Good diagnostic skills should begin at the bedside
Improving physical exams and history-taking can help you become more efficient and compassionate
By Christine Kuehn Kelly
A University of Miami patient had experienced chronic undulating fevers for six months, but tests continued to be inconclusive. It wasn't until an infectious disease specialist asked him about his hobbies that the diagnosis became obvious. An avid hunter, the patient spent most of his vacations in the Southwest, hunting and skinning the animals he killed. The diagnosis: brucellosis.
Echocardiograms, CT scans, ultrasound—there's no question that imaging and lab tests play a key role in making the difficult diagnosis. But it's the physical exam and history that account for 80% of diagnoses, experts point out.
"The labs and imaging studies complement the picture of the patient created by a good history and physical exam," said Kavita Patel, ACP-ASIM Associate, a second-year internal medicine resident at Oregon Health Sciences University in Portland. That's why educators and residents alike say it's essential that residents learn how to conduct effective physical exams and practice on patients.
"Don't let your residency go by without learning all you can about the physical exam and history," emphasized ACP-ASIM Associate Max Brito, a fellow in infectious disease at the University of Miami Jackson Memorial Hospital.
Physical diagnosis is an important therapeutic instrument, noted Faith Fitzgerald, MACP, professor of medicine at University of California, Davis, School of Medicine. Physical examination and bedside diagnosis put the patient at the center of the physician's attention. "The physical exam is gratifying to doctors," she said. "It gives you a chance to get to know the patient, satisfy your basic impulse to make a diagnosis and make the patient feel better."
Furthermore, the bedside exam gives attendings the best chance to teach intuitive diagnostic skills and therapeutic techniques that make a patient feel better, Dr. Fitzgerald said. Ten minutes with a patient will teach you more than 20 pages with a textbook, added Dr. Brito.
And once you reach private practice, physical diagnosis skills can help you practice more efficiently. Expert diagnosticians point out that when you're pressed for time, it's important to maximize your face-to-face time with patients. Knowing what to look for—and how to rank a patient's symptoms—comes from experience and bedside teaching.
As you become more experienced, for example, you aren't likely to routinely do certain maneuvers when examining a heart patient who complains of a sore knee, and not shortness of breath. While first-year residents will think of dozens of possible diagnoses, third-year residents can zero in on the top five or six possibilities. With experience, you will learn which questions you can safely rule out when you take a history.
Physical diagnosis skills also serve as a filter for more intelligent use of diagnostic testing, according to Sal Mangione, MD, associate professor of medicine and director of the physical diagnosis curriculum at Jefferson Medical College in Philadelphia. Because unnecessary tests beget more tests (you usually find something unexpected), the lack of any filtering can increase costs and perhaps even harm the patient.
Take evaluation of a systolic murmur, a very common and usually benign finding. Studies indicate that an accurate physical examination can usually separate innocent from pathologic murmurs, thus leading to more intelligent, cost-effective use of technology.
Building your skills
Here are some tips to help you get through the bedside physical diagnosis more efficiently—and compassionately:
Control the environment. The noisy hospital room, with its ever-present television, dim lights and busy corridor sounds is not conducive to an accurate examination. Draw the curtain, turn up the lights and find a comfortable position to begin the physical exam.
Build rapport. Know the patient's name when you walk into a hospital or exam room. Always ask patients' permission before you begin the exam. Then ask questions and listen. If you're visiting for just five minutes, try to spend at least three minutes listening to the patient.
Start at the top. When performing the physical exam, start with the eyes and hands, and work your way down. You can learn a lot from visible signs such as clubbed fingers (possible respiratory disease) or a crease in the earlobe (possible cardiovascular problems).
Consider environmental factors. Asking about hobbies, sports activities, travel, country of origin, family history, pets and diet can help pinpoint genetic conditions or disease vectors you might not otherwise consider.
Look for mentors. Ask your program director about attendings or faculty who are expert at physical diagnosis, and round with them. A mentor is especially important when learning auscultation skills.
Get help from journals. A large body of evidence-based medicine can help you pinpoint the most effective physical maneuvers to help you diagnose. A frequently cited series of articles that has been published in The Journal of the American Medical Association (JAMA) called "The Rational Physical Exam" discusses key physical signs and diagnostic maneuvers for major conditions.
Take the long view. Honing physical diagnosis skills is a lifelong process. Building these skills in the hospital will ease the transition to an office or clinic setting, where patients want an immediate diagnosis and you generally cannot rely on a technological quick fix for the answer.
Although there are many benefits to knowing how to do a good physical exam and history, said Dr. Mangione from Jefferson, most physicians still spend too little time during residency and medical school teaching these skills. "Bedside rounds are often not at the bedside at all," he explained. "Surveys have indicated that less than 16% of attending time may be spent at a patient's side." Another study showed that residents on rounds spent a median of nine minutes per patient at the bedside, compared to 32 minutes spent elsewhere on the floor.
The constraints of managed care also affect how attendings and residents interact with patients. With outpatient visits limited to an average of 15 minutes and hospital encounters growing shorter all the time, residents have less time to interact with patients. Faculty also face increasing constraints on their bedside teaching time as they are required to take on more patients.
Another reason educators are not teaching physical exam skills may be that many faculty simply lack confidence in their bedside diagnostic skills, pointed out Herbert S. Waxman, FACP, the College's Senior Vice President for Education. "Teachers put themselves on the line when they teach," he said, "and the greatest vulnerability is at the bedside."
But faculty must make the effort to do more bedside teaching because it pays off for residents. Studies have shown that residents' skills in physical examination correlate with estimates of relative time spent by attending physicians at the bedside.
Auscultatory proficiency is one major area where skills are lacking. This may stem in part from the lack of structured teaching of cardiac and pulmonary auscultation. (For more on auscultation tips, see Improve your auscultation skills, this page.) As a result, residents are often inaccurate.
In one study conducted by Dr. Mangione, residents were incorrect four out of five times when they identified 12 commonly encountered cardiac auscultatory events. The rate did not improve throughout training: Residents were not significantly better than third-year medical students.
That's why we need the return to formal training in the physical exam, said cardiologist Howard Weitz, FACP, deputy chairman of the Jefferson Medical College department of medicine and co-author with Dr. Mangione of an editorial on the value of beside skills in JAMA (Sept. 3, 1997).
Fortunately, internal medicine programs are beginning to see the value of the physical exam. After years of absence in the curriculum, the physical exam is being taught in a structured way in more programs, according to Dr. Mangione.
"There's a beauty in the physical exam," said Dr. Weitz. "The laying on of hands creates a tangible connection with the patient. The physician who relies on technology only approaches patients from a distance."
Christine Kuehn Kelly is a Philadelphia-based freelance writer specializing in health care.
"The Auscultation Assistant," available online at www.med.ucla.edu/wilkes/intro.html, teaches heart and lung sounds. It was created by Chris Cable, ACP-ASIM Associate, a clinician teaching fellow at Seattle VA Medical Center.
"Residents could improve their auscultation skills," Dr. Cable said, "and the best way to learn is to hear the sounds repeated."
An annotated bibliography of literature on physical examination and interviewing is available from ACP-ASIM at www.acponline.org/public/bedside/index.html.
Auscultation case studies from Agilent Technologies, a medical equipment manufacturer, are available at www.healthcare.agilent.com/
The RALE Repository contains a collection of respiratory and heart sounds on the Web at www.rale.ca.
"Physiological Origins of Heart Sounds and Murmurs" by J. Michael Criley, FACP. For information go to the Lippincott Williams & Wilkins Web site at http://lww.com/home/, or call 800-638-3030.
The Rational Clinical Exam series, published from 1992 to present in The Journal of the American Medical Association, presents evidence-based approaches for more than 30 conditions.
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