to be cared for in the patient's situation acknowledging that you are different and your preferences may not be the same most clinicians approach and care for patients differently once they have their own or relative experiences as a patient I've personally seen that myself I've had various breaks and bones and things cycling over the years and having seen the way that the orthopedic team can treat certain new injuries I think I've changed my practice a lot I no longer see a walking injury I actually see a patient who is injured doctors nurses and everyone involved in health care will have a profound influence on how patient experiences their illness and their sense of dignity when you're dealing with patients always consider the ABCs your attitude how would I feel in this patient situation your behavior always treat patients with kindness and respect compassion recognize the human story that accompanies each illness dialogue listen to and acknowledge the patient confidentiality and consent as a student and as a doctor or nurse you will be given private intimate information about patients and their families this information is confidential even after the patient's death this is a general rule although it's legal application varies between countries in the UK the following guidelines issued by the General Medical Council are in the above box better finally bow box duties of a registered doctor the care of your patient is your first concern protects and promotes the of patients and the public provide a good standard of practice in the care keeping your professional knowledge and skills up to date recognize and work within the limits of your competence and part of that is being able to say to a patient I don't know that's actually quite powerful because it brings you and the patient to the same level and actually lets you and go and find the best way to treat your patient work with colleagues to serve your patients interests best treat patients as individuals and respect their dignity treat patients politely and considerately respect patient confidentiality work in partnership with the patient listen to your patient and respond to their concerns and preferences give information in a way that they can understand respect their right to reach decisions with you about their care and this is me here allow the patient to make their own decisions even if you don't think they're the best or the wisest option as long as the patient has been informed by yourself it's their body and they have the right to make the decision they want support patients in caring for themselves to improve maintain their health be honest and open and act with integrity act without delay if you have good reason to believe that you or a colleague may be putting patients at risk never discriminate unfairly about patients or colleagues never abuse your patients or the public's trust in you or the profession there are exceptions the general rules governing patient confidentiality where failure to disclose information would put the patient or someone else at risk of death or serious harm or where disclosure might assist in the prevention detection or prosecution of a serious crime if you find yourself in this situation contact the senior doctor in charge of the patient's care immediately and inform him or her of the situation that might seem a bit of a strange thing to read but I assure you as soon as the curtains are closed or the doctor's consultation door closes patients will open up to you in ways you cannot comprehend right now the things that people will tell you the the joys the sadnesses and the crevices of their soul that they'll probably be prepared to bear to you because they need someone to speak to and I think that that's something that as doctors we can't in any way diminish take all reasonable steps to ensure that the consultation and examination of a patient is private as I second you to shut that door and make sure it's private never discuss patients where you can be overheard or leave patients records either on paper or on screen where they can be seen by other patients unauthorized staff or the public always obtain consent or other valid authority before undertaking any examination or investigation providing treatment or involving patients in teaching or research I probably argue that that's one of the most fundamental parts of the doctor-patient interaction even when it comes to taking a history it would you mind if I asked some questions of you you're gaining that consents to have the conversation with the patient about potentially difficult topics when you want to do something which currently might consider innocuous such as listening to your patients chest you're still coming into their personal space and so asking for that consent asking for that patient's permission to have that conversation or just put a stethoscope on somebody's chest is paramount importance and if nothing else it's going to show respect to the patient and help you build the consultation and the rapport with the patient at that time even when you've been given consent to disclose information about the patient only disclose what is being asked for a good example there might be filling in an insurance report for a patient if you have any doubts discuss your rapport with the patient so that he or she is clear about what information is going to a third party record your findings in the patient's case notes immediately after the consultation these case notes are confidential and must be recorded and stored securely they constitute a legal document that could be used in a court of law I remember in my second year the first time I actually got into the hospitals to see a real-life patient and the consultant Miss Marshall a fabulous vascular surgeon she gave us the patient notes and said right over there take a history and write everything on the notes but can't writing a note with medical students this is important Tammy said yeah your medical students get on and writing the notes is important so I think that highlights how important the medical notes are that even though we were astonished to be writing in them we were having an interaction with the patient and we were taking a history from them that was still a legal thing and needed to be documented appropriately keeping accurate and up-to-date case notes is an essential part of good patient care remember that what you write might be seen by the patient as in many countries including the UK the patient can ask for and receive access to their medical records in years gone by things have been written in medical records which patients would be less than happy to have had written about them certainly activities like that would never take place today thankfully personal responsibilities always look after yourself and maintain your own health register with a general practitioner do not self diagnose and self treat yeah good luck with that one in medical school certainly you're not going to be able to self treat because you can't self-prescribed yourself things but every single student that I have known whilst a student myself and subsequently now as a teacher of students has a horrible habit of self diagnosing and catastrophizing and it tends to come directly after a clinical school session for example we'll do something on orthopedics and the following week I'll be dealing with five students who think that they've all got patellar tendonitis they've got you know arthritis of the hips and you know there's one who's worried about rheumatoid arthritis and that's why we say medical school make sure you've registered with the general practitioner because along with the tens of students who are worried that they have a condition which they've just read about there's always one in every year who we do ask to see their own general practitioner but no we tell them to go and see their registered doctor we don't sort them out in clinic there because we don't know and the student doesn't know either and you must make sure that you don't treat your friends and similarly like your students you make sure that proper channels are followed if you know or think that you might have a serious condition you could pass on to patients or if your judgment or performance could be affected by a condition or its treatment you must consult your GP and be guided as the need for a secondary referral heed your doctor's advice regarding investigations treatment and changes to your working practice protect yourself your patients and your colleagues by being immunized against common but serious communicable diseases where vaccines are available eg hepatitis B as a result of running often doing Mountain medicine and various things like that I think I've had just about every vaccination available under the Sun and to be honest a bit of a a slight concern about my own health my opinion on vaccines and similar treatments at medical school was always if it's available take it your professional possession is a privileged one do not use it to establish or pursue a sexual or improper emotional relationship with a patient or someone close to the patient do not give medical care to anyone with whom you have a close personal relationship do not express your personal beliefs including political religious or moral ones to your patients in ways that exploit their vulnerability or could cause them distress with that I do think that there is something to be said for sharing a small amount of personal information with the patient when talking about a case you talk about your own experiences and things like that if it will be beneficial for the patient you've got to remember this all times the patient is the focus of your consultation the focus of your history and your overarching duty your overarching aim is going to be helping of that person and improving their ket dress and demeanor yeah shop and take a breath here I've seen some things people in my year war medical school the way you dress is important in establishing a successful patient Doc's at relationship your dress style and demeanor should never make your patient or colleagues uncomfortable or distract them smart sensitive and modest dress is appropriate expressing your personality is not exposing your chest midriff and legs may not only create offense but impede communication have short or three-quarter length sleeves or roll sleeves up away from your wrists before examining the patient's or carrying out procedures I'd also add to that essentially make sure that you are better below the elbow that means removing watches bangles or anything else that you might have having bare below the elbows allows you to clean your hands effectively and reduces the risk of cross infection whilst antibiotics are considered to be one of them most amazing things for 21st century medicine perhaps one of the biggest leaps forward we had in medicine was much more simple soap and soup making sure that you are cleaning your hands reduce the spread of transmission between patients and making sure the patients were adequately provided with nutrition in order to be able to recover also improved mortality rates greatly tie back long hair and keep jewelry simple and limited to allow effective hand-washing some medical schools and hospitals require students and staff to wear white coats on the UK all scrubs for reasons of professionalism identification and a barrier to infection if this is the case these must be kept clean and smart and should always wearing main badge which can be easily read ie not at your waist whenever you see a patient or relative introduce yourself fully and clearly a friendly smile helps to put your patients at ease when I was focusing on communication skills that was one of the bits of feedback I always used to have James smile a little bit more looking far too intense you'll scare the patient away and actually that small thing just open consultation hello my name's dr. Gill smile how can I help has actually improved things tremendously for me how are you speak and address a patient depends on the patient's age background and cultural environment many older patients refer not to be called by their first name and it's best to ask patients how they prefer to be addressed and in my experience going with sir or man is never really going to get you in trouble although that said I did once to have to treat a lord and lady and did go into the cubicle set out terribly sorry this they've clearly made a mistake on the paperwork here it says your Lord and Lady whatever you name is you know cause you're not something if I to normal for that they looked at me and said we're terribly sorry dr. bitter we are actually Lord and Lady weather we just don't like to shout about it so so make sure you know exactly who it is you're pulling in for your consultation before you start communication skills a consultation is a meeting of two experts use the clinic and the patient is an expert on his or her own body and mind excellent communication skills allows you to identify a patient's problem rapidly and accurately and improve patient satisfaction poor communication skills are associated with increased medical legal vulnerability and clinician burnout there we go and I'll say that right at the beginning clearly something that was taught to me at war acquainted improve your skills by videoing yourself consulting with patients having obviously obtained signed consent but when you do the video angle can back it yourself try not to be too distressed about your own voice I know I absolutely it's the sound of myself recorded the recording a podcast as you can tell I'm probably not there to listen to this back and review this with your senior clinician using one of the many techniques developed for this sort of review continually seek to improve your communication skills these will develop with experience but can always be improved most doctors and nurses work in teams with colleagues in other professions working in teams does not change your personal accountability for your conduct and the care you provide try to act as a positive role model and motivate and inspire your colleagues always respect skills and contributions of your colleagues and communicate effectively with them particularly when handing over care expectations and respect the literary and media stereotypes of doctors frequently involve miraculous institutions the confirmation of rare and brilliant diagnosis and the performance of dramatic life-saving interventions and in the case of house a surly demeanor and a walking cane sorry I think house is absolutely terrific but each of their own actually I actually learnt a lot from house I think it's a great way of taking a mental break from studied whilst also still keeping medicine fresh in your head you can kind of play that diagnosis the patient game before he does you know the reality is different medicine often involves seeing and treating patients with common conditions and chronic diseases where we may only be able to provide palliation or simply bear witness to a patient suffering the best doctors are humble and recognize that humans are infinitely more complex demanding and fascinating than one can imagine they understand that much so-called medical wisdom is at best incomplete and often simply wrong one of the things I think they told us to what the end of medical school was when you graduate from medical school ten percent of what you were told was out of date by the time you complete your specialty training twenty-five percent of what you were told Medical School is out of date and by the time we retire that can have risen to up to 50% of the information you were given is now outdated which in some ways isn't too bad we don't have to carry around leeches anymore not that I'm saying I did I graduated in 2010 we didn't use leeches down there although I have seen patients using maggots before but that's that's not go there at this precise moment in time I'm sure we'll talk about something like that when we discuss about reviewing wounds if a patient under your care has suffered harm or distress act immediately to put matters right if it is possible apologize and explain fully and promptly to the patient what has happened and the likely effects patient complaints about their care or treatment are often the result of a breakdown in communication see it's so important it's been discussed three times now and we're only on page three of McLouth and they have patients have the right to respect prompt open constructive appliance response do not allow a patient's complaint to adversely affect the care or treatment you provide one of the things that I've found that goes an awful long way in any situation is simple honest I'm sorry you know we've all done small things and you know drop the ball at times called in the wrong patients name something like that or in my case mangle the patient's surname a simple sorry and a heartfelt smile with it and go a long way to smoothing over those cracks hand-washing and cleanliness transmission of microorganisms from hounds of health care workers is the main source of cross infection in hospitals primary care surgeries and nursing homes healthcare acquired infections complicate up to 10 percent of hospital missions and in the UK five holes and people die from them each year hand-washing is the single most effective way to prevent the spread of infection it is your responsibility to prevent the spread of infection and routinely wash your hands after every clinical examination to not be put off by lack of hand hygiene agents or facilities for hand-washing or being short of time if your hands are visibly soiled or thoroughly with soap and water if your hands are not obviously dirty wash with soap and water or use an alcohol-based rub or gel note that there's something like DMV rotavirus the alcohol won't protect patients against that virus you need to go back to that good old fashioned soap and water always wear surgical gloves when you bare may be in contact with blood mucous membranes or non-intact skin whilst washing with alcohol-based channels will remove most microorganisms but will be ineffective against viruses such as influenza and norovirus okay that's the end of chapter one of McLeod's so what do you guys think it's taken 27 minutes to get four pages into this and if we exclude the index there are 439 pages in the book I'm probably going to need to get more drinking water but no seriously um I've been really grateful to know what it is that you guys think about this however I just wasted 27 minutes of your life how many of you actually managed to survive more than the first five minutes before going off to I know what videos of cats and how many banners do not fall asleep I'd be interesting though and see whether what you think this is useful whether or not you prefer me to just read it wrote or whether or not my continual interjections provide a little bit of context for you yeah we'll see how we go from there but I'm going to leave this probably a week or so before I put up the next one just to get some feedback to see what's going to be most beneficial to you guys because at the end of the day I teach the clinical examinations I'm always happy to have a brush up on it but this is out there for you guys to sort of be able to as I said go running listen to in the car when you're traveling heck fall asleep to whatever I'm rambling okay thank you very much for getting this far again feel free to drop me in the comments and send me messages directly if you want to via Twitter I'm at literally at dr. James Gill thank you good night oh good day whichever okay right