Viewpoint: suggestions for a shift in teaching clinical skills to medical students: the reflective clinical examination.

How medical students are taught physical examination (PE) skills appears to have changed little since the 1950s. Textbooks are organized according to organ systems and describe methods of eliciting and recording history and PE data using a routine format. In many medical schools, the preclinical teaching programs for clinical examination skills similarly emphasize an orderly collection of data. Teaching students to use diagnostic reasoning is postponed until students have learned history-taking and PE skills. The authors propose three modifications to this educational approach. First, rather than performing the clinical examination using a routine format, students should be encouraged to form diagnostic hypotheses early on while listening to the patient's narrative, and conduct the subsequent search for history and PE data in a reflective way in order to confirm or refute these hypotheses. Second, the authors propose that interviewing patients and conducting the PE be taught by one-on-one tutoring until students achieve mastery. Last, they suggest that the PE be guided not only by students' diagnostic hypotheses, but also by patients' expectations. These modifications are consistent with current trends in medical education that encourage a reflective practice and problem-based learning (PBL), and they also introduce medical students to the precepts of clinical reasoning. The authors suggest that challenging students to seek specific physical findings may increase the likelihood of detecting findings when they are present, and may transform patient interviewing and conducting the PE from routine activities into intellectually exciting experiences.