Hyposkillia-old and current concerns

Vitorino Modesto dos Santos^1, Taciana Arruda Modesto Sugai², Lister Aruda Modesto dos Santos³

Author Affiliation

¹Adjunct-Professor of Internal Medicine, Department of Medicine, Armed Forces Hospital, Catholic University of Brasília, 
²Department of Medicine, American Society of Neurophysiology, and Dermatologist of Brasília, Brasília-DF, 
³Preceptor, Department of Surgery, Advanced General Surgery and Oncosurgery of IAMSPE, São Paulo-SP, Brazil.

Abstract

The deleterious diminished clinical skills (hyposkillia) associated, at least in part, with reforms in medical education around the world have been little discussed over the past two decades. In fact, very expensive instrumental examinations, and diagnostic tests have now replaced the ancient art of clinical diagnosis, as William Osler anticipated when he said that medicine is learned at the bedside, not in the classroom

DOI: 10.32677/yjm.v2i2.4048

Pages: 64-65

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Download: 4

DOI URL: https://doi.org/10.32677/yjm.v2i2.4048

Publish Date: 28-09-2023

Full Text

The noxious decreased clinical skills (hyposkillia), at least partially related to reforms in worldwide medical education, has been sparsely discussed in the last two decades [1-6]. As a matter of fact, very expensive instrumental examinations and diagnostic tests have currently taking the place of the ancient art of clinical diagnosis, as preconized by William Osler when said that “Medicine is learned by the bedside and not in the classroom” [1-5]. Therefore, it would be better to associate the resources of the art and the science of medicine to lessen the possibility of misdiagnosis as well as underdiagnosis in clinical practice. Another cornerstone in this scenario is the mandatory constant relationships between general practitioners and specialists from different fields, mainly of anatomopathology [6]. The best example is the clinic-pathological sessions with multidisciplinary participation to exchange impressions on previous diagnosis and management of necropsied cases [6].

We read with interest the recent article by Dhaniwala NS about causes and consequences of hyposkillia in medical education involving both undergraduate and postgraduate stages; besides, the adverse role played by COVID-19 pandemic contributing to utilize online simulation tools in detriment of the traditional practice on the standard patient [2]. Clinical skill acquisition by medical students has gradually less importance in the scenery; with scarce traditional bedside teaching by unmotivated not fully competent instructors. In fact, accurate semiotic techniques of anamnesis and physical examination of patients propitiate up to 80% of data needed to establish correct clinical diagnostic hypotheses [2]. The author highlighted that more time on practical clinical training must be utilized during the undergraduate and postgraduate courses, ever under supervision of competent teachers to demonstrate the role of semiology guiding physicians to correct diagnoses [2]. In conclusion, medical students should spend more time in the bedside training and the direct interaction with patients, as the best option to prevent or minimize hyposkillias [2]. The interesting article enhanced the aim to comment some other papers with a same focus. Datta A emphasized with very adequacy the careful performance of anamnesis and physical examination as a good way to optimize the patient-physician relationships [1]. This contributes to obtain more adequate information and elaborate diagnostic hypothesis, besides to gain total confidence and adherence to the further management. While in the 1960s up to 75% of medical student teaching time was at the bedside, today this irreplaceable formative activity occupies no more than 17% of their total training, resulting in a persistent hyposkilliac status among medical students of several regions [1]. The author also commented the indispensable continuous participation of competent trainers to proceed the necessary reversion of this high rate of the medical hyposkillia [1]. Jain A gave us a personal historical lesson under the format of a chronicle involving major aspects of true salutary relationships between patients and physicians from old times; and, with a meridian clarity he made well exemplified the meaning of “the human touch” [3]. This basic issue was duly valorized by the author, who called attention to the increasing general tendency to deterioration with the time, becoming a mechanical relationship; and the patient could be considered as mere object of work instead of a true human being [3]. He also highlighted the influence of the teachers’ actions on the students or patients; they should in fact practice what they teach, because of effects on the future practitioners [3]. Worthy of note was the suggestion to patients writing their impressions about the failures during the hospital medical assistance, besides presenting the respective suggestions [3]. Comments about Brazilian articles focusing on the afore mentioned issues are included aiming to enhance the interest of general physicians, in special about need changes [4-6]. Hippocrates taught that the objective of medicine should be centered on the patient care, but nowadays it is becoming impersonal, superficial, and more centered on technology; in addition to a growing reduction of clinical skills among the younger physicians because learning develops by medical activity, and technology is only a complement of work [4]. William Osler said that it is a safe rule to have no teaching without a patient as the text, and the best teaching is that which is taught by the patient himself; and Bela Schick affirmed that the patient ranks from the first to the fifth place, and science comes after, meaning that the technology does not always improve the quality of the patient care [4]. Sometimes, the simulators try compensate the absence of competent trainer for students; this is not equivalent to the interactive supervised clinical bedside evaluation of patients by teachers with a longstanding experience in daily practice of Medical Semiology [4,5].

In conclusion, modern diagnostic technology is very useful to confirm challenging hypotheses, while humanistic patient care and basic semiology at the bedside should be maintained as the cornerstones of clinical medicine, and quality of the health services.

References

1. Datta A. Clinical skill: the ebbing art of medicine. Malays J Med Sci. 2021;28(1):105-108.

2. Dhaniwala NS. Declining clinical skills in medical education: a perspective on its causes and potential solutions. Yemen J Med. 2023;2(1):1-3. 

3. Jain A. Demise of the stethoscope. Med J Armed Forces India. 2022;78(1):1-2. 

4. Santos VM. [Hyposkillia: should the William Osler’s ideals be retaken?] Rev Med Saude Brasilia. 2018;7(2):310‐312. 

5. Santos VM. Health care reforms: old and new concerns. J Biosc Med. 2011;1(3):1-2. 

6. Santos VM. Pathologist-clinician collaboration. Gen Int Med Clin Innov. 2016;1.