Windsor University School of Medicine has made it mandatory for all its students to learn History taking skills on a patient with physical diagnosis. These sessions will be scheduled once a week from the first semester and will be introduced in the master class schedule. it is mandatory that all students will be required to attend the session. History and physical diagnosis sample is presented below
Clinical Competence Skills capacity = requirement “ the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individuals and communities being served”.
A recent study from England examined the effects of four specific health related behaviors – moderation in drinking, not smoking, regular exercise and plenty of fruits and vegetables in the diet. These health behaviors added 14 more years to the life span of the individuals.
Electronic medical records: Drs.Pamela Hartzband and Jerome Groopman (N Engl J Med 358: 1656-1658, 2008).
The habit of cutting and pasting passages from other physician’s notes, instead of taking one’s own history, may lead to errors in diagnosis and management.
Notes written on templates may be insufficient to document some of the unique features of individual patients and may interfere with critical thinking.
Automatic reproduction of ALL laboratory results may lead to errors and delay in identifying critically important data.
New developments in the condition of the patient and sequences in change of status get buried in the mass of data.
Physicians keep looking at the computer screen when the patient is talking thus missing important non-verbal cues.
Filling in boxes may help obtain and record important and critical data consistently, but does not allow entry of free texts on observations other than what the “pigeon-holes” require. (This is not the problem of the computer).