Clinical skills should be prized

Clinical experience has been defined, tongue-in-cheek, as ‘making the same mistakes with increasing confidence over an impressive number of years’.1 There is a wealth of difference, however, between unexamined clinical experience and clinical acumen. For example, when assessing a febrile child for serious infection, the history and the clinical signs and symptoms are the most reliable tools available.2 Despite my expressed scepticism about our over-reliance on numbers generated by laboratory tests,3 the value of the clinical assessment can be augmented by urinalysis and inflammatory markers,2 but this does not detract from the message that there is no substitute for good clinical skills (Fig. 1). More mistakes are made by not asking (poor history) and not looking (poor examination) than by not knowing. When faced with an acutely ill child, we have to make a quick assessment about the severity of illness and the need for immediate intervention. The great Canadian physician William Osler (1849–1919) said: ‘There is no more difficult art to acquire than the art of observation’. We know about the emergency ABC of airways, breathing and circulation, but there is also an ABC of observation that begins at first sight. We should immediately assess the child's level of alertness and activity and his or her breathing and their colour (pallor or cyanosis), as well as their circulation (cold peripheries, poor capillary return). Cyanosis is a sinister sign in asthma, bronchiolitis and infant pertussis, necessitating urgent assessment, oxygen, admission and emergency monitoring and treatment. The vital signs are not given that name for nothing: always feel the pulse and beware the child with marked tachycardia. Dyspnoea, tachypnoea and apnoea are all worrying signs. Hypovolaemic children maintain their blood pressure within the normal range by vasoconstriction until near circulatory collapse, so a normal blood pressure is not necessarily reassuring. Never be afraid to ask for help. If in any doubt, consult with a senior colleague (or if you are the senior colleague, consult with a colleague whose opinion you value). The junior doctor who does not ask for help is in danger of missing an ill child. The senior doctor who does not help or, worse, reprimands a junior doctor for asking for help is a fool. Having decided on a course of action, be open to the possibility that you are wrong. There is no place for arrogance and overconfidence in clinical medicine.4 All clinicians, no matter how experienced, occasionally make mistakes. They get diagnoses wrong and underestimate or overestimate the severity of an illness. The important thing is to have the humility to recognise one's fallibility and the open-mindedness to consider alternate diagnoses.4 A word of advice: because we need to rapidly assess a child who is acutely ill, we sometimes make the mistake of jumping to conclusions based on superficial information when it would be better to take time to gather more information. This is particularly true for children with a disability. When examining, in the FRACP clinical examination, I was asked to assess the gait of J, a teenager with prominent chorea. To my shame, it took me 5 min to realise J was intellectually normal. The first three of four candidates all made the same initial mistake but did not realise their error. In frustration, and perhaps out of guilt, I asked the third candidate: ‘What do you think of J's intellectual capacity?’ The candidate said: ‘He's clearly intellectually impaired’. ‘What is your evidence for that statement?’ Pause. ‘Oh. He did do everything I asked’. ‘Well, maybe you would like to ask him a question’. The candidate asked J how he was going at school. ‘Dux of the school’, said J. I did not fail the candidate, whose neurological examination had been reasonable, but I hope he learned the same lesson I had just learned – not to jump to superficial judgements. I am glad to say the final candidate of the day talked immediately to J as if he understood her every word. We passed her with flying colours (she did get the diagnosis right, too). American clinicians have bemoaned the loss of clinical skills due to over-reliance on tests.5 I witnessed this first hand when two young US junior doctors visited our department recently. Their academic knowledge was superb, but when I took them to see a child with pneumonia, they both missed lower lobe consolidation by auscultating the chest without lifting the child's vest. When I pointed this out, they said they were never taught to examine children's chests, just to interpret chest X-rays. Australian and British paediatricians are highly valued in the USA for their clinical skills. We can and should value our clinical skills and hone them through clinical practice. My thanks to Henry Kilham and Ken Nunn for helpful advice.

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