From medical student to junior doctor: the scripted guide to patient clerking
In the second article of our series to help medical
students make the leap to budding doctors, Richard Beasley and coauthors explain how you can improve your patient clerking skills and
impress your consultant
Undergraduate teaching of
patient clerking is based primarily on the systematic and detailed
elucidation of the history and clinical examination, from which a summary
of the key findings is made and a differential diagnosis is developed.1-3 While this
approach represents good training and a basic introduction for medical
students learning the art of clinical medicine, it is insufficient for the
demands of the junior doctor in hospital based clinical practice. A more
practical and problem oriented method is required, which is based on the
systematic analysis and synthesis of the case (box 1).
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You know you are in for a shaky ride…
Using a focused approach
A practical way in which this can be achieved is to
undertake an initial history and examination and then revisit key features
in a more focused manner as one works through the analysis and synthesis of
the case. For junior doctors, this provides a practical solution to the
problems of forgetting or missing out key features of the history or
examination, and not recognising the importance or relevance of these
features when elicited as part of a general, rather than the focused
approach. This method of patient clerking also allows the junior doctor to
develop an integrated plan for the investigation and management of patients
within a time frame whereby on-call commitments can be met, which may
involve admitting many patients on each day on call.
Get ready for the consultant
With this approach, it should also be possible for
junior doctors to answer the questions that are likely to be put to them by
the consultant on the post-acute ward round (box 2). To assist recall of
this approach, the acronym SCRIPTED could be used. Over time, the junior
doctor should be able to develop his or her own style, based on the
principles of this prototype system, and learn how to vary its use
depending on the clinical situation in which it is employed.
Box 1: Systematic approach to patient clerking
Differential diagnosis
- Try to weight
the likelihood of the differential diagnoses based on the key positive and
negative features
- Always force
yourself to consider at least one alternative diagnosis, owing to the
variation in presentation of even common disorders
- Return to the
history and clinical examination to elicit or confirm the key features
Risk factors
- Consideration of
risk factors for the differential diagnoses may influence their relative
probabilities
- Recognising and
treating the risk factors may be as important as treating the presenting
complaint
Problem list
- Coexisting
conditions may have a major impact on the presenting illness; likewise the
presenting illness may influence the co-morbidities
Complications
- The major
determinants of long term outcome may be the complications of the
presenting illness or concomitant conditions
Investigation
- Investigate with
judgment, undertaking only tests which are relevant to the case. Ordering
the initial test is not the only responsibility; it is also necessary to
obtain the results from tests that have been ordered
Severity and prognosis
- Recognition of
severity and prognosis are important determinants of management
Treatment
- Consider the
risks as well as the benefits of treatment
Evaluation
- Can all the
different aspects of the case be brought together within a single disorder
or does the case need to be divided into different unrelated disorders?
This is potentially the most difficult aspect of the case but is made
considerably easier by consideration of the above key issues
The order of the systematic approach may vary
depending on the features of the case. This approach can be recalled
through use of the acronym SCRIPTED
Box 2: Consultant questions from the case presentation
- What do you
think is the presenting diagnosis and what else do you think it could be?—Differential diagnosis
- Why has it
occurred?—Risk
factors
- What other
problems does the patient have?—Problem list
- Are there any
issues relating to the presenting complaint or other problems?—Complications
- What tests have
been undertaken and what are the results?—Investigations
- How have you
managed this case?—Treatment
- What has the
patient been told in terms of outlook?—Severity and prognosis
- Is there
anything else about the case that you want to tell me?—Evaluation
Richard Beasley, general
physician and professor of medicine
Email: Richard.Beasley@mrinz.ac.nz
Geoffrey M
Robinson, general physician and chief medical
officer
Sarah Aldington, senior research fellow, Medical Research
Institute of New Zealand/Wellington Hospital, Wellington, New Zealand
studentBMJ 2005;13:397- 440 November ISSN 0966-6494
- Epstein O, Perkin GD, Cookson V, de Bono DP, eds. Clinical examination. 3rd ed.
New York: Mosby, 2003.
- Edwards CR, Kendall RE, Munro JF. The principles of
a clinical examination. In: Munro J, Edwards CRW, eds. Macleod’s clinical examination.
9th ed. Edinburgh: Churchill Livingstone, 1995.
- Talley NJ, O’Connor S, eds. Clinical examination: a systemic guide to physical diagnosis. 4th ed. Oxford: Blackwell Science, 2001.
