Overview of JABSOM Clinical Skills Program
Longitudinal Clinical Preceptors (LCPs) provide first and second year medical students with some of their first encounters with real patients who complain of real problems. This role is critical and quite formative. Students are paired with an LCP for a 2-year commitment : beginning in September of year 1 and completing in March of year 2. Students will spend 7 days in clinical practice with first years and 5 days during year 2.
Students should practice obtaining histories and performing physical exams on patients with LCP guidance. As the relationships develop, preceptors can weave in clinical reasoning, patient education, oral and written presentations and patient management. JABSOM teaches a Problem-Based Learning (PBL) curriculum with foundational sciences, clinical skills and community health supplementing this process.
The pre-clerkship years begin with PBL tutorials in 1) health and illness, followed by 2) cardiovascular and pulmonary problems, 3) renal and hematologic problems, 4) gastrointestinal and endocrine problems, then 6) locomotor, neurological and behavioral problems and finishing with the specific issues in 7) the complete life cycle. Students also receive formal instruction in clinical skills during their organ-specific blocks or units. Students also participate in simulation scenarios and standardized patient experiences each unit. We hope the LCP sessions partly incorporate what the students are learning at the same time. Faculty are expected to have teaching appointment in their departments and adhere to all JABSOM policies regarding student treatment and professionalism.
A Brief History
The LCP program began in 2020-2021 and was initially called the Longitudinal Clinical Mentors program. JABSOM moved from a organ system-based teaching faculty structure, which was termed Clinical Skills Preceptors, to a longitudinal and holistic model of instruction with a priority placed on the student-preceptor relationship which is instrumental in physician identity formation. Faculty from the general disciplines and primary care (Pediatrics, Family Medicine, Internal Medicine) are sought to provide students a broader foundation of clinical skills. Some specialists also serve as preceptors in our program.
Where We Are Today
We embark on our fifth year in academic year 2024-2025. We love to have preceptors take one first year and one second year student each academic year. We also welcome preceptors who choose to take one student per year. The commitment to the student is for both the first and continued second year of medical school.
All LCPs hold a faculty appointment at JABSOM.
We have approximately 114 preceptors for 156 students. 37% of our LCPs work with both a first year and a second year during the academic year.
Leadership
Dr. Dennis Bolger is the Director of Clinical Skills. He moved into this position in April 2022 after previously serving in various teaching and administrative positions in Graduate Medical Education (GME) for Internal Medicine, University of Hwai'i Internal Medicine Residency Program and The Queens Medical Center. He brings his GME experience to Undergraduate Medical Education (UME).
Meet the Team
Clinical Skills collaborates with the Office of Medical Education (OME), especially the Center for Clinical Skills (SPEs) and SimTiki Simulation Center.
I. Lifelong Learning
Graduates will be lifelong learners.
Following PBL tutorial, patient care interactions, or in anticipation of future learning needs, students will be life-long, self-directed learners by:
A) Identifying gaps in knowledge and utilizing learning activities to refine their knowledge base.
B) Addressing learning needs by acquiring, integrating, and evaluating their ability to utilize credible resources.
C) Demonstrating commitment to obtaining new knowledge associated with improving patient/population outcomes.
D) Demonstrating commitment to improving personal performance and acknowledging limits in knowledge.
II. Foundational Knowledge and Discovery
Graduates will understand the foundational knowledge and discovery supporting clinical medicine.
Students will apply foundational knowledge and discovery to the practice of medicine by:
A) Describing the normal structure and function of each organ system and their interaction within the human body as a whole.
B) Explaining the various biological (molecular, cellular, and biochemical) mechanisms and non-biological (social, behavioral, psychological, and environmental) determinants that maintain the body’s homeostasis and maintenance of good health.
C) Explaining the various biological (molecular, cellular, and biochemical) and non-biological (social, behavioral, psychological, and environmental) causes of illness and the way in which they impact the body and mind (pathogenesis).
D) Describing the altered structure and function (pathology and pathophysiology) of the body and its organ systems
and tissues that are seen in various diseases and disorders.
E) Explaining the mechanisms by which various treatment modalities impact the pathogenesis and natural history of
diseases and disorders.
F) Discussing the principles of biomedical research methods, common biostatistical tools, scientific rationale, and
evidence-based medicine in determining the cause of disease and the efficacy of conventional, complementary and/
or alternative therapies, to evaluate the validity and application of research results.
III. Care of Patients
Graduates will provide patient-centered care that is compassionate, appropriate and effective for the
treatment of health problems and promotion of health in the ambulatory and hospital setting.
When seeing a patient presenting with a concern or illness in the ambulatory or hospital setting, students will be able to
care for that patient by:
A) Approaching each patient with an awareness of and sensitivity to the impact the patient’s age, gender, culture,
spiritual beliefs, socioeconomic background, lifestyle, social support, sexuality, and healthcare beliefs may have on
the diagnosis and treatment of their illness.
B) Understanding the components of the informed consent process and being capable of obtaining informed consent
for tests, procedures, and/or other interventions while respecting patient confidentiality and autonomy, and
preserving patient dignity.
C) Applying clinical reasoning and critical thinking to develop functional problem lists and differential diagnoses during
a patient encounter.
D) Performing a complete or complaint-focused history and physical exam following an appropriate exam sequence as
indicated by the context of the encounter and utilizing correct technique in a manner that reflects a clear
understanding of the manifestations of common illnesses.
E) Selecting and interpreting appropriate diagnostic tests with careful consideration of the test characteristics, risks,
potential complications, discomfort to patients, cost, and patients’ overall therapeutic goals.
F) Performing routine procedural skills under appropriate supervision that are considered essential for a particular area
of medical practice.
G) Developing and implementing an appropriate treatment plan, including the practice of order and prescription entry,
that takes into account efficacy, adverse effects, socioeconomic, safety, and compliance issues in the context of the
patient’s values and overall goals for treatment.
H) Recognizing and initiating therapy for acute life-threatening conditions.
I) Understanding the complex decision making that is intertwined with palliative and end-of-life care for patients.
J) Incorporating principles of inter professional, high quality, team-based patient care.
K) Learning to apply the principles of quality improvement and systems-based practice to the care of patients.
IV. Communication and Interpersonal Skills
Graduates will be able to communicate effectively with patients, families and other providers in the
interdisciplinary healthcare team.
When in a classroom, clinical, or other healthcare setting, students will communicate effectively with others by:
A) Communicating and effectively educating patients, families, members of the interprofessional team across a broad
range of backgrounds and identities, demonstrating collaboration, sensitivity, cultural modesty, and respect for
individual perspectives.
B) Demonstrating emotional awareness needed to develop and manage interpersonal interactions. This may include
how one’s own biases, identities, and lived experiences may influence one’s perspectives, interactions and clinical
decisions.
C) Effectively conveying clinical information and reasoning, with appropriate assertiveness, in all types of formal and
informal oral and written presentations.
D) Effectively documenting clinical care in medical records.
E) Delivering and receiving feedback effectively from peers, faculty, administration, staff and patients.
V. Population and Community Health
Graduates will understand, advocate, and apply principles and strategies of population and
community health that will result in equitable care of diverse patients and communities.
When in a classroom, clinical, or community setting, students will provide equitable care of diverse patients and
communities by:
A) Demonstrating an understanding of Native Hawaiian and other Indigenous peoples’ views of health and illness, the
impact of social and cultural determinants on their health status, and applying effective strategies for providing
culturally safe, appropriate, and competent care to improve their overall health and wellbeing.
B) Demonstrating meaningful participation in collaborative community health activities that optimize the health and
quality of life of all persons who live and/or work in a defined community or communities.
C) Evaluating the influence of social determinants of health, including economic, psychological, behavioral,
environmental, political, and cultural factors, as well as the effects of racism, that contribute to the maintenance of
health and the care of patients, their families, and communities.
D) Demonstrating knowledge of the physician’s role in global health issues such as climate change, emerging infections
and pandemics, bioterrorism, war, and environmental disasters.
E) Utilizing data from medical records, insurance claims, or other datasets to identify important public health or
population health management strategies (including telehealth) that support the health of communities.
F) Applying the epidemiology of common illnesses within diverse populations to integrate systematic approaches in
reducing the incidence and prevalence of such illnesses.
G) Caring for all patients, regardless of ability to pay, and advocating for equitable access to health care for
underserved and vulnerable populations.
H) Integrating important legal considerations in the practice of medicine by understanding the relationship between
public health practice and national and state laws.
I) Effectively tailoring healthcare strategies to constantly changing conditions faced by populations and their
communities.
VI. Professionalism
Graduates will be professional and ethical and demonstrate an enthusiasm for medicine while
delivering compassionate care to their patients.
When practicing medicine or representing JABSOM both inside and outside the classroom or clinical setting, students
will exhibit the highest standards of professional and ethical behavior by:
A) Applying the theories and principles that govern ethical decision-making including those related to the major
dilemmas in medicine.
B) Adhering to JABSOM policies regarding academic integrity, completing school and professional requirements in a
timely manner, cheating, plagiarism, fabrication, and falsification and to JABSOM and UHM policies regarding
student conduct.
C) Showing respect, honesty, altruism, accountability, honor, excellence, integrity, and humility.
D) Presenting a professional attire and demeanor.
E) Respecting patient confidentiality and preserving patient dignity.
F) Recognizing potential conflicts of interest inherent in various financial and organizational arrangements in the
practice of medicine.
G) Dealing with professional mistakes openly and honestly in ways that promote patient and clinical team trust and self-
learning.
H) Acknowledging personal limitations, ability to reflect and self-assess, and the need for lifelong learning.
I) Contributing to a safe and positive environment by active participation in JABSOM learning opportunities,
willingness to teach and support others, and demonstrating respect for diversity.
J) Incorporating principles of interdisciplinary collaboration, especially in the areas of communication and patient
safety.
K) Developing professional identity formation to embody the JABSOM Professionalism Philosophy.
VII. Wellness and Resiliency
Graduates will have the skills and strategies to maintain wellness and resiliency.
Students will maintain their wellness and resiliency by:
A) Describing strategies to maintain personal physical and mental health while fostering positive connections with
others.
B) Stating healthy habits to manage stress and exam anxiety.
C) Stating strategies to maintain personal safety and the safety of others in both academic and clinical environments.
D) Debriefing critical clinical incidents, such as unexpected outcomes and mistakes, with colleagues to reflect on
lessons learned.
E) Identifying resources available for treating physical and mental illness, including substance use disorder, and other
forms of physician impairment.
F) Stating the key elements of the student mistreatment policy, including the definition of mistreatment and how to
report it.
G) Recognizing and reflecting upon the importance of wellness and its impact on one’s personal and professional life.
The Basic Physical Exam Sequence (BPES) is a screening physical exam that all students are introduced to at the beginning of medical school in MD 1 unit. By the end of year 1, students will successfully perform the exam on a standardized patient with faculty observation and summative feedback. This screening head to toe exam covers the important elements of the physical exam, with emphasis on an efficient sequence of examination that minimizes patient repositioning and redundancy. This is by no means a comprehensive examination of every organ system and body area. Extended organ-specific exams and maneuvers are taught and practiced in the respective units: MD2 cardiopulmonary, MD3: hematology and renal, MD4: endocrine and gastrointestinal, MD6: musculoskeletal, neurological and behavioral and MD7: the life cycle with attention to the reproductive/genitourinary system, pediatric components and selective elements of geriatric medicine. We updated the BPES in June 2023 and ensured that it's consistent with the National Directors of Clinical Skills Education Organization's (DOCS) history, communication and physical exam assessment checklists updated July 2022.
Click Here to Access Basic Physical Examination Sequence Evaluation - Revised 2023
The pre-clerkship years are divided into eight instructional units, six of which are organized around problem-based learning (PBL) tutorials.
Click Here to View the MD Curriculum Overview
MD 1 - Health and Wellness
Basic medical communication skills
Medical data gathering (the standard components of the patient “history”)
Basics of documenting and orally-presenting clinical cases
The basic physical examination sequence (BPES): This is what we introduce and teach our pre-clerkship students (see separate page)
Introduction to basic elements of professional identity formation as a physician
MD 2- Cardiovascular and Pulmonary Health Problems
Identify components of the EKG
Understand the basics approach and organization to reading a 12 lead EKG
Obtain a chest pain history (lecture, practice, SPE)
Recognize illness scripts
Apply a systematic approach to reading CXRs
Participate in the clinical reasoning process
Practice specific cardiopulmonary exam skills:
Identity components of oral case presentation
Organize and recite opening statements
Become familiar with POCUS for cardiopulmonary exams
Begin to synthesize medical information (history, PE, ABG, CXR, EKG) to suggest assessment and plan
MD 3 - Renal and Hematologic Health Problems
Define and articulate common urinary symptoms and signs (dysuria, hematuria, pyuria, frequency, incontinence)
Interpret basic components of urinalysis
Classify acute kidney risk, injury, failure, loss and end-stage renal disease (RIFLE) and Kidney disease international improving global outcomes (KDIGO) by stages
Obtain and interpret orthostatics vital signs
Assess volume status
Percuss costophrenic angles
Understand physical exam techniques used to palpate bladder and kidneys
Examine patients for edema in the following areas: periorbital, abdominal wall, lower extremities, sacrum
Determine if pallor is present and discuss its’ significance
Elaborate the pertinent review of systems questions for the hematological system
Describe the physical exam technique for assessing hepatosplenomegaly
Explain and interpret the elements of complete blood count
Perform examination of the shoulder and knee with denotation of surface anatomy landmarks
Identify common signs of anemia
Obtain and interpret an electrolyte panel
Recognize the limitation of the eGFR based on creatinine
List the ddx for fatigue with particular attention to the heme and renal causes
MD 4 - Endocrine and Gastrointestinal Health Problems
Describe the anterior and posterior approach to examination of the thyroid gland
Appreciate the importance of the eye, skin, foot, sensory neurological exam and reflexes exam in the diabetic patient
Discuss modalities to measure peripheral sensory nerves
Considers a differential diagnosis of common endocrine diseases after reviewed a patient scenario/case
Generates a hypothesis-generated history and physical exam after presented with a brief patient complaint (endocrine issue)
Conducts the gastrointestinal exam in the organized sequence (BPES)
Assesses a patient’s liver size by physical exam palpation, percussion and auscultation
Examines abdomen for evidence of ascites (shifting dullness, fluid wave, bulging flanks)
Describes advanced steps of the GI exam (Mc Burney point, Murphy’s sign)
Positions the patient properly for the abdominal exam
Auscultates the abdomen for bowel sounds and bruits
MD 5 Summer session and Selective experiences
MD 6- Locomotor, Neurological and Behavioral Health Problems
Describe components of both the basic and extended examination of the joints
Review elements of the history important for rheumatologic diseases
Articulate the proper nomenclature for descriptions of joint movement, positions and surface anatomy
Characterize the elements of the screening sports exam
Describe spinal vertebral levels, nerve roots, myotomes and dermatomes and how they relate
Delineate the nerve roots responsible for the basic reflexes
Grade muscle strength
Define the sub-disciplines of ophthalmology
Demonstrate the basic functions of direct ophthalmoscopy
Point out the anatomical components of the eye
Explain the 7 elements of the screening neurological exam
Appreciate when to expand the neurological exam
Define the sub-disciplines of neurology
Describe exam techniques to test the 12 cranial nerves
Discuss the Glasgow Coma Scale
Explain the components of the mental status exam
Describe the biopsychosocial model
MD 7- The Life Cycle
Examines newborn in proper sequence (follows checklist)
Understands the principle concept of teams
Know the team leader’s (manager’s) role
Know standard formats for communication in medical teams
Employ depression screening tools for adolescents and children (i.e.PHQ-A, MFQ)
Compare risk factors for suicide between adolescents and adults
List resources for suicide prevention
Define HEEADSSS acronym used in adolescent and young adult medicine
Describe ADLs and iADLs
Highlight prominent pediatric developmental disabilities
Calculate a child’s age and when to compensate for prematurity
Interpret child’s age and development on growth chart
Describe the components of the female pelvic examination sequence and technique
Articulate how you examine the breasts
Compare/contrast different types of oral presentation based on setting: new pt to hospital H&P, outpt visit SOAP note, follow-up inpt SOAP 2.0, ICU pt by organ system
Differentiate the elements of the written note and oral patient presentation
Detail the proper positioning of a male patient for the genitorectal exam
The pre-clerkship years are divided into eight instructional units, six of which are organized around problem-based learning (PBL) tutorials.
Click Here to View the MD Curriculum Overview
General Texts & Handbooks
This is JABSOM's required textbook for clinical skills. It is comprehensive. Anyone with a hawaii.edu email can access this text from the JABSOM Health Sciences Library
Orient, Jane. Sapira’s Art and Science of Bedside Diagnosis. Lippincott, Williams and Wilkens.
This is another comprehensive textbook on the physical examination, with a special emphasis on history and (some) basic pathophysiology interjected. This book is particularly useful when you have that “tough” learning issue about the rationale for specific physical examination maneuvers. We don’t suggest you rush out to purchase this one, but you might want to familiarize yourself with it.
Coulehan JL, Block MR. The Medical Interview: Mastering Skills for Clinical Practice. F.A. Davis.
This is a terrific book about the medical interviewing process and communication skills. Well-organized, with easy to read format. Worth checking out.
DeGowin RL, Brown DD. DeGowin’s Diagnostic Examination. McGraw-Hill.
This is a “classic”. More of a reference book than a beginner’s learning aid. Fairly extensive explanation of abnormal physical findings.
Gomella LG, Haist SA. eds. Gomella and Haist’s Clinician’s Pocket Reference, 12e. McGraw Hill; 2022.
This is useful and practical for clerkship preparation.
Talley NJ, O’Connor S. Talley and O'Connor's Clinical Examination, 9e. Elsevier; 2022.
Excellent and concise book with very good photos.
Problem-Based Learning at JABSOM
https://moodle.jabsom.hawaii.edu/course/view.php?id=2
General Medicine Websites
Note- many of these websites will require an @hawaii.edu login.
Stanford 25 - This is one of the most popular clinical skills resources available.
JoVE - This site has a nice collection of short clinical skills videos and is comprehensive, including some POCUS.
Loyola University – Chicago, clinical skills website - This site has some photos and offers a fairly extensive menu of physical examination steps.
Martinsdale's Virutal Medical Center - This site has links to various online videos, including pediatric physical exxam, etc.
University of Washington School of Medicine website - This site has nice video and audio clips.
Introduction:
Consider analyzing each historical question and physical exam component as a diagnostic test with sensitivity, specificity, predictive values and receiver-operator-characteristics. Laboratory, imaging and diagnostic tests also have characteristic utilities such as likelihood ratios which can be found in the literature.
https://drive.google.com/file/d/1mdGDeCsg4SbUeYjgzyjEF8vUfCiZKEVL/view
https://drive.google.com/file/d/1mDr-0EOUgxTGrG0AGwomLuuRx6vmWUaf/view
Some tips and quotes (also found merged in the Teaching Tips and Illuminating Quotes page)
Our senses as diagnostic aids have been almost completely replaced by laboratory instruments and the consequences may sometimes be disastrous. (Louis K. Diamond, MD 1902-1999)
The physical exam can be viewed as a coordinated series of lab tests, each component of which has its own limitations in sensitivity, specificity and predictive values.
Worth re-emphasizing is the importance of examining patients with direct visualization and palpation, not through the gown, which can mask findings (e.g. skin lesions, decrease tactile sensitivity and lead to false-positive findings (e.g. spurious "rales")).
The physical exam is an active, iterative process. Try to focus your exam on the clinical context of the patient being examined. Look, feel and listen FOR, not TO.
MD 1 Health and Illness
MD 2 Cardiopulmonary
Auscultation of a pericardial friction rub is 100% specific for pericarditis
Auscultation of an S3 gallop has a LR+ of 11 for heart failure
+ abdominojugular reflux (sustained neck vein elevation of >=4cm H2O during 10s) has a LR+ of 8 for elevated cardiac filling pressures
Estimation of elevated central venous pressure (>8 cm) has a LR+ of 8.9. Its absence has a LR- of 0.3.
Auscultation of egophony on pulmonary exam has a LR+ of 8.6 for pneumonia
ADVANCED CARDIAC (not covered directly in PBL cases)
Palpation of a slow carotid upstroke has a LR+ of 9.2 for aortic stenosis
Auscultation of a systolic murmur radiating to the right carotid artery has a LR+ of 7.5 for aortic stenosis
Systolic murmur that increases from squatting to standing has a LR+ of 5.9 for hypertrophic cardiomyopathy
Systolic murmur that decreases in intensity with passive leg elevation has an LR+ of 9.4 for hypertrophic cardiomyopathy
Syncope that occurs during exertion is associated with a LR+ 6.5-14 for a cardiac cause
An abnormally decreased femoral pulse has a LR+ of 7 for peripheral arterial disease (PAD)
An abnormally decreased posterior tibial pulse has a LR+ of 8 for peripheral artery disease (PAD)
Tips for assessment of heart murmurs:
Right-sided murmurs increase in intensity with during inspiration
Hypertrophic cardiomyopathy murmurs increase in intensity with Valsalva and from squatting to standing
Fixed splitting of S2 occurs with: RBBB, pulmonary valve stenosis, VSD and ASD
Paradoxical splitting of S2- splitting during expiration - occurs with: LBBB, HCM and severe AS
Signs of serious cardiac disease: S4, murmurs >=3/6, any diastolic murmur, continuous murmurs, abnormal splitting of S2
ADVANCED PULMONARY
In pts with dyspnea and or pleurisy but normal physical exam, obtain upright CXR (assess for pneumothorax)
Approximated 35% of solitary pulmonary nodules are bronchogenic carcinomas
Do not use long-acting beta-agonists (LABAs) as single agents for patients with asthma (increased mortality)
A normal PaCO2 in an asthmatic pt with severe symptoms may indicate impending respiratory failure
In COPD, do not use short-acting and long-acting anticholinergics together
MS 3 Renal and Hematology
Inspection and observation of conjunctival rim pallor has a LR+ of 16.7 for anemia
Palpation of the spleen tip in a supine patient has a LR+ of 8.2 for splenomegaly
Orthostatic hypotension defined as pulse increase >30 bpm from supine to standing, has a LR+ of 48 for volume depletion or blood loss
Increased pulse >30 bpm or SBP < 20 mmHg or DBP <10 mmHg from supine to upright has LR+ of 3-48 for volume depletion
MD 4 Endocrine and Gastrointestinal
In patients who develop large bowel obstruction, 94% have had previous abdominal surgery (LR+ 11.5)
MD 6 Locomotor, Neurological and Behavioral
Urinary retention has a LR+ of 18 for cauda equina syndrome, and LR- of 0.1 when absent
A history of cancer has a LR+ of 14.7 for patients with back pain due to vertebral metastases
A history of corticosteroid use has a LR+ of 12 for patients with osteoporotic compression fractures
A wide-based gait has a LR+ of 13 for patients with spinal stenosis
Presence of rheumatoid nodules have a LR+ 30 for the diagnosis of rheumatoid arthritis
MD 7 Life Cycle
References:
Morrow D.A. (2022). Chest discomfort. J Loscalzo J, et. al. Harrison's Principles of Internal Medicine, 21e. McGraw Hill.
Bickley L.S. (2021). Bates’ Guide to Physical Examination and History Taking, 13e. Wolters Kluwer.
Henderson M. C., & Tierney L.M., Jr., & Smetana G.W.(Eds.), (2012). The Patient History: An Evidence-Based Approach to Differential Diagnosis, 2e. McGraw Hill.
McGee S. (2022). Evidence Based Physical Exam Diagnosis, 5e. Saunders Elsevier.
Stern, SDC, Cifu, AS, Altkorn D. (2020) Symptoms to Diagnosis- An Evidence-Based Guide, 4th edition. McGraw Hill.
Alguire PC. et. al. (2022). Board Basics- An enhancement to Medical Knowledge Self Assessment Program (MKSAP) 6th edition: ACP
MD 1 Health and Disease- Diagnostic Tests
Interpreting diagnostic tests for SARS-CoV-2 relies on timeline for diagnostics markers such as antibodies and viral RNA particles.
Sethuraman N, Jeremiah SS, Ryo A. Interpreting Diagnostic Tests for SARS-CoV-2. JAMA. 2020;323(22):2249–2251. doi:10.1001/jama.2020.8259
MD 2 Cardiopulmonary Diagnostic Tests
CXR for diagnosing lower respiratory tract infections in the community
Chest X-ray sensitivity: 75% (95% CI 54%-88%); specificity: 75% (95% CI 42%-92%) The majority of studies (86%) were performed in adults (78%), emergency departments (92%) and in European countries. The comparator was CT scan of chest.
Gentilotti E, De Nardo P, Cremonini E et. al. Diagnostic accuracy of point-of-care tests in acute community-acquired lower respiratory tract infections. A systematic review and meta-analysis. Clin Microbiol Infect. 2022 Jan;28(1):13-22. doi: 10.1016/j.cmi.2021.09.025.
MD 3 Heme and Renal Diagnostic Tests
Serum Cystatin C is an accurate estimation on eGFR in patients with or at risk for Chronic Kidney Disease
eGFRcr is the initial equation recommended for estimation of GFRa; its accuracy may be affected by muscle mass, diet, frailty, advanced heart failure or liver failure, and medications: trimethoprim, dronedarone, and tyrosine kinase inhibitors.
eGFRcys may underestimate actual GFR in people who smoke cigarettes, with obesity, with hypothyroidism, or who take systemic corticosteroids. In these individuals, eGFRcr-cys typically provides the most accurate estimate of GFR.
Shlipak MG, Inker LA, Coresh J. Serum Cystatin C for Estimation of GFR. JAMA. 2022;328(9):883–884. doi:10.1001/jama.2022.12407
24-h urine magnesium level for Mg++ wasting differentiates renal from non-renal causes
A urinary magnesium test (24 h collection assesses polyuria also) differentiates between renal and non-renal causes of magnesium wasting. Hypomagnesemia secondary to glycosuria-induced polyuria improves with glycemic control.
Tucker BM, Pirkle JL, Raghavan R. Urinary Magnesium in the Evaluation of Hypomagnesemia. JAMA. 2020;324(22):2320–2321. doi:10.1001/jama.2020.18400
MD 4 Endocrine and Gastrointestinal Diagnostic Tests
Clostridioides difficile multi-step testing algorithms
Multistep CDI test algorithms consist of a sensitive stool screening test, such as a nucleic acid amplification test (NAAT) [96%] or glutamate dehydrogenase (GDH) antigen testing, and a specific test, enzyme immunoassay (EIA) [99%] for C difficile toxin A and B. Multistep CDI testing may help distinguish CDI from colonization, potentially avoiding unnecessary antibiotics. Patients with a positive NAAT or GDH antigen test and a negative toxin EIA result may have symptomatic CDI or may be asymptomatic carriers of C difficile. Pre-test probability and clinical context should determine care.
Nicholson MR, Donskey CJ. Multistep Testing Algorithms for Clostridioides difficile Infection. JAMA. 2023;330(10):966–967. doi:10.1001/jama.2023.15875
FIBROSCAN (VCTE) is diagnostic test for cirrhosis
Vibration-Controlled Transient Elastography for Diagnosing Cirrhosis & Staging Hepatic Fibrosis
Vibration-controlled transient elastography (VCTE) accurately confirms the presence or absence of cirrhosis in many etiologies of chronic liver disease. Liver stiffness measurement (LSM) should be interpreted within the clinical context for each patient, and results should be corroborated with other noninvasive tests or liver biopsy if questions persist regarding LSM accuracy. Clinicians must be aware of the limitations of VCTE in order to use and interpret results correctly.
Wilder J, Choi SS, Moylan CA. Vibration-Controlled Transient Elastography for Diagnosing Cirrhosis and Staging Hepatic Fibrosis. JAMA. 2018;320(19):2031–2032. doi:10.1001/jama.2018.13073
Hepatitis C RNA tests are 96-98% sensitive and 98-99% specific for diagnosis of infection.
Any patient with known risk factors for HCV or born between 1945 and 1965 should be screened for HCV. Enzyme immunoassays for anti-HCV are used to screen for HCV infection and are very sensitive and specific. A patient with a positive anti-HCV should have an HCV RNA tested to determine whether there is ongoing infection.
Konerman MA, Lok AS. Diagnostic Challenges of Hepatitis C. JAMA : the journal of the American Medical Association. 2014;311(24):2536-2537. doi:10.1001/jama.2014.306
MD 6 Musculoskeletal, Neurological and Behavioral Diagnostic Tests
Hip X-ray for diagnosis of fracture
The sensitivity of plain x-rays in detecting hip fracture is 90–98%, based on multiple studies.
Heikal S, Riou P, Jones L. The use of computed tomography in identifying radiologically occult hip fractures in the elderly. Ann R Coll Surg Engl. 2014 Apr;96(3):234-7. doi:10.1308/003588414X13824511650533
MD 7: LIFE CYCLE: Genitourinary, Reproductive, Pediatric and Geriatric Diagnostics
Serum hCG test (and quantitative values) for diagnosis of pregnancy
Serum hCG testing should be considered in all patients with possible pregnancy given significant variability in hCG levels and their degradation products in urine. Urine hCG can be falsely-negative during weeks 1-4 and 6-8 of gestation. Sensitivity is 90-97% for pregnancy.
Latifi N, Kriegel G, Herskovits AZ. Point-of-Care Urine Pregnancy Tests. JAMA. 2019;322(23):2336–2337. doi:10.1001/jama.2019.15833
Podcasts
Containsts transcripts and associated Youtube videos.Websites
Review methods of effective learning such as spaced learning, retrieval practice, elaboration, interleaving, dual coding and concrete examplesFocus is on clinical rotations, rotation prep for various specialty rotations, skills with interactive cases, review of seminal articles and work/job preparation. Some content requires paid subscription.
Focuses on diagnostic skills development for both learners and instructors. Highlights skill development and competencies (EKG,CXR,US, ECHO interpretations and clinical cases to assess reasoning.
Clinical Reasoning exercises from JGIM web series. Offers concrete examples and practice with problem rep, illness scripts, dual processing and dx schema.
Apps
EBM=EBP
Evidence-based medicine, coined in 1992 by Gordon Guyatt of McMaster University, has also be called 'enlightened skepticism.' Listen to these inspirational stories of EBM: the past, present and future: An oral history. https://files.jamanetwork.com/sdebm/
Granular components of EBM:
Scientific skepticism
Critical analysis of literature
Constant reappraisal of the evidence/literature
Combined with:
Clinical experience --> clinical expertise via deliberate practice (planning, performing, reflecting)
Patient values and preferences
Clinical context of a given patient, physicians & system at a given moment in time
Beware of clinical inertia and evidence-based exit block where clinical practice has failed to become fully aligned with strong evidence supporting a change in diagnosis or therapy.
-Goldberger LA and Goldberger ZD. Becoming a Consummate Clinician: What Every Student, House Officer, and Hospital Practitioner Needs to Know. Wiley-Blackwell: 2012.
Always listen to the learner, try not to interrupt right away and pause before comment.
Only connect.... (EM Forster: 1897-1970)
"Feedback is a gift." (Emilia Benjamin, Jane Liebschutz)
I can either give you feedback that will make you feel good, or I can give you feedback that will make you a better clinician. My job is to make you a better clinician. (ML Boehler)
The task of the excellent teacher is to stimulate 'apparently ordinary' people to unusual effort. The tough problem is not in identifying winners: it is in making winners out of ordinary people. (K. Patricia Cross: 1926-2023)
The mind is not a vessel to be filled but a fire to be kindled. (Plutarch: 46-120)
Keep the light of curiosity aflame.
A doctor who cannot take a good history and a patient who cannot give one are in danger of giving and receiving bad treatment. (Paul Dudley White, MD)
You can observe a lot just by watching. (Yogi Berra:1925-2015)
Oslerian Quotes - Sir William Osler: 1849-1919
We miss more by not seeing than by not knowing.
Medicine is learned by the bedside and not in the classroom.
The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.
To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.
The good physician treats the disease; the great physician treats the patient who has the disease.
Listen to the patient, he is telling you the diagnosis.
Remember... that every patient upon whom you wait will examine you critically and form an estimate of you by the way in which you conduct yourself at the bedside. Skill and nicety in manipulation, in the simple act of feeling the pulse or in the performance of a minor operation will do more towards establishing confidence in you, than in a string of Diplomas, or the reputation of extensive hospital experience.
The greater the ignorance the greater the dogmatism.
The master-word in medicine in work.
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When you have exhausted all possibilities, remember this: you haven't. (Thomas Edison: 1847-1931)
Being too certain--never being in doubt-- paradoxically results in lower-quality care through over-testing, premature conclusions & tunnel vision. (Renee Fox, JP Kassirer, Ronald Epstein)
Experts know the answers. Masters know the important questions. Experts revel in what they know. Masters revel in what they don't. (Hubert & Stuart Dreyfus)
Mahatma Gandhi Quotes 1869-1948
A 'No' uttered from deepest conviction is better than a 'Yes' merely uttered to please, or what is worse, to avoid trouble.
The best way to find yourself is to lose yourself in the service of others.
Be the change you are trying to create.
Our greatest ability as humans is not to change the world, but to change ourselves.
It’s easy to stand with the crowd. It takes courage to stand alone.
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Our senses as diagnostic aids have been almost completely replaced by laboratory instruments and the consequences may sometimes be disastrous. (Louis K. Diamond, MD 1902-1999)
The physical exam can be viewed as a coordinated series of lab tests, each component of which has its own limitations in sensitivity, specificity and predictive values.
Worth re-emphasizing is the importance of examining patients with direct visualization and palpation, not through the gown, which can mask findings (e.g. skin lesions, decrease tactile sensitivity and lead to false-positive findings (e.g. spurious "rales")).
The physical exam is an active, iterative process. Try to focus your exam on the clinical context of the patient being examined. Look, feel and listen FOR, not TO.
Art consists of limitation. The most beautiful part of every picture is the frame. (Gilbert K Chesterton 1874-1936)
Doctors must be wary of 'going with their gut' when what's in your gut is a strong emotion about a patient, even a positive one. This species of affective bias can skew a physician's judgement and lead to misdiagnoses. (Jerome Groopman)
We don't see things as they are; we see things as we are. (Anais Nin 1903-1977)
Everything should be made as simple as possible, but not simpler. (Albert Einstein 1879-1955)
The teacher is the one who gets the most out of the lessons, and the true teacher is the learner. (Elbert Hubbard 1856-1915)
Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing. (Voltaire 1694-1778)
Francis Weld Peabody Weld 1881-1927
One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.
Medicine is not a trade to be learned, but a profession to be entered. It’s an ever-widening field that requires continued study & prolonged experience in close contact with the sick...
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These are duties of the physician: First... to heal his mind and to give help to himself before giving it to anyone else. (Epitaph of an Athenian doctor 2 AD)
Confucius Quotes (551-479 BCE)
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I hear and I forget. I see and I remember. I do and I understand.
By three methods we may learn wisdom: First, by reflection, which is noblest; Second, by imitation, which is easiest; and third by experience, which is the bitterest.
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Having courage does not mean that we are unafraid. Having courage and showing courage means we face our fears. We are able to say, ‘I have fallen, but I will get up.' (Maya Angelou: 1928-2014)
People don't care how much you know until they know how much you care. (Theodore Roosevelt: 1858-1919)
Life's most urgent question is, "What are you doing for others?" (Martin Luther King, Jr.: 1928-1968)
If you want others to be happy, practice compassion. If you want to be happy, practice compassion. (Dalai Lama)
Learn to listen with your fingers. (Helen Taussig: 1898-1986)
What I want in my life is compassion, a flow between myself and others based on a mutual giving from the heart. (Marshall B. Rosenberg: 1934-2015)
Practice the 3 C's as much as possible: calmness, clarity and compassion.
Compassion is defined as the emotional response to another's pain or suffering, involving an authentic desire to help.
Without data, you're just another person with an opinion. (W. Edwards Deming: 1900-1993)
Our sorrows and wounds are healed only when we touch them with compassion. (Buddha: 6th-4th century BCE)
We sincerely thank all of our preceptors who are largely volunteer, unpaid faculty members who practice the tenets of medical education and our oath to teach future generations!
MAHALO to all of our dedicated Longitudinal Clinical Preceptors (LCP)s!
Physicians in bold precept 2 students per year.
Angelica Agapito Masahisa Amano Vernon Azuma
Bryan Brown Michiko Bruno Lisa Camara
Jonathan Carlson Daniel Chan Deborah Chang
Li-Hsieh Chen Selena Chen Nathan Chin
Baron Ching Galen Chock Rachel Coel
Roui DeCastro Serena Del Mundo Jennifer Di Rocco
Maegan Doi Nate Enriquez Kristin Fernandez
Edward Fong Larissa Fujii-Lau Jami Fukui
Alexandra Galati Ali Goo Nour Hamade
Sara Harris Mi'i Hawkins Deborah Hirose-Ridao
Marina Hitosugi-Levesque Martin Ho Nataliya Holmes
Ryan Honda Daniel Hong Travis Hong
Aaron Hoo Jill Inouye Marcus Iwane
Ankur Jain Shilpa Jain Flo Kan
Janet Kao Jennifer Katada Kelly Kawaoka
Jennifer King Yusuke Kobayashi Elizabeth Koehler
Jeremy Kort Sreenandh Krishnagopalan David Kurahara
Scott Kuwada Jannet Lee-Jayaram David Lee
Jordan Lee Nicholas Leo Nikki Leong
Kuo-Chiang Lian William Loui Christina Marzo
Traci Masaki Tesoro Brent Matsuda Joan Meister
Marian Melish Magdy Mettias Matthew Mitschele
Barry Mizuo Anjul Moon Nani Morgan
Mitchell Motooka David Naai Gail Nakaichi
Jennifer Nakamatsu Stuart Nakamoto Kelly Nakamura
Jeffrey Okamoto Fernando Ona Mel Ona
Jessica Ono Gabriela Ortiz-Omphroy Lauren Oshima
Brennen Owan Gypsy Paar Abby Pandula
Suha Patel Marie Pescador Elizabeth Quinn
Darlene Ramones Malia Rasa Young Soo Rho
Kahealani Rivera Ray Romero Megan Sakamoto-Chun
Scott Serrano Robin Seto James Sim
David Singh Randall Suzuka Alain Takane
Brandon Takase Cody Takenaka Bryce Tanaka
Dawn Taniguchi Jinichi Tokeshi Michael Tom
Catherine Tsang Travis Watai Nash Witten
Calvin Wong Lydia Wong Marie Yamamoto-Ya
James Yess
(last updated 06/2024)
Resources for MD 2: Cardiovascular and Pulmonary Health Problems
Easy Auscultation.com. Very nice resource, with video and audio clips. May require registration to access some of their resources.
New England Journal of Medicine clinical videos
Teaching medicine - reviews how to teach clinical skills: clinical cases, EKGs, CXRs, ABGs, imaging (must register)
Resources for MD4: GI & Endocrine Health Problems
Thyroid palpation
https://stanfordmedicine25.stanford.edu/the25/thyroid.html
Deep tendon reflexes focus on biceps and ankle
https://stanfordmedicine25.stanford.edu/the25/tendon.html
Monofilament sensory test
https://www.youtube.com/watch?v=ZzP_gijk6TA
Vibration sensory test - use 128 Hz tuning fork- test
https://www.youtube.com/watch?v=zgM90zmYvM0
Proprioception test - check position sense of first toe (up or down)
https://www.youtube.com/watch?v=V75Bc35Qr7I
Exam of liver
https://stanfordmedicine25.stanford.edu/the25/liver.html
Liver palpation and percussion demonstration - liver scratch test demonstration
https://www.youtube.com/watch?v=DBif1jjAfKk
Another example of liver palpation and hooking technique demonstration
https://www.youtube.com/watch?v=839KX_-B1O0
Tests for ascites - shifting dullness and fluid wave
https://stanfordmedicine25.stanford.edu/the25/avp.html
Murphy's sign
https://www.youtube.com/watch?v=2T0XUQ1M-x0
McBurney's point
https://www.youtube.com/watch?v=Fp8txG-DBDM
Spleen exam
Hip exam:
https://stanfordmedicine25.stanford.edu/the25/HipRegionExam.html
https://www-nejm-org.eres.library.manoa.hawaii.edu/doi/full/10.1056/NEJMvcm2000815
Hand exam:
https://stanfordmedicine25.stanford.edu/the25/hand.html
https://www-nejm-org.eres.library.manoa.hawaii.edu/doi/full/10.1056/NEJMvcm1407111
Carpal tunnel:
https://stanfordmedicine25.stanford.edu/the25/carpaltunnel.html
Knee exam:
https://stanfordmedicine25.stanford.edu/the25/knee.html
https://www-nejm-org.eres.library.manoa.hawaii.edu/doi/full/10.1056/NEJMvcm0803821
Knee arthrocentesis
https://www-nejm-org.eres.library.manoa.hawaii.edu/doi/full/10.1056/NEJMvcm051914
Low back exam:
https://stanfordmedicine25.stanford.edu/the25/BackExam.html
Shoulder exam:
https://stanfordmedicine25.stanford.edu/the25/shoulder.html
https://www-nejm-org.eres.library.manoa.hawaii.edu/doi/full/10.1056/NEJMvcm1212941
Tarsal tunnel exam:
https://stanfordmedicine25.stanford.edu/the25/tarsaltunnel.html
Pupillary exam:
https://stanfordmedicine25.stanford.edu/the25/pupillary.html
Fundoscopic exam:
https://stanfordmedicine25.stanford.edu/the25/fundoscopic.html
https://www-nejm-org.eres.library.manoa.hawaii.edu/doi/full/10.1056/NEJMvcm1308125
Gait exam:
https://stanfordmedicine25.stanford.edu/the25/gait.html
Internal capsule stroke exam/findings:
https://stanfordmedicine25.stanford.edu/the25/ics.html
Involuntary movement exam:
https://stanfordmedicine25.stanford.edu/the25/involuntary-movements-and-tremors.html
Parkinson’s disease findings:
https://stanfordmedicine25.stanford.edu/the25/parkinsondisease.html
Resources for MD 7: The Life Cycle
Modified Checklist for Autism in Toddlers
CDC A Guide to Sexual History Taking
https://www.cdc.gov/std/treatment/sexualhistory.pdf
CDC developmental milestones
https://www.cdc.gov/ncbddd/actearly/milestones/index.html
American Academy of Pediatrics
http://pediatrics.aappublications.org/content/138/1/e20161420
Oral presentations
-Wolpaw, TW, Wolpaw, TR, and Papp, KK. SNAPPS: A Learner-centered Model for Outpatient Education. Academic Medicine, vol.78, Sept 2003.
-Picchinoni M. Primer to the Internal Medicine Clerkship. Second edition. AAIM publications: 2008.
-Guerrasio J. Remediation of the Struggling Medical Learner. Second edition. Association for Hospital Medical Education: 2018.
-Academic Alliance in Internal Medicine - Subinternship curriculum 2018
https://drive.google.com/drive/folders/1QE9k9JXfCm_8zFAGkEzZI1xoLRI05ECL
Core Entrustable Professional Activities for Entering Residency (CEPAER) - From AAMC
https://www.aamc.org/media/20196/download?attachment
Rectal exam:
https://www-nejm-org.eres.library.manoa.hawaii.edu/doi/full/10.1056/NEJMvcm1510280
Pelvic exam:
https://www-nejm-org.eres.library.manoa.hawaii.edu/doi/full/10.1056/NEJMvcm061320