Developing Clinical Skills
Why Clinical Skills?
Put simply, to promptly improve patient care.
Somaliland’s first training institutions opened in the early 2000s, leaving more than a decade after the war with no formal health worker training. This gap, combined with the continued shortage of lecturers and clinical teachers, has led to a number of essential areas in which external support is needed to supplement existing local provision. Particularly notable are the underdevelopment of clinical skills (as opposed to clinical knowledge) and the neglect of certain clinical specialties.
In the core specialties taught in the curriculum – surgery, paediatrics, medicine, and obstetrics and gynaecology – the lack of opportunities to learn in a clinical setting undercuts students’ professional development; though most young doctors are able to demonstrate sound theoretical knowledge, they often struggle to apply that knowledge in practice. For this, they need small group interactive teaching, which is time-intensive and is rarely provided by already over-stretched and under-resourced faculty. Clinical specialties outside that core, on the other hand, have been until recently neglected from formal training altogether, with disastrous consequences for patients.
It is worth noting that clinical training complements KSP’s other streams of work, especially support for the faculties at partner training institutions. Many students who receive our training go on to become the lecturers and clinical teachers that are now training Somaliland’s next generation of health professionals.
Fostering Skills Through Online Training
- Clinical reasoning course is demonstrated by PhD research to advance participants’ clinical competence.
- Delivered to 25% of all Somaliland medical graduates and now formally incorporated into the curriculums of Somaliland’s two principal medical schools.
Clinical reasoning is important because medicine is not something that we should learn by heart… Normally students learn things by heart to pass the exam, and that is what we need to avoid.
Dr Ali Mahdi, Clinical Coordinator at University of Hargeisa
The Clinical Reasoning Course is KSP’s flagship online course, designed for final year medical students to support learning during their clinical ward placements in surgery, medicine, obstetrics and gynaecology and paediatrics. Before each session, two students write up particularly interesting or difficult patient cases which they have seen on the wards that week and present them in guided, small-group discussions led by KSP volunteer specialists. The groups discuss the patient’s history, how to reach a diagnosis and decide appropriate care for that patient. Participants report that this helps them to better understand specific cases, and to develop more systematic approaches to thinking about patient treatment:
I remember in the ward, a child was in a very critical condition. We discussed his case a lot in the tutorial that week and our teacher helped us see a differential that we did not think of before. That improved our investigations in the ward and helped the patient.
Clinical reasoning participant
This is supported by the findings of a PhD on online medical education that focuses on the MedicineAfrica platform developed for KSP:
Our research shows that online case-based education is teaching students analytic clinical reasoning skills. Clinical reasoning is the cornerstone of clinical competence. MedicineAfrica facilitates opportunities for small group learning and immediate feedback from tutors, which are critical to the development of clinical reasoning. Case-based teaching requires significant faculty time, and providing it online addresses the shortage of medical teaching faculty in Somaliland.
Example of a Medical Case Presented by a Student on MedicineAfrica
Medical History: 10-month old male accompanied by his mother. The mother is the primary historian. Cc: Cough and fever for 3 days HPI: This is a 10-month old male, who presented with sudden onset cough which is worsening more at night, which awakes him from sleep associated with shortness of breath and decreased feeding, and 3 episodes of vomiting which is not projectile and contains the food he took, also has a fever which is firstly low grade and the last day became high and continues, no aggravating or relieving factors, no cyanosis and no other associated symptoms. Birth Hx: Unremarkable. He was not exclusively breast fed for the first 6 months, the mother was adding a goat’s milk along with the breast milk. He took no immunization and no abnormal developmental milestones. Past History: he was hospitalized for acute gastroenteritis before 3 weeks. No chronic illnesses and no previous surgery. No current ongoing medications and NKDA. No similar case in the family and no chronic illnesses. Social History: the father smokes
EXAMINATION NOTES: On physical examination 10-month old child looks ill lying on his mother’s lap. Vitals: Pulse: 120pbm RR: 60 b/min Temp: 38.2oC Nutritional assessment: Height: 65cm weight: 7kg z-score: -1 Dehydrational status: No sunken eyes. Capillary refill was less then 2 sec. the skin pinch goes slightly slowly. On chest exam: Lungs: Chest in-drawing diffuse crackles on both sides. heart: S1 and S2 were audible no murmurs or other added sound.
Improving Care for Patients with Sexually Transmitted Infections (STIs)
- Doctors completing KSP training are significantly more likely than their peers to screen and examine patients with suspected STIs.
- Co-designed and co-taught with Somaliland doctor
If I change the ideas of one doctor, at least it is a doctor that can treat many patients
Dr Zienab Musa, STI Course Co-Creator
KSP’s regular STI course was designed in response to the alarming findings of a clinical audit that revealed only 35% of junior doctors in Somaliland’s main hospital screened patients with suspected STIs, and only 17% conducted a physical examination. This was due primarily to the societal taboo surrounding sexual health and the lack of awareness and training of the medical community.
KSP volunteers worked closely with the audit’s author, a doctor at Hargeisa Group Hospital, to develop an online course to train in the identification and management of patients with STIs as well as community awareness raising. The course was jointly delivered to the junior doctors. Two months afterwards, a follow-up audit was conducted and the results were dramatic: 71% of course participants carried out physical examinations on patients with suspected STIs, compared with 29% of non-participants.
Establishing Basic Psychiatry Training for All Medical Students
- 98% of medical graduates have completed an intensive course in psychiatry, taught by KSP volunteers and KSP-trained local trainers.
In the absence of any local providers, KSP volunteers introduced psychiatry training for medical students in 2008, providing a two-week intensive course, and subsequent revision course, to every medical student to graduate since then, inspiring some to pursue a career in mental health.
The outcomes of this course are amongst the best documented within the Partnership. There is strong evidence that the course increases students’ knowledge of mental illness – a study published in 2014 showed that mean scores in pre- and post- tests went up significantly from 59% to 85%.