- Email: [email protected]
Teaching students the art and science of physical diagnosis
APM
Association of Professors of Medicine
Teaching Students the Art and Science of Physical Diagnosis
A
recollection of Osler’s advice to his students is as follows: “Observe, record, tabulate, communicate. Use your five senses. . . . Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert. Medicine is learned by the bedside and not in the classroom. Let not your conceptions of disease come from words heard in the lecture room or read from the book. See, and then reason and compare and control. But see first” (1). The time is right for internists who teach medical students to reevaluate and improve their teaching of physical diagnosis. Although calls for improved physical diagnosis teaching are not new, several recent trends make it particularly important for the teachers of internal medicine to reexamine how they are teaching and evaluating this essential clinical skill and to reconsider whether their teaching is effective in producing skilled clinicians. There are multiple reasons to expend the time and resources to advance physical diagnosis teaching. First, studies continue to show clinically important deficiencies in physical diagnosis skills among students, residents, and practicing physicians, and these results indicate that current methods of teaching are not optimally effective (2,3). In 1995, Paauw and colleagues (4) found that only 26% of practicing primary care physicians correctly identified the physical finding of Kaposi’s sarcoma in a standardized patient examination. Only 23% correctly identified oral hairy leukoplakia. These results support the conclusion that the physical diagnosis skills of the graduates of our medical schools and residency programs are inadequate. Ironically, these are often the same physicians we recruit as physical diagnosis teachers. Increasing pressures on faculty and curricular time may be leading to decreased attention to the teaching of the physical examination as well as decreased opportunity for faculty to improve their own skills. Second, on the positive side, medical educators now have available to them an increasing body of critiqued information about the test characteristics of many physical findings and maneuvers. The Journal of the American Medical Association (JAMA) Rational Clinical Examination series (a series of more than 25 articles published in JAMA at intervals from 1992 through the present) provides physical diagnosis teachers with a large body of evidence-based information about the test characteristics of physical examination findings. Faculty now can focus
䉷2001 by Excerpta Medica, Inc. All rights reserved.
their physical diagnosis teaching on those maneuvers and findings that have been found to have diagnostic utility and avoid maneuvers that may be time-honored but diagnostically unhelpful. Internists who teach physical diagnosis now also have access to a wide variety of technological aids to enhance their teaching. These include websites, CD-ROMs, simulators, videotapes, and infrared multiuser stethoscopes. Although reliance on technology has been cited as a cause of decline in physical diagnosis skill, many new technologies can actually be used to improve physical diagnosis teaching. Third, an additional development in medical education that offers an opportunity for physical diagnosis teachers is the emphasis at many medical schools on a competency-based curriculum. Physical diagnosis skills are routinely identified by clerkship directors as a core competency in medical student education (5,6). The Association of American Medical Colleges (AAMC) Learning Objectives for Medical Student Education state that each student should demonstrate the ability to perform both a complete and an organ system specific examination (7). Many schools are reevaluating whether they are reliably teaching and assessing this skill in their students. Internists, who typically play a large role in physical diagnosis teaching through introduction to clinical medicine courses, internal medical clerkships, subspecialty electives, and acting internships, should play a significant role in ensuring that physical diagnosis is successfully taught and evaluated. Departments of internal medicine need to ensure that resources are available to support this faculty activity. Fourth, more patient care and student education activities are taking place in the outpatient setting. In the ambulatory clinic, problems are more undifferentiated and physical diagnosis skills are necessary to determine the need for follow-up studies. In spite of increasing use of technologically advancing diagnostic testing and procedures, physicians must be adept at physical diagnosis if they are to make cost-effective clinical judgments. These trends make it appropriate to revisit how internists teach physical diagnosis. In this commentary, we identify commonly encountered barriers to physical diagnosis teaching, suggest ways of overcoming these barriers, and provide examples of successful physical diagnosis teaching methods that have been used at medical schools in the United States. 0002-9343/01/$–see front matter 419 PII S0002-9343(00)00621-0
Association of Professors of Medicine
TEACHING PHYSICAL DIAGNOSIS: BARRIERS AND SOLUTIONS Barrier 1: Lack of Bedside Ward Teaching for Medical Students Faculty on wards are not teaching at the bedside. LaCombe (8) reported that actual teaching at the bedside has declined from an incidence of 75% in the 1960s to less than 16% today. In a survey of students completing a medicine clerkship at one medical school, students reported that they were observed examining an inpatient by an attending physician an average of 1.6 times in 8 weeks of inpatient medicine (personal communication). Bedside teaching provides a forum for internists to demonstrate physical examination techniques and share physical findings with members of the team. With bedside teaching, the patient is the focus and the physical findings are immediately available to observe and correlate with the case history. The solution? Bedside rounds. Objective: To review the basic techniques of the physical examination and to share common as well as interesting physical findings with fellow students. Method: On the third-year medicine rotation at the Medical College of Wisconsin, faculty spend an hour each week with a small group (three to four students) rounding on patients and reviewing physical findings. The students identify patients from their ward teams to show the group. Evaluation: The exercise is not evaluative and is completely student-driven. On the end-of-clerkship evaluation form, students rate these sessions as one of the most useful activities of their medicine clerkship.
Barrier 2: Perceived Subjective Nature of the Physical Examination Students may feel less comfortable with the physical examination than with more objective laboratory and imaging information. The solution? Evidence-based physical diagnosis. Objective: To improve student knowledge, skill and confidence in physical diagnosis. Method: At Brown University School of Medicine, groups of four students and one preceptor meet weekly for eight 1-hour sessions. Eight articles from JAMA’s Rational Clinical Examination series form the knowledge base and curriculum for the project. The topics include central venous pressure, carotid bruit, ascites, systolic murmur, deep venous thrombosis, hypovolemia, low back pain, and splenomegaly. For each session, one student is assigned the responsibility of presenting the article to the group and identifying an inpatient with the finding that is willing to be visited and examined by the group. Emphasis is placed on viewing the physical examination 420
April 1, 2001
THE AMERICAN JOURNAL OF MEDICINE威
Volume 110
as a series of diagnostic tests with defined sensitivity and specificity. After discussing the article, the group visits the patient to ensure that each student has a chance to practice the examination technique with observation by the preceptor. Finally, the group visits other patients that the students have identified as having interesting physical findings. Evaluation: Students take a physical diagnosis quiz that is based on the eight Rational Clinical Examination articles. To evaluate physical examination skills, students perform a series of physical examination maneuvers on fourth-year students who are trained to evaluate physical examination skill and score the students using a checklist. Initial experience with the program has been quite positive. By including chief residents and general internal medicine fellows as preceptors, the importance of physical diagnosis teaching is being disseminated throughout the department of internal medicine.
Barrier 3: Residents as Teachers of Physical Examination Skills Residents, who spend a great deal of time teaching medical students and serve as important role models, may themselves lack confidence in the utility of physical diagnosis and therefore may foster a focus on imaging studies rather than careful attention to physical findings. There are several solutions: 1. Grand Rounds sessions addressing physical diagnosis topics. 2. Utilization of special skills within the department (musculoskeletal examination skills of rheumatologists, for example) to develop the skills of other clinical teachers in faculty and resident development sessions. 3. Inclusion of physical diagnosis topics in morning report. 4. Use of physical diagnosis topics as examples of evidence-based medicine in residency curricula.
Barrier 4: Lack of Time and Patients for Physical Examination Teaching Escalating economic pressures have impacted on time for clinical teaching. The shift of medicine to the outpatient setting and the decreasing hospital length of stays have decreased patient availability. However, numerous emerging resources that are described below can support and augment clinical teaching. As a solution, educational resources must be utilized innovatively to offset the effects of changing practice patterns on student education. For example, the clerkship director can serve as a departmental clearinghouse for information about electronic resources (CD-ROM, Internet) for physical diagnosis teaching and for skills workshops offered by organizations such as the American College of Physicians-American Society of Internal Medicine.
Association of Professors of Medicine
Excellent opportunities to practice listening to murmurs and extra heart sounds include heart sound simulators, infrared stethoscopes (example: SimulScope; Cardionics, Inc., Houston, Texas), and CD-ROMs (9). Web-based curricula can provide links to eye findings, rashes and other observational physical findings. Eric Alper, MD, at the University of Massachusetts Medical School has assembled a collection of physical diagnosis Internet links (http://www.ummed.edu/dept/dept_communityprog/internal.html). The Society for General Internal Medicine website contains links to clinical and research information on the physical examination (http:// www.sgim.org/interestgroups/clinexamination.html# RCE). Medical schools also should have resources available, such as breast and prostate models or videotapes and books for students to consult and study. Introduction to clinical examination courses may use nontraditional teaching sites. Nursing homes, retirement facilities, shelters and even prisons have been utilized as sites for teaching introductory physical diagnosis. In addition to increasing the availability of patients and the time to conduct a complete history and physical, these sites provide students with a unique opportunity to examine patients in their home environment. At the Medical College of Wisconsin, second-year students visited geriatric retirement communities and a home for the blind, and performed complete history and physical examinations. Also, fourth-year students can be utilized in teaching roles in introduction to physical examination courses (10). Objective: At the Medical College of Wisconsin, a fourth-year elective, entitled “Apprenticeship with a Master Clinician,” specifically trains students to be teachers. By actively teaching, students have to master the skills sufficiently to be able to teach other students. Method: Students receive instruction on basic teaching skills, including priming, identifying learner needs and feedback. Subsequently, the fourth-year students assist in the instruction of the physical examination by observing second-year students and demonstrating physical diagnosis maneuvers. Also, fourth-year students have conducted sessions introducing first-year students to the stethoscope and otoscope. Evaluation: Second-year students rate this as a valuable experience. Objective structured clinical exams (OSCEs) and videotape review reveal the fourth-year students are effective teachers.
Barrier 5: Inconsistent and Episodic Nature of Physical Diagnosis Skills Education Across the Curriculum Introduction to Clinical Medicine courses struggle to compete for time and resources with basic science courses
and preparation for USMLE Step 1. Furthermore, students do not retain physical diagnosis skills learned in their second and third years of medical school. There are several solutions. The first solution is integration of physical diagnosis across the curriculum. Although physical diagnosis has traditionally been taught as a single course in the first or second year, physical diagnosis teaching must extend into the clinical clerkships and fourth-year acting internship and electives. Schools that have developed competencybased curricula are in a particularly good position to make sure that all clinical courses teach and evaluate competence in physical diagnosis. An education committee can be utilized to monitor and evaluate the effectiveness of physical diagnosis teaching across the curriculum The second solution would involve the development of advanced physical diagnosis courses. Objective: To reinforce basic physical examination skills and to teach advanced physical diagnosis skills. Method: Physical diagnosis is put into a clinical context by teaching focused examinations related to patient complaints. For example, an abdominal examination for a patient complaining of abdominal pain will be more detailed than a routine abdominal examination on a healthy patient. Evaluation: Students are tested by performance examinations where their physical examination techniques are observed and evaluated. This fourth-year student elective was one of the highest rated fourth-year electives at the Medical College of Wisconsin (11).
Barrier 6: Failure to Test What We Teach When students know that their physical examination skills will be rigorously evaluated, then they will be motivated to develop these skills. Students report that they are not observed performing the physical examination during medical school (1998 AAMC graduating seniors’ survey). Solutions include (1) OSCEs and standardized patients (SPs), who are trained to simulate a patient illness and can evaluate student clinical performance; and (2) physical diagnosis log books. Objective: To evaluate specific physical examination skills. Method: A regional examination (cardiac, abdominal) or a problem-focused examination can be observed directly with the OSCE (12). Evaluation: A checklist approach or a global rating scale may be utilized to evaluate completeness (13). Also, individual maneuvers may be measured qualitatively on proper technique. The evaluator may be a faculty member or a trained SP. Videotape review with a student may be utilized to promote self-reflection. Direct and timely April 1, 2001
THE AMERICAN JOURNAL OF MEDICINE威
Volume 110 421
Association of Professors of Medicine
feedback to students identifies specific areas of performance that are well done and areas that need improvement. Objective: To document performed physical diagnosis maneuvers. Method: Students can be given logbooks or Personal Digital Assistants. They are instructed to record when specific physical diagnosis maneuvers are performed.
●
Evaluation: This instrument allows closer monitoring and forces student accountability in performing and documenting physical examination maneuvers (14). ●
RECOMMENDATIONS FOR DEPARTMENTAL AND INSTITUTIONAL SUPPORT FOR TEACHING PHYSICAL DIAGNOSIS Overcoming barriers to teaching and evaluating physical diagnosis requires a department-wide initiative. Although this cannot be expected to occur overnight, a clerkship director or director of the introduction to physical examination course can promote innovative solutions with the support of the department chair, the medical school dean’s office, and other clerkship directors. Medical schools should reward the teacher of physical diagnosis by acknowledging teaching efforts through personal recognition awards, salary as well as time allocated to enable faculty to teach. Promotion criteria should recognize the clinician-educator and utilize the educator’s portfolio (15) in rank and tenure decision making. Funding for research to examine the utility of physical diagnosis maneuvers will clarify which areas of the physical examination are most important to emphasize in teaching and assessment. Further study also is needed to assess the efficacy of teaching methods and interventions. Specific suggestions for departments of internal medicine to enhance physical diagnosis curricula are: ●
●
●
Provide protected time and administrative support to the course director of the Introduction to Clinical Examination course. This job will require at least 25% of full-time effort and may take more time depending on the length of the course and logistical complexities such as the number of sites or faculty involved. Administrative support should include a secretary devoting 50% of full-time to the course. Provide time for the faculty preceptors of the course to teach. During the Introduction to Clinical Examination course, faculty should have their clinical duties reduced for at least one half-day per week in order to teach students. Provide yearly faculty development sessions to en-
422
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●
hance faculty bedside teaching skills and to update faculty on new information about the utility (or lack of utility) of specific physical examination maneuvers and findings. Residency program directors, chief residents, and other key clinical teachers should be encouraged to participate. Developing resident skill in physical diagnosis is critical, so that residents can model these skills for students. Reward faculty for physical diagnosis teaching by including this activity in consideration of promotion decisions. Create awards that specifically recognize faculty or residents with outstanding physical diagnosis skills. Make available funds for purchasing physical diagnosis teaching materials such as CD-ROMs, simulators, audiotapes, and videotapes. Support faculty with an interest in research in physical diagnosis.
CONCLUSIONS The physical examination is a useful diagnostic tool and a key component of the patient-physician interaction. With the emergence of new resources and technologies, complemented by traditional teaching methods, this is a fortuitous time to pursue the development, implementation, and evaluation of advanced physical diagnosis curriculum for medical students. Faculty should use existing time more effectively and efficiently to teach physical diagnosis. Faculty development and workshops about physical diagnosis will help clinician-educators refine and advance their own diagnostic and teaching skills. The predictive value and clinical utility of many physical examination techniques and physical findings have been questioned and evaluated. Continuing to study these issues will keep the teacher of physical diagnosis up to date and direct physical diagnosis teaching and evaluation to the clinically most useful techniques and findings. Innovative methods to teach physical diagnosis include bedside rounds, advanced physical diagnosis courses, utilizing fourth-year students as teachers, evidence-based physical diagnosis, and the use of OSCEs and SPs, web-based curriculum, and nontraditional teaching sites. Students can be evaluated effectively on their physical diagnosis skills through the use of direct observation and feedback, the OSCE with SPs, and physical diagnosis logbooks. By integrating physical diagnosis across the curriculum, this core clinical skill will be reinforced, increasing student competence and confidence. Ruric C. Anderson, MD Mark J. Fagan, MD James Sebastian, MD
Association of Professors of Medicine
Dr. Anderson is Associate Program Director in the Department of Medicine at the Medical College of Wisconsin. Dr. Fagan is the Third Year Clerkship Director in the Department of Medicine at Brown University School of Medicine. Dr. Sebastian is Director of Student Teaching Programs for the Department of Medicine at the Medical College of Wisconsin.
ACKNOWLEDGMENTS The authors thank Deborah Simpson, PhD, Associate Dean for Educational Services at Medical College of Wisconsin, for helpful suggestions for this manuscript.
REFERENCES 1. Belkin BM, Neelon FA. The art of observation: William Osler and the method of Zadig. Ann Intern Med. 1992;116:863– 866. 2. Mangione S. Nieman LZ. Cardiac auscultatory skills among internal medicine and family practice trainees: a comparison of diagnostic proficiency. Chest. 1996;110:2S. 3. Dunnington G, Reisner E, Witzke D, et al. Teaching and evaluation of physical examination skills on the surgical clerkship. Teach Learn Med. 1992;4:110 –114. 4. Paauw DS, Wenrich, MD, Curtis R, et al. Ability of primary care physicians to recognize physical findings associated with HIV infection. JAMA. 1995;274:1380 –1382. 5. Society of General Internal Medicine and Clerkship Directors in Internal Medicine. Core Medicine Clerkship Curriculum Guide: A
6.
7.
8. 9.
10.
11.
12. 13.
14. 15.
Manual for Faculty. Version 2.0. Rockville, Md: Health Resources and Services Administration; 1998. Bass EB, Fortin AH, Morrison G, et al. National survey of clerkship directors in internal medicine on the competencies that should be addressed in the medicine core clerkship. Am J Med. 1997;102:564 – 571. Association of American Medical Colleges. Learning Objectives for Medical Student Education—Guidelines for Medical Schools. Medical School Objectives. Washington, DC: Association of American Medical Colleges; 1998. LaCombe MA. On bedside teaching. Ann Intern Med. 1997;126: 217–220. Criley JM, Criley D, Zalace C. The Physiological Origins of Heart Sounds and Murmurs: The Unique Interactive Guide to Cardiac Diagnosis. Philadelphia: Lippincott-Raven; 1997. Haist SA, Wilson JF, et al. Comparing fourth-year medical students with faculty in the teaching of physical examination skills to firstyear students. Acad Med. 1998;73:198 –200. Berg D, Sebastian J, Heudebert G. Development, implementation and evaluation of an advanced physical diagnosis course for senior medical students. Acad Med. 1994;69:758 –764. Barrows HS. An overview of the uses of standardized patients for teaching and evaluating clinical skills. Acad Med. 1993;68:443– 451. Regehr G, MacRae H, Reznick RK, et al. Comparing the psychometric properties of checklists and global rating scales for assessing performance on an OSCE-format examination. Acad Med. 1998;73: 993–997. Mangione S, Peitzman SJ. Physical diagnosis in the 1990’s: art or artifact? J Gen Intern Med. 1996;11:490 – 493. Simpson D, Morzinski J, Beecher A, Lindemann J. Meeting the challenge to document teaching accomplishments: the educator’s portfolio. Teach Learn Med. 1994;6:203–206.
April 1, 2001
THE AMERICAN JOURNAL OF MEDICINE威
Volume 110 423
Association of Professors of Medicine
Teaching Students the Art and Science of Physical Diagnosis
A
recollection of Osler’s advice to his students is as follows: “Observe, record, tabulate, communicate. Use your five senses. . . . Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert. Medicine is learned by the bedside and not in the classroom. Let not your conceptions of disease come from words heard in the lecture room or read from the book. See, and then reason and compare and control. But see first” (1). The time is right for internists who teach medical students to reevaluate and improve their teaching of physical diagnosis. Although calls for improved physical diagnosis teaching are not new, several recent trends make it particularly important for the teachers of internal medicine to reexamine how they are teaching and evaluating this essential clinical skill and to reconsider whether their teaching is effective in producing skilled clinicians. There are multiple reasons to expend the time and resources to advance physical diagnosis teaching. First, studies continue to show clinically important deficiencies in physical diagnosis skills among students, residents, and practicing physicians, and these results indicate that current methods of teaching are not optimally effective (2,3). In 1995, Paauw and colleagues (4) found that only 26% of practicing primary care physicians correctly identified the physical finding of Kaposi’s sarcoma in a standardized patient examination. Only 23% correctly identified oral hairy leukoplakia. These results support the conclusion that the physical diagnosis skills of the graduates of our medical schools and residency programs are inadequate. Ironically, these are often the same physicians we recruit as physical diagnosis teachers. Increasing pressures on faculty and curricular time may be leading to decreased attention to the teaching of the physical examination as well as decreased opportunity for faculty to improve their own skills. Second, on the positive side, medical educators now have available to them an increasing body of critiqued information about the test characteristics of many physical findings and maneuvers. The Journal of the American Medical Association (JAMA) Rational Clinical Examination series (a series of more than 25 articles published in JAMA at intervals from 1992 through the present) provides physical diagnosis teachers with a large body of evidence-based information about the test characteristics of physical examination findings. Faculty now can focus
䉷2001 by Excerpta Medica, Inc. All rights reserved.
their physical diagnosis teaching on those maneuvers and findings that have been found to have diagnostic utility and avoid maneuvers that may be time-honored but diagnostically unhelpful. Internists who teach physical diagnosis now also have access to a wide variety of technological aids to enhance their teaching. These include websites, CD-ROMs, simulators, videotapes, and infrared multiuser stethoscopes. Although reliance on technology has been cited as a cause of decline in physical diagnosis skill, many new technologies can actually be used to improve physical diagnosis teaching. Third, an additional development in medical education that offers an opportunity for physical diagnosis teachers is the emphasis at many medical schools on a competency-based curriculum. Physical diagnosis skills are routinely identified by clerkship directors as a core competency in medical student education (5,6). The Association of American Medical Colleges (AAMC) Learning Objectives for Medical Student Education state that each student should demonstrate the ability to perform both a complete and an organ system specific examination (7). Many schools are reevaluating whether they are reliably teaching and assessing this skill in their students. Internists, who typically play a large role in physical diagnosis teaching through introduction to clinical medicine courses, internal medical clerkships, subspecialty electives, and acting internships, should play a significant role in ensuring that physical diagnosis is successfully taught and evaluated. Departments of internal medicine need to ensure that resources are available to support this faculty activity. Fourth, more patient care and student education activities are taking place in the outpatient setting. In the ambulatory clinic, problems are more undifferentiated and physical diagnosis skills are necessary to determine the need for follow-up studies. In spite of increasing use of technologically advancing diagnostic testing and procedures, physicians must be adept at physical diagnosis if they are to make cost-effective clinical judgments. These trends make it appropriate to revisit how internists teach physical diagnosis. In this commentary, we identify commonly encountered barriers to physical diagnosis teaching, suggest ways of overcoming these barriers, and provide examples of successful physical diagnosis teaching methods that have been used at medical schools in the United States. 0002-9343/01/$–see front matter 419 PII S0002-9343(00)00621-0
Association of Professors of Medicine
TEACHING PHYSICAL DIAGNOSIS: BARRIERS AND SOLUTIONS Barrier 1: Lack of Bedside Ward Teaching for Medical Students Faculty on wards are not teaching at the bedside. LaCombe (8) reported that actual teaching at the bedside has declined from an incidence of 75% in the 1960s to less than 16% today. In a survey of students completing a medicine clerkship at one medical school, students reported that they were observed examining an inpatient by an attending physician an average of 1.6 times in 8 weeks of inpatient medicine (personal communication). Bedside teaching provides a forum for internists to demonstrate physical examination techniques and share physical findings with members of the team. With bedside teaching, the patient is the focus and the physical findings are immediately available to observe and correlate with the case history. The solution? Bedside rounds. Objective: To review the basic techniques of the physical examination and to share common as well as interesting physical findings with fellow students. Method: On the third-year medicine rotation at the Medical College of Wisconsin, faculty spend an hour each week with a small group (three to four students) rounding on patients and reviewing physical findings. The students identify patients from their ward teams to show the group. Evaluation: The exercise is not evaluative and is completely student-driven. On the end-of-clerkship evaluation form, students rate these sessions as one of the most useful activities of their medicine clerkship.
Barrier 2: Perceived Subjective Nature of the Physical Examination Students may feel less comfortable with the physical examination than with more objective laboratory and imaging information. The solution? Evidence-based physical diagnosis. Objective: To improve student knowledge, skill and confidence in physical diagnosis. Method: At Brown University School of Medicine, groups of four students and one preceptor meet weekly for eight 1-hour sessions. Eight articles from JAMA’s Rational Clinical Examination series form the knowledge base and curriculum for the project. The topics include central venous pressure, carotid bruit, ascites, systolic murmur, deep venous thrombosis, hypovolemia, low back pain, and splenomegaly. For each session, one student is assigned the responsibility of presenting the article to the group and identifying an inpatient with the finding that is willing to be visited and examined by the group. Emphasis is placed on viewing the physical examination 420
April 1, 2001
THE AMERICAN JOURNAL OF MEDICINE威
Volume 110
as a series of diagnostic tests with defined sensitivity and specificity. After discussing the article, the group visits the patient to ensure that each student has a chance to practice the examination technique with observation by the preceptor. Finally, the group visits other patients that the students have identified as having interesting physical findings. Evaluation: Students take a physical diagnosis quiz that is based on the eight Rational Clinical Examination articles. To evaluate physical examination skills, students perform a series of physical examination maneuvers on fourth-year students who are trained to evaluate physical examination skill and score the students using a checklist. Initial experience with the program has been quite positive. By including chief residents and general internal medicine fellows as preceptors, the importance of physical diagnosis teaching is being disseminated throughout the department of internal medicine.
Barrier 3: Residents as Teachers of Physical Examination Skills Residents, who spend a great deal of time teaching medical students and serve as important role models, may themselves lack confidence in the utility of physical diagnosis and therefore may foster a focus on imaging studies rather than careful attention to physical findings. There are several solutions: 1. Grand Rounds sessions addressing physical diagnosis topics. 2. Utilization of special skills within the department (musculoskeletal examination skills of rheumatologists, for example) to develop the skills of other clinical teachers in faculty and resident development sessions. 3. Inclusion of physical diagnosis topics in morning report. 4. Use of physical diagnosis topics as examples of evidence-based medicine in residency curricula.
Barrier 4: Lack of Time and Patients for Physical Examination Teaching Escalating economic pressures have impacted on time for clinical teaching. The shift of medicine to the outpatient setting and the decreasing hospital length of stays have decreased patient availability. However, numerous emerging resources that are described below can support and augment clinical teaching. As a solution, educational resources must be utilized innovatively to offset the effects of changing practice patterns on student education. For example, the clerkship director can serve as a departmental clearinghouse for information about electronic resources (CD-ROM, Internet) for physical diagnosis teaching and for skills workshops offered by organizations such as the American College of Physicians-American Society of Internal Medicine.
Association of Professors of Medicine
Excellent opportunities to practice listening to murmurs and extra heart sounds include heart sound simulators, infrared stethoscopes (example: SimulScope; Cardionics, Inc., Houston, Texas), and CD-ROMs (9). Web-based curricula can provide links to eye findings, rashes and other observational physical findings. Eric Alper, MD, at the University of Massachusetts Medical School has assembled a collection of physical diagnosis Internet links (http://www.ummed.edu/dept/dept_communityprog/internal.html). The Society for General Internal Medicine website contains links to clinical and research information on the physical examination (http:// www.sgim.org/interestgroups/clinexamination.html# RCE). Medical schools also should have resources available, such as breast and prostate models or videotapes and books for students to consult and study. Introduction to clinical examination courses may use nontraditional teaching sites. Nursing homes, retirement facilities, shelters and even prisons have been utilized as sites for teaching introductory physical diagnosis. In addition to increasing the availability of patients and the time to conduct a complete history and physical, these sites provide students with a unique opportunity to examine patients in their home environment. At the Medical College of Wisconsin, second-year students visited geriatric retirement communities and a home for the blind, and performed complete history and physical examinations. Also, fourth-year students can be utilized in teaching roles in introduction to physical examination courses (10). Objective: At the Medical College of Wisconsin, a fourth-year elective, entitled “Apprenticeship with a Master Clinician,” specifically trains students to be teachers. By actively teaching, students have to master the skills sufficiently to be able to teach other students. Method: Students receive instruction on basic teaching skills, including priming, identifying learner needs and feedback. Subsequently, the fourth-year students assist in the instruction of the physical examination by observing second-year students and demonstrating physical diagnosis maneuvers. Also, fourth-year students have conducted sessions introducing first-year students to the stethoscope and otoscope. Evaluation: Second-year students rate this as a valuable experience. Objective structured clinical exams (OSCEs) and videotape review reveal the fourth-year students are effective teachers.
Barrier 5: Inconsistent and Episodic Nature of Physical Diagnosis Skills Education Across the Curriculum Introduction to Clinical Medicine courses struggle to compete for time and resources with basic science courses
and preparation for USMLE Step 1. Furthermore, students do not retain physical diagnosis skills learned in their second and third years of medical school. There are several solutions. The first solution is integration of physical diagnosis across the curriculum. Although physical diagnosis has traditionally been taught as a single course in the first or second year, physical diagnosis teaching must extend into the clinical clerkships and fourth-year acting internship and electives. Schools that have developed competencybased curricula are in a particularly good position to make sure that all clinical courses teach and evaluate competence in physical diagnosis. An education committee can be utilized to monitor and evaluate the effectiveness of physical diagnosis teaching across the curriculum The second solution would involve the development of advanced physical diagnosis courses. Objective: To reinforce basic physical examination skills and to teach advanced physical diagnosis skills. Method: Physical diagnosis is put into a clinical context by teaching focused examinations related to patient complaints. For example, an abdominal examination for a patient complaining of abdominal pain will be more detailed than a routine abdominal examination on a healthy patient. Evaluation: Students are tested by performance examinations where their physical examination techniques are observed and evaluated. This fourth-year student elective was one of the highest rated fourth-year electives at the Medical College of Wisconsin (11).
Barrier 6: Failure to Test What We Teach When students know that their physical examination skills will be rigorously evaluated, then they will be motivated to develop these skills. Students report that they are not observed performing the physical examination during medical school (1998 AAMC graduating seniors’ survey). Solutions include (1) OSCEs and standardized patients (SPs), who are trained to simulate a patient illness and can evaluate student clinical performance; and (2) physical diagnosis log books. Objective: To evaluate specific physical examination skills. Method: A regional examination (cardiac, abdominal) or a problem-focused examination can be observed directly with the OSCE (12). Evaluation: A checklist approach or a global rating scale may be utilized to evaluate completeness (13). Also, individual maneuvers may be measured qualitatively on proper technique. The evaluator may be a faculty member or a trained SP. Videotape review with a student may be utilized to promote self-reflection. Direct and timely April 1, 2001
THE AMERICAN JOURNAL OF MEDICINE威
Volume 110 421
Association of Professors of Medicine
feedback to students identifies specific areas of performance that are well done and areas that need improvement. Objective: To document performed physical diagnosis maneuvers. Method: Students can be given logbooks or Personal Digital Assistants. They are instructed to record when specific physical diagnosis maneuvers are performed.
●
Evaluation: This instrument allows closer monitoring and forces student accountability in performing and documenting physical examination maneuvers (14). ●
RECOMMENDATIONS FOR DEPARTMENTAL AND INSTITUTIONAL SUPPORT FOR TEACHING PHYSICAL DIAGNOSIS Overcoming barriers to teaching and evaluating physical diagnosis requires a department-wide initiative. Although this cannot be expected to occur overnight, a clerkship director or director of the introduction to physical examination course can promote innovative solutions with the support of the department chair, the medical school dean’s office, and other clerkship directors. Medical schools should reward the teacher of physical diagnosis by acknowledging teaching efforts through personal recognition awards, salary as well as time allocated to enable faculty to teach. Promotion criteria should recognize the clinician-educator and utilize the educator’s portfolio (15) in rank and tenure decision making. Funding for research to examine the utility of physical diagnosis maneuvers will clarify which areas of the physical examination are most important to emphasize in teaching and assessment. Further study also is needed to assess the efficacy of teaching methods and interventions. Specific suggestions for departments of internal medicine to enhance physical diagnosis curricula are: ●
●
●
Provide protected time and administrative support to the course director of the Introduction to Clinical Examination course. This job will require at least 25% of full-time effort and may take more time depending on the length of the course and logistical complexities such as the number of sites or faculty involved. Administrative support should include a secretary devoting 50% of full-time to the course. Provide time for the faculty preceptors of the course to teach. During the Introduction to Clinical Examination course, faculty should have their clinical duties reduced for at least one half-day per week in order to teach students. Provide yearly faculty development sessions to en-
422
April 1, 2001
THE AMERICAN JOURNAL OF MEDICINE威
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hance faculty bedside teaching skills and to update faculty on new information about the utility (or lack of utility) of specific physical examination maneuvers and findings. Residency program directors, chief residents, and other key clinical teachers should be encouraged to participate. Developing resident skill in physical diagnosis is critical, so that residents can model these skills for students. Reward faculty for physical diagnosis teaching by including this activity in consideration of promotion decisions. Create awards that specifically recognize faculty or residents with outstanding physical diagnosis skills. Make available funds for purchasing physical diagnosis teaching materials such as CD-ROMs, simulators, audiotapes, and videotapes. Support faculty with an interest in research in physical diagnosis.
CONCLUSIONS The physical examination is a useful diagnostic tool and a key component of the patient-physician interaction. With the emergence of new resources and technologies, complemented by traditional teaching methods, this is a fortuitous time to pursue the development, implementation, and evaluation of advanced physical diagnosis curriculum for medical students. Faculty should use existing time more effectively and efficiently to teach physical diagnosis. Faculty development and workshops about physical diagnosis will help clinician-educators refine and advance their own diagnostic and teaching skills. The predictive value and clinical utility of many physical examination techniques and physical findings have been questioned and evaluated. Continuing to study these issues will keep the teacher of physical diagnosis up to date and direct physical diagnosis teaching and evaluation to the clinically most useful techniques and findings. Innovative methods to teach physical diagnosis include bedside rounds, advanced physical diagnosis courses, utilizing fourth-year students as teachers, evidence-based physical diagnosis, and the use of OSCEs and SPs, web-based curriculum, and nontraditional teaching sites. Students can be evaluated effectively on their physical diagnosis skills through the use of direct observation and feedback, the OSCE with SPs, and physical diagnosis logbooks. By integrating physical diagnosis across the curriculum, this core clinical skill will be reinforced, increasing student competence and confidence. Ruric C. Anderson, MD Mark J. Fagan, MD James Sebastian, MD
Association of Professors of Medicine
Dr. Anderson is Associate Program Director in the Department of Medicine at the Medical College of Wisconsin. Dr. Fagan is the Third Year Clerkship Director in the Department of Medicine at Brown University School of Medicine. Dr. Sebastian is Director of Student Teaching Programs for the Department of Medicine at the Medical College of Wisconsin.
ACKNOWLEDGMENTS The authors thank Deborah Simpson, PhD, Associate Dean for Educational Services at Medical College of Wisconsin, for helpful suggestions for this manuscript.
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