Let's get (more) physical

Physical examinations, patient interactions are emphasized as part of the art of medicine.

In the 1960s, observation studies showed that learning at the bedside accounted for 75% of clinical teaching. In 2013, that percentage had fallen to 15% of time spent on teaching rounds by hospitalists, according to a study conducted at four teaching hospitals in Denver and published in May by JAMA Internal Medicine.

The decline of instruction on the bedside physical exam has coincided with the exponential increase in access to diagnostic testing and imaging, a faster pace of inpatient care, and increased use of computers in patient care, experts said.

Photo by Thinkstock
Photo by Thinkstock.

“It starts with one busy year of practice where a physician decides, for example, that instead of auscultating the lungs, they will just order a chest X-ray because it is faster and allows them to move on to the next patient quickly,” said Jeffrey G. Wiese, MD, FACP, professor and associate dean for graduate medical education at the Tulane University Health Sciences Center in New Orleans.

“If you let that play out over several years, physicians start questioning if they have those skills, and if you go for a period of time without using a skill, then you will lose it,” he added.

The result is a culture where attending and resident physicians no longer feel confident teaching these skills at the bedside. In a 2009 study at Brigham and Women's Hospital in Boston, 67% of survey respondents said they did not receive adequate training in how to teach the physical examination, and only 50% werte confident in their ability to teach it.

“It is a lack of confidence and a lack of time that drives the lack of teaching,” agreed Daisy Smith, MD, FACP, ACP's senior medical associate for content development.

Luckily, members of the medical community have taken notice of the trend and are beginning to establish teaching programs to re-familiarize hospitalists with the essential exam skills that they were taught in the first years of medical school.

A hands-on approach

New York University's Langone Medical Center has a two-year program to help physicians improve bedside teaching skills and develop curricula in the areas of dermatological, musculoskeletal and cardiac physical exams. The facility now is looking to expand into pulmonological and critical care exams.

“After an assessment, we found that our faculty required development in their own skills,” said Michael P. Janjigian, MD, FACP, associate director of Langone's Merrin Bedside Teaching Faculty Development Program. “Our goal was to create a top-down education model where the attendings would become more confident and proficient in their bedside skills, which they would then teach at the bedside to residents and medical students.”

Through an open call for applications, faculty are recruited, and a limited number are chosen by an executive committee to develop their own individual programs for improving, then teaching, bedside exam skills.

Since the program began in 2003, 19 physicians have gone through it and have become valuable resources within the institution by creating curricula for the medical school, residency programs, and faculty continuing medical education programs, Dr. Janjigian said.

Meanwhile, Stanford School of Medicine in Palo Alto, Calif., has the Stanford Medicine 25, a program that teaches 25 technique-dependent physical diagnosis skills to residents, to reinforce what has been learned already in the classroom.

“We did not want to try to reinvent the whole physical examination course all over again, but like golf or tennis, it is a skill you get better at with time, and it is very technique-dependent,” said Abraham Verghese, MD, MACP, professor of medicine and senior associate chair for the theory and practice of medicine at Stanford. “We teach 25 things we want them to see us do, that we want them to do, and that we want them to teach.”

The program includes skills for physical exams of the thyroid, gait abnormalities, the spleen and liver, knees, deep tendon reflexes, precordial movements, involuntary movements, pupillary responses and more. “Many students assume, ‘I know where the liver is. Feel here. Feel there. I've got it,’ but they don't understand how nuanced it is,” Dr. Verghese said. “Exact technique makes a difference in whether they elicit the findings.”

Skills in real life

Practicing physical exam skills at the bedside is crucial, so these programs also involve interacting with patients. This helps teach related skills such as how to protect a patient's modesty during an exam and how to minimize his or her anxiety.

“It is important to learn in real-life situations that include getting the hospital bed or examination table to move, positioning the learners in a non-threatening way, asking patients to remove their shoes, having the necessary equipment on hand, and narrowing down their differential diagnosis as they go,” Dr. Smith said.

Failure to teach young physicians these skills can lead to missed diagnoses and diminishes the physician/patient relationship that is established by conducting a physical examination, Dr. Verghese said.

“There could be an obvious diagnosis that simply requires making the patient disrobe and conducting the type of examination that all of us were taught in medical school,” he said.

It's important to incorporate physical examination skills into rounds in a way that makes sense, Dr. Wiese noted.

“We can't say that we will do a full physical exam on every patient, every day,” Dr. Wiese said. “Instead, attendings have to look for areas where doing a physical examination makes sense to get better buy-in from learners who can then say, ‘This is a skill that I can see myself using later.’”

For hospitalists whose employers haven't developed a physical exam learning curriculum, one important resource is the Herbert S. Waxman Clinical Skills Center at ACP's annual scientific meetings. The center provides hands-on activities and simulation models to practice office-based procedures, examination skills, and assessment and interpretation skills.

“It can be hard for doctors to admit that they do not know these skills,” said Dr. Smith. “We try to create an environment where it is safe to admit that and to learn and get feedback.”

Creating a hospital culture where clinical examination skills are taught, practiced and valued is one of the most important steps toward bringing back physicians' proficiency with these skills, experts said.

“A physical examination is readily available, inexpensive and virtually risk-free and helps to build the physician/patient relationship,” said Dr. Smith. “Going to the bedside is an art that needs to be taught and celebrated.”