Teaching the Physical Exam: Best Practices

Teaching the Physical Exam: Best Practices

This transcript has been edited for clarity.

Molly Heublein, MD: Hi. I’m Dr. Molly Heublein. Welcome to Curbsiders Teach, our Curbsiders family podcast on teaching medical education.

Era Kryzhanovskaya, MD: I am Dr Kryzhanovskaya. We’re excited to recap one of our favorite Curbsiders Teach Season 2 episodes, Teaching a Physical Exam with Dr. Andre Mansoor.

Heubléin: It was so awesome. Dr. Mansoor is clearly passionate about the subject and has shared some great examples of the power of physical examination. We like to rely on technology in medicine, but sometimes the exam can be even more powerful in saving patients time and getting the right diagnosis. It is really essential to show our learners how valuable the exam can be. As educators, we need to demystify the myth that physical examination is not helpful.

Kryjanovskaya: I remember after that episode I started to pay more conscious attention to the physical exam – the patient’s nail beds, pulses, heart sounds, uvula and other parts of the exam that André pointed out to us. Recently, I was looking at a patient’s hands based on the chief complaint and the diagnosis I was considering. I noticed an unexpected nail find. After scratching my head for a while and making some guesses, Andre’s voice came to mind. The plaques on the patient’s hands were psoriatic arthritis. The oil drop sign came to mind. It was really wild, and I think it was entirely due to our conversation with Andre.

Heubléin: And there’s no good blood test or scan we can order to confirm this, so it’s just a matter of finding it on an exam. I had a great one yesterday when I showed up at the clinic. One of my favorite diagnoses to make in the clinic is BBPV – benign paroxysmal positional vertigo. One of our interns introduced this very complex older woman. We were concerned that his dizziness might suggest something dangerous. Would it be something central? Arousing his vertigo with the Epley maneuver was so satisfying – being able to diagnose the patient based on physical exam alone and initiate treatment, and reassure him that he doesn’t need more testing.

We are excited about the power of physical examination. Let’s think about how we’re actually going to teach this. Dr. Mansoor emphasized the one-two punch: teaching the expected results with very brief didactics, then going to the bedside to observe them.

Kryjanovskaya: Let’s dive a little deeper into that. André encouraged us to do a little preparation to amplify what we will see on the exam.

He encouraged us to start with whiteboard or blackboard didactics, followed by bedside teaching for a bit of a punch. The didactics must be based on the result of the physical examination that the learner or the team is about to encounter. How do clinicians differentiate between these physical exam findings? Asking learners to anticipate what they will see or hear helps them identify the differential diagnosis for each physical examination finding.

For example, we can review the defining aspects of the differential for a holosystolic murmur and the clinical scenarios in which we might hear them. This is where we perform a hypothesis generating physical examination to help us more efficiently arrive at the correct diagnosis. It saves time for us, for our team and for the patient as well, and it avoids the kind of push-and-pull approach of ordering tests immediately and allows us not to overuse the technology or the tests.

Heubléin: Now that we have prepared the ground and framed the examination for the learner, we go to the patient’s bedside. Think about the learner’s level of experience and adapt the teaching from there. If you have a new learner, do the test first to model the behavior, then ask the learner to follow you and describe their findings. If you worked with a learner for a few weeks and you know that last week you did a volume status review with another patient and you felt like the learner was learning those skills, ask the learner to start the exam and you can give pointers. It is so important to link the results to the clinical context. Ask each student to describe aloud what they observed and then talk about the differential diagnosis.

Kryjanovskaya: Another great tip André taught us is to solidify the results if possible. Have learners examine patients with different exam findings within the same organ system. For example, with the holosystolic murmur, try examining patients with diastolic murmurs to solidify differences in murmurs and other findings in other patients on our teams. We could take the learner to see patients with interesting physical exam results (after asking the patient’s permission) and get an idea of ​​what results those other patients might have. This is again the physical examination based on assumptions. Most patients enjoy being part of the teaching experience.

Heubléin: I wish that when I was in residence these methods were used more, because it’s an amazing way to see things in practice and learn on the job. During our podcast, we had fun walking through a heart murmur case with Dr. Mansoor. So I encourage you to listen to the podcast and check out his website, Physical Diagnoses CPX. You will find a wealth of information on ways to improve your teaching of physical examination – cases that you can walk through alone or with your learners to reinforce these results.

Another tip from Dr. Mansoor was for educators trying to improve their physical exam skills and teach the exam better is to have a physical diagnosis buddy. If you see something that excites you at the clinic or on the wards, text or call your friend and say, “Hey, let’s see this patient together and learn about this case together.”

You can listen to the entire podcast here, and also see our show notes and charts. I’m Dr. Molly Heublein.

Kryjanovskaya: And I’m Dr. Era Kryzhanovskaya. Please join us for this brief recap of the Physical Exam Skills episode with Dr. Andre Mansoor as part of Curbsiders Teach Season 2.

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