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Changing the Learning Objectives for Teaching Physical Examination at the Medical School Level

  • Daniel M. Gelfman
    Correspondence
    Requests for reprints should be addressed to Daniel M. Gelfman, MD, Associate Professor of Internal Medicine (Cardiology), Marian University College of Osteopathic Medicine, 3200 Cold Spring Road, Indianapolis, IN 46222.
    Affiliations
    Division of Clinical Affairs, Marian University College of Osteopathic Medicine, Indianapolis, Ind.
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      There have been several editorials
      • Feddock C.A.
      The lost art of clinical skills.
      • Alpert J.S.
      Will physicians stop performing physical examinations?.
      • Alpert J.S.
      How accurate are the findings noted during a physical examination? Will physicians stop performing physical examinations? (Part 2).
      lamenting the loss of physician physical examination skills. In two recent editorials in The American Journal of Medicine,
      • Alpert J.S.
      Will physicians stop performing physical examinations?.
      • Alpert J.S.
      How accurate are the findings noted during a physical examination? Will physicians stop performing physical examinations? (Part 2).
      it was pointed out that the information obtained from the physical examination is quite helpful in patient management, and the performance of a physical examination is generally welcomed by patients. Interestingly, this decline in physical examination proficiency is not new and has been documented since the 1960s.
      • Feddock C.A.
      The lost art of clinical skills.
      Though much effort has been made to solve the problem, it still remains.
      • Feddock C.A.
      The lost art of clinical skills.
      • Alpert J.S.
      Will physicians stop performing physical examinations?.
      • Alpert J.S.
      How accurate are the findings noted during a physical examination? Will physicians stop performing physical examinations? (Part 2).
      • Shrestha M.P.
      • Borgstrom M.
      • Trowers E.
      Digital rectal examination reduces hospital admissions, endoscopies, and medical therapy in patients with acute gastrointestinal bleeding.
      The problem continues to exist most likely because there is at least 1 major issue not being currently addressed: the ability to perform an accurate physical examination is not valued by the majority of physicians today. While not directly stated, this is strongly implied in the Association of Professors of Medicine (APM) perspective by Feddock.
      • Feddock C.A.
      The lost art of clinical skills.
      Why do today’s medical students and physicians place so little value on mastering the skill of physical examination? There appear to be 3 reasons. First, learning how to perform the complete physical examination as taught in medical school can be quite overwhelming and time-consuming. Second, students and physicians clearly have an enormous amount of other material to master and simply do not want to devote the time to become proficient in physical examination skills. Third, many physicians appear able to practice medicine, although not ideally (see below) by relying more on the history and laboratory testing without the use of a detailed examination in decision-making.
      • Feddock C.A.
      The lost art of clinical skills.
      • Alpert J.S.
      Will physicians stop performing physical examinations?.
      Students observe and acquire this approach to patient care when they enter their clinical years, and the pattern continues.
      • Feddock C.A.
      The lost art of clinical skills.
      The lack of the use of the physical examination in decision-making can adversely affect patient care.
      • Feddock C.A.
      The lost art of clinical skills.
      It leads to the overutilization of testing as a substitute for performing a physical examination, and easily recognized abnormalities can be missed because the physical examination was not performed or was not performed adequately.
      • Alpert J.S.
      Will physicians stop performing physical examinations?.
      • Alpert J.S.
      How accurate are the findings noted during a physical examination? Will physicians stop performing physical examinations? (Part 2).
      • Shrestha M.P.
      • Borgstrom M.
      • Trowers E.
      Digital rectal examination reduces hospital admissions, endoscopies, and medical therapy in patients with acute gastrointestinal bleeding.
      One needs to ask the question, “Why do we need to try to teach all students to perform a physical examination at an advanced skill level instead of at a more basic level?” Why not change our learning objectives to a less lofty goal that would be more acceptable to students and that we can actually achieve? In years past, the physical examination was the main “test” that was performed to establish a diagnosis and was used to direct treatment and decide if further testing or possibly consultation were warranted. Further testing and consultation were often difficult to obtain. Today, the practice of medicine is different. Testing and consultation are generally easily obtained and often times the severity of disease is now defined by those test results and the specialist’s interpretation of the tests as well as their own physical examination. From a cardiac standpoint, most physicians today do not need to be able to distinguish severe aortic stenosis from mild stenosis or even mitral regurgitation. The skill they really need is to perform enough of an examination to recognize that there is a significant systolic murmur to prompt the decision to obtain an echocardiogram and possibly a consultation. What is necessary for the “screening” physician is the desire and ability to perform a basic examination recognizing normal from abnormal, with the capability to either diagnose what is abnormal or categorize it in a useful fashion. The screening physician is really anyone who will not ultimately be the treating physician. For example, a patient came to see me years ago with an appointment for a pre-op “cardiac clearance” for knee surgery and actually had developed acute appendicitis hours before the appointment. He had a classic history and right lower quadrant guarding. Though I inferred that acute appendicitis was the correct diagnosis, I did not need to perform an advanced abdominal physical examination to further define his acute abdomen. I just needed to get him to the hospital and call a general surgeon.
      I am not claiming that there are no benefits to having additional training and skill in examination. However, having the additional training and skill is not essential for someone who will refer the patient on to another physician who specializes in treatment of the disease in question. For the treating physician such as the cardiologist or astute internist in the cardiac murmur example, recognizing the specific clinical disease and its severity on examination is important in the patient’s management. The findings on examination serve as another confirmation of the diagnosis in question in conjunction with other testing, and this ultimately can limit further potentially dangerous testing. For example, many patients today do not need to undergo a hemodynamic cardiac catheterization to confirm severe aortic stenosis if the physical examination and noninvasive testing are diagnostic. If the risk of coronary artery disease is high enough, patients then only require coronary angiography. This significantly lowers the risk of embolization during the cardiac catheterization by making unnecessary the placement of a catheter though the stenotic aortic valve if surgical and not transcatheter valve replacement is planned.
      • Nishimura R.A.
      • Otto C.M.
      • Bonow R.O.
      • et al.
      2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
      Why not change our medical school learning objectives for physical examination to emphasize the recognition of normal from abnormal as described above? This has the advantages of decreasing the time necessary to learn as well as perform the physical examination. It should also help in developing physician confidence in their ability to perform the physical examination with accuracy because the process will be less complicated. Students and physicians should then see value in the physical examination, which will serve as a relatively quick aid in decision-making.
      This point is well illustrated in the following two examples: The most interesting diagnosis that I initiated as an intern (in 1981) concerned a woman with preterm labor who was being treated with a beta agonist and developed runs of ventricular tachycardia. She was therefore transferred to our service in the coronary care unit. The beta agonist was discontinued and her ventricular tachycardia eventually resolved. I dutifully performed my cardiac examination and heard an extra early diastolic cardiac sound. The timing was too late to be an opening snap and too early to be a third heart sound gallop. I ordered an echocardiogram late that night as I felt that her runs of ventricular tachycardia were likely due to more than just the medication. However, I did not have a diagnosis other than “abnormal cardiac examination.” On rounds the next morning, no one actually believed that the sound I had heard was anything more than a normal third heart sound, common in pregnant patients. The order for the echocardiogram had already been processed, and thus the echocardiogram was obtained. In those days, it was not routine to obtain an echocardiogram in such a situation, and she would likely have otherwise been transferred back to the obstetrics and gynecology floor without it. The cardiology fellow came back to get me in the afternoon and took me to the echo suite to show me what I had heard. The university had just obtained a 2-dimensional echocardiographic machine. The patient had a left atrial myxoma, and the sound was that of a tumor plop. Fortunately, the tumor was successfully resected several months later after she gave birth. Clearly what was key on physical examination was knowing abnormal from normal, not recognizing the tumor itself. The same concept can be applied to the case of aortic stenosis in Alpert’s editorial in The American Journal of Medicine.
      • Alpert J.S.
      Will physicians stop performing physical examinations?.
      The resident did not actually need to recognize the critical aortic stenosis, just that there was a significant murmur that required evaluation.
      What I am proposing is that we change our learning objectives in teaching physical examination education at the medical school level. Our objectives should include a briefer, less detailed examination emphasizing normal from abnormal, and the ability to either diagnose what is abnormal or categorize it in a fashion that facilitates medical decision-making. This would require a consensus approach from each specialty, especially primary care. By emphasizing the usefulness of the more limited physical examination in clinical decision-making, students and physicians would likely, as in the past, value and perform the examination. One example from the field of cardiology would be the recognition of a significant systolic murmur, but less important the maneuvers to differentiate the exact diagnosis (other than describing the hemodynamic effect of those maneuvers to aid in understanding pathophysiology). Teaching a more limited physical examination at the medical school level is an obtainable goal that has the potential to improve patient care, patient safety, and decrease unnecessary testing.

      References

        • Feddock C.A.
        The lost art of clinical skills.
        Am J Med. 2007; 120: 374-378
        • Alpert J.S.
        Will physicians stop performing physical examinations?.
        Am J Med. 2017; 130: 759-760
        • Alpert J.S.
        How accurate are the findings noted during a physical examination? Will physicians stop performing physical examinations? (Part 2).
        Am J Med. 2019; 132: 663-664
        • Shrestha M.P.
        • Borgstrom M.
        • Trowers E.
        Digital rectal examination reduces hospital admissions, endoscopies, and medical therapy in patients with acute gastrointestinal bleeding.
        Am J Med. 2017; 130: 819-825
        • Nishimura R.A.
        • Otto C.M.
        • Bonow R.O.
        • et al.
        2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
        J Am Coll Cardiol. 2014; 63: 2438-2488