The Physical Examination: How Focusing Teaching Can Teach Focus

1. The Physical Examination: How Focusing Teaching Can Teach Focus Heather Harrell, MD, FACP Associate Professor of Medicine University of Florida

2. 8:45 AM on work rounds outside the room of a patient admitted for “r/o stroke”

3. Does this sound familiar? • MS 3 “ Ms. J was resting comfortably w/o complaints. On exam: NCAT, heart sounded good… regular rate and rhythm, lung are clear, abdomen has good bowel sounds in all 4 quadrants, soft, nontender, no rebound or hepatosplenomegaly.”

4. On entering Ms. J’s room, you discover • Vital signs: T38.5 P110 BP 92/50 R 24 O2 sat 88% (RA) • She is obtunded • Posterior lung exam reveals dullness at the right base with crackles and egophony • Left patellar and Achilles reflexes are now hyperactive with a positive Babinski • …just for starters

5. This is not time efficient. And this is not optimal patient care.

6. Objectives • Be able to describe 2-3 strategies to teach physical examination at the bedside without disrupting rounds. • Be able to describe a template for teaching students how to focus the physical examination correctly on an inpatient medical service. • Be able to identify written and web-based resources for improving physical examination skills.

7. Rounds Approach to Physical Exam • “Pre-rounds”- prepare the student by giving a template (set expectations) • Work rounds- demonstrate only pertinent findings • Teaching rounds- save interesting (but less pertinent) or more time consuming physical findings for teaching rounds

8. “Pre-rounds”:Template for focused physical examination presentations • Vitals are vital, always start with them. • General appearance* • Does the patient look sick? • Has there been a big change overnight? (Will the team be surprised by how the patient looks today?) • What parts of the physical exam relate to the chief complaint? Those are the pertinent parts to mention. • Are there any new findings overnight? If so, will it affect the plan? (If not, you probably don’t need to bring it up on rounds.) *Omit if making true bedside rounds, as it will be obvious to the team. (LaCombe MA: On bedside teaching. Ann Intern Med 1997;126:217-20.

9. For Those Who Like Mnemonics… • Vitals • Appearance • Chief complaint • Abnormal findings • New findings • Treatment (would change)

10. Work Rounds: Observation is Critical to Assessing Technique …And it can be time efficient.

11. “Show Not Tell” • “Show me what you found on exam.” • Allows direct observation of student technique • Allows resident to perform/confirm key parts of the exam that they need to do anyway • Allows resident to direct student to the pertinent parts of the exam • Allows immediate feedback

12. Teaching Rounds Tips • Difficult to keep everyone engaged while awaiting a turn to examine the patient but all learners can practice observation skills by asking them what they notice • Students frequently overlook lines, catheters, infusions, old scars, skin and nail abnormalities, movement disorders • Ask “what did you hear, see, feel?” rather than “did you hear, see, feel____?” • Ask students to predict what an x-ray or ECHO will show based on the exam

13. Focusing Teaching, Helps Teach Focusing • By demonstrating the parts of the physical exam that you need to perform for patient care, you role model to students how to focus their physical examinations. • Conversely, reviewing every detail of the physical examination during rounds (as interesting as it may be) could encourage students to present every detail of the exam during work rounds….something you may regret on a busy service. • (Save something for the attending to cover on teaching rounds.)

14. Role-Modeling Caveat • Demonstration and role-modeling are critical when teaching physical examination. • Never assume students realize you are role-modeling: make it explicit. • “Watch how I position the patient.” • “Make a note of the parts of the exam I am going to repeat as this is what we mean by a focused exam for this patient.”

15. Sample Case Using a “Rounding” Approach • RC is a 76 yo man with CHF and MR admitted last night for CHF exacerbation. • After diuresis overnight his lung exam, JVP, and peripheral edema have improved.

16. “Rounds” Approach • “Pre-round”- Student has template and should have gathered pertinent data • Work rounds- Student demonstrates JVP, pulmonary exam (residents listens with student), and peripheral edema • Teaching rounds- Attending (or resident) reviews cardiac exam with an emphasis on heart murmurs and may review technique of measuring JVP if the resident noted confusion on rounds.

17. “I desire no other epitaph…than the statement that I taught medical students on the wards as I regard this by far as the most useful and important work that I have been called to do.” ~ Sir William Osler

18. Application • Using sample scenarios, residents can discuss how they would focus an exam on work rounds • Role play can reinforce that this is time efficient • See handout

19. Consider the following questions when discussing the practice cases • As the resident, what part of the exam do I need to perform/confirm on rounds? • Is this an appropriate patient for several people to exam? • What 1-2 key findings could be reviewed with the whole team that would not slow down rounds? • What 1-2 key findings should I make sure someone reviews with the medical students? • Would the physical findings of this case be good to save for attending rounds? • How can I involve the students?

20. Case 1 • L.R.- 52 yo man w/ ETOH cirrhosis admitted 2 days ago w/ encephalopathyHe has all the classic stigmata of chronic liver disease.

21. Case 2 • J.C.- 70 yo woman w/ emphysema and community acquired pneumoniaShe has a classic emphysema exam along w/ consolidation in the LLL.

22. Case 3 • M.K.- 85 yo woman w/ severe dementia “social admit”She is thin w/ multiple contractures and not interactive at all.

23. Case 4 • S.T. - 23 yo woman w/ sickle cell crisis HD 5 w/ pain 5/10 on morphine PCAFit appearing young woman, who looks uncomfortable but o/w normal exam.

24. Case 5 • R.G. - 45 yo man w/ “atypical chest pain” admitted for R/O MIHe is moderately obese w/ II/VI systolic murmur at LUSB (c/w his old “flow murmur”).

25. Author Contact Information Heather Harrell, MD, FACP harrehe@medicine.ufl.edu