How Can I Increase My Confidence in Doing Physical Exams?

Adam Kawalek, MD

Disclosures

December 18, 2008

Question
What should I do if I lack confidence when examining patients, regardless of how knowledgeable I am?

Response from Adam Kawalek, MD
Internal Medicine resident, Cedars-Sinai Medical Center, UCLA, Los Angeles, California

What a wonderful question! One of the most important traits that a physician should nurture is humility. I want to point out that the reader who sent in this question identified her lack of poise, related it to her fund of knowledge, and then sought advice on how to improve. I often find that medical students who question their abilities and look for ways to improve their skills are more respected by their peers and appreciated more by patients for their humility and self-awareness.

Examining the human body is a privilege, and an intimate act that truly distinguishes medical professionals from any other profession on earth. No wonder you are nervous! Realize first and foremost that good exam skills take years to develop. Any encounter with a patient represents, in a sense, a snapshot of their physical history and a moment in time for a certain disease process.

Recognizing the manifestations of that disease and applying what you have seen before is the ultimate goal. For example, liver cirrhosis can manifest with many subtle physical exam findings. If you synthesize and apply the knowledge you learn from examining several hundred patients with cirrhosis, I promise that by the end of medical school you will be able to accurately diagnose liver cirrhosis without any laboratory or diagnostic imaging help! Cultivating your physical diagnosis skills will serve you throughout your career.

Medical school is a time for curiosity, inquiry, and building a strong foundation or "fund of knowledge" that will continue to grow. Take the time to understand and experience what is in front of you. I encourage you to practice your skill set as often as possible. If you are too nervous during your clerkship rotations, try volunteering in a free clinic; they tend to be a lot more casual. Alternatively, practice your physical exam skills on a friend or family member. Any environment that will allow you to explore what you see, hear, and feel without the constraints of time or pressure will work to your benefit.

Another suggestion is to focus your examination skills on a single organ system at a time. From a practical standpoint, you may need to document or present an entire physical exam; however, if you focus your energies on a single system, you may find yourself more confident in less time.

Try to read several pages of a physical diagnosis book and apply what you have learned the next day. Attempting new techniques or maneuvers when examining patients will enhance your comfort level. Also, make an effort to apply new vocabulary or adjectives to describe what you have examined.

Finally, you owe it to yourself and to your patients to be honest. There is nothing wrong with prefacing a physical exam by stating humbly that you are a medical student doctor and that you are learning skills that will make you a great doctor. Feel free to apologize for your overzealous abdominal exam, or for blinding your patient with a lengthy funduscopy. Patients are aware that they are participating in a centuries-old ritual. Most are eager to subject themselves because they are inspired by our dedication. Use your inexperience and lack of self-confidence to make a connection with your patient. You just may find that their acceptance is all you need ... to feel confident.

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