Once you learn how to develop your clinical skills, you will unlock your true potential. From benefiting patients to benefiting financially; it will all happen believe me.
Faheem Ahmed, award-winning pharmacist prescriber
You can become a great clinician
How? That is the million-dollar question. How can we transform from a pharmacist to a clinician? Can you imagine yourself examining patients, writing referral letters and prescribing where necessary? Honestly, until I did it myself I never thought it would be possible. I mean think about it, as a pharmacist, we are so use to being behind the counter that I just could not see myself doing this. But, let me tell you something, you can defiantly do it and do it really well if you are prepared to learn.
Definition of clinical skills
The term clinical skills may have different meanings depending on the context within which it is used. When I use the term I am referring to a pharmacist being able to take a patient history and undertake a thorough consultation coupled with the ability to apply that information in order to diagnose the cause of the patient complaint.
First things first
Right. The first thing that you must do to develop your clinical skills is understand surface anatomy and physiology.
For your understanding the structure of the human body ie. anatomy can be studied on a microscopic level (called histology or cytology; here you study about tissues and cells) or on a macroscopic level also termed surface anatomy; here you you learn to name parts of the body that can be seen with the naked eye and the function of those parts.
Why should you bother to learn this? Because you cannot go and treat the human body without understanding what is normal. You need to first understand;(1) how the human body works, (2) how it functions and (3) what is normal. Once you grasp this, only then you can treat and recognize abnormalities in the body. I am sure that makes sense?
Anatomy and physiology textbooks
There are many text books that can help, but I have found not all of the books are relevant to our learning needs and tend to be geared more towards medical school such as Grey’s Anatomy (mammoth text book)
However there’s a very good book that is easier to digest and read which combines both anatomy and physiology called Anatomy and Physiology for Nurses. I think it’s a great book and one I found useful when teaching my students.
Once you understand the human body and you know how it functions, the next step is internal medicine.
The key to diagnose and treat disease
Right. Internal medicine is the discipline where you will learn everything about the individual diseases. This is where you will learn; (1) causes of individual diseases, (2) changes the diseases make on a tissue level and (3) how the disease manifests itself in terms of signs and symptoms.
Now when you read some of these textbooks it can be overwhelming. I would suggest you should understand the following for every single disease; (1) disease incidence; this will help you know how likely the disease may present and so you’re prepared, (2) aetiology; once you know the cause you can then treat it, (3) age and sex; knowing how ones gender and age can influence a disease can be helpful. For example, middle ear infections are more common in children relative to adults and urinary tract infections are more common in females than men, (4) geography; being familiar with how diseases may be more prevalent in certain parts of the world can be helpful ie. a patient presenting with fever, muscles aches and pain having travelled from Africa may prompt you to consider malaria, (5) pathology; I’d suggest you focus on the macroscopic manifestations of the disease ie. those changes you can see with the naked eye such as Otitis Externa causes inflammation of the external ear canal and you can visually see redness and swelling of the canal but you can not see the microscopic changes that occur, (6) signs and symptoms; now this is relatively straight forward but I want to highlight that you focus on identifying those key features that allow you to distinguish the condition from those that present similarly and below is an example illustrating this:
Pneumonia
Type of cough: Usually chesty cough (unless atypical and can start of as dry), duration: Less than 3 week, alarm features: Blood, Chest pain (usually pleuretic), Shortness of breath , systemic findings: fever usually greater than 38 degrees, Increase respiratory rate and increased pulse, risk factors: smoking, extremes of age, alcoholism, diabetic, HIV, asthma/COPD, GORD, social history: smoker, travel history: legionella pneumonia. Key: Upper right quadrant pain.
Examination
Inspection: Start from the mouth and look for use of increased effort in breathing, palpation: possible tenderness, percussion: dullness, increased tactile fremitus, auscultation: crackles, vitals: Tachypnoea, fever and hypoxia (if extensive but not always)
Important: the presence of fever is important in history. Care with elderly who may not have an increased temp but tachypnoea and altered mental state and decreased oxygen saturation may be there.
Acute bronchitis
Type of cough: dry or chesty mucopurulent (yellow) , duration: less than 3 weeks, alarm features: chest pain (secondary to cough and maybe pleuretic), vomiting (vaccine history) , systemic findings: low grade fever (less than 38 degrees), risk factor: smoker. Key: On examination, most findings are normal other than a local wheeze +/- ronchi
Examination
Inspection: start from the mouth , palpation: possible tenderness, percussion: normal, auscultation: ronchi , not wide spread wheeze, vitals: low grade fever
Notes:
Shifted trachea- Not normal, asymmetric chest expansion- Not normal, dullness/hypersisonant to percussion- not normal, reduced or absent breath sounds- not normal
Important:
Usually you do not have a high grade fever. Presence of vomiting after coughing will prompt treatment with antibiotics
Consultation skills and examination skills
So, lets say for arguments sake you already are comfortable with anatomy and physiology and internal medicine or have now gained a better understanding of this; then the next stage for you is to learn how to extract the information form the patient and undertake the appropriate examination. This skill is called history taking and physical examination.
I can not stress how important it is for you to master this skill. The key is to be able to ask the right questions to ensure your time is used efficiently. There is no skill in asking a bunch of random generic questions just for the sake of it such as; ‘when did the symptoms start? describe the character, do you have any other symptoms’ etc. You have to learn to ask questions that help you decipher between the likely causes of symptoms. The books I would recommend for history taking and examination of the body systems are Macleod clinical examination or Bates guide to physical examination and history taking.
Practice what you preach
Once you’ve done this, then you need to get clinical practice. This is essential to allow you to bridge the gap between theory and practice. Just remember your time at university and your pre registration year. You had learned all the theory at university and it was your training year that allowed you to put this learning into practice. The same applies here.
There is no hard and fast rule to getting clinical practice other than having someone who is willing to act as a mentor or someone who you can discuss cases with. I was fortunate to have a group of doctors support me and it is invaluable.
Another learning tool is taking patient histories and examining patients (with consent of course) as they present to you with prescriptions. For example, think of how many times you must have dispensed phenoxymethylpenicillin 250mg tablets for a throat infection? Imagine working backwards and taking the patient history to see if it matches your theoretical knowledge and ask yourself what you would expect to find on examination and then examine the patient to see what you find. For me this way of learning has been a revelation and I get to learn without taking any risks of trying to diagnose and treat and then wait to see if the patient responds to treatment to confirm my diagnosis. I just wish I would have done this for every single condition from the day I qualified. Can you imagine how much we all could learn?
You can do it
So, I have just shown you that it is possible and you can develop your clinical skills. What you need to do is dedicate time to your learning and remain disciplined. If you can spend 20-30 minutes everyday, you can not go wrong.
