Bringing Back Bedside Exams: The Stanford Symposium

Rabia Mughal

October 04, 2017

PALO ALTO, CA — It is not his first knee exam, but for this one, Andrew Parsons, MD, is not proceeding with a business-as-usual manner. Instead, as he positions the patient's leg, Dr Parsons is practicing techniques and asking questions based on what he and other participants just learned at a hands-on training session on performing knee exams. The interactive session was part of annual event, the Stanford 25 Bedside Medicine Symposium, that aims to improve the quality and value of physical exams.

The Stanford 25 Symposium, held September 29 and 30 this year, was created to address what Abraham Verghese, MD, professor at Stanford University School of Medicine in Palo Alto, California, saw as a "crisis" in medicine a decade ago: an overreliance on ordering diagnostic tests and scans rather than using skills at the bedside such as hands-on tests and talking to the patient.

Dr Verghese, who is a founding member of the Stanford Medicine 25 team, said in his opening address that the goal of the event is to "teach the teachers," so they can then return to their training programs and pass on the skills to their residents.

The 2-day symposium covers theory on the first day and offers hands-on training seminars on the second. The purpose of both the meeting and the overall program is to teach 25 technique-dependent, high-yield bedside maneuvers, from thyroid exams to deep tendon reflexes, and to build a community that is dedicated to bedside medicine.

Dr Parsons, an assistant professor of medicine at the University of Virginia in Charlottesville, wants to reemphasize bedside exam techniques in the medical school program.

Dr Parsons believes physical exams can be just as effective as, or even more effective than, diagnostic tests. "If done correctly, they are extremely accurate, and free," he told Medscape Medical News. "We have become almost lazy with so much diagnostic testing."

Amy Welcome, MD, from Internal Medicine Associates in Greenville, South Carolina, concurs with that statement. She teaches first- and second-year medical students as well as residents and says the lectures and hands-on training at this weekend's meeting will improve her own teaching methods.

For example, she nodded along with the rest of the group, as the presenter pointed out common mistakes during a hip and back exam, such as not applying an appropriate amount of pressure or lack of proper positioning during the FABER (flexion, abduction, and external rotation) test, which can make the exam less effective.

"We rely too much on imaging," Dr Welcome said. "If we were more confident in our physical skills, we would spend less dollars."

5-Minute Exams, Beating the Time Crunch

In an interactive session, participants learn how to develop and teach their own bedside moments. Many conference participants cite lack of time as a key reason for physicians doing fewer physical exams. Therefore, during "Creating your own 5-minute bedside moments," moderators keep time as two participants — one posing as teacher and the other as learner — tackle everything from abdominal pain to dilated pupils in approximately 5-minute sessions.

The moderators emphasize that although technique is important, it is also necessary to engage your learner. You can do that by providing history or context related to the condition, using visuals on an electronic device, and incorporating anecdotes, or even humor. Also, they note that physical exams can be uncomfortable for patients, so positioning them comfortably and helping them relax will give you better results.

During the session, Samuel Lai, MD, assistant clinical professor at the University of California at Irvine, participated in a teaching moment on lymph node exams. He told Medscape Medical News that he is currently developing a physical exam curriculum and was looking for a conference that could help him with teaching techniques. He found that this is probably the only conference of its kind and considered it a great opportunity to learn from the experts.

"The physical exam has been largely replaced by technology," he said. "The current thinking, especially among millennials, is that technology cannot be wrong — a [magnetic resonance imaging scan] cannot be wrong."

However, the two approaches should not be pitted against each other, Dr Lai noted. "Physical exam is not more or less important than technology. It is not competing with imaging, and they should work together."

He thinks that there is a need, especially among younger physicians who grew up with technology, to relearn the physical exam. "We did not grow up having to rely on our physical exam skills," he said.

Operationalizing Bedside Medicine

An afternoon session titled, "Clinical examination for the practicing physician" focused on exactly these skills. Participants learned high-yield cardiac exam skills with simulation and real patients. In one case, participants listened to a patient's heartbeat and discussed the type of murmur they heard, coming to a consensus that it was a systolic murmur.

Esther Johnson, MD, a faculty member at a community-based family medicine residency in Seattle, says the conference really taught her how to operationalize the concept of bedside exams in a limited amount of time, ways to capture the learner's attention, and techniques that show a physical exam can be just as accurate as, or even more accurate than, an imaging study. She looks forward to taking back these skills, noting that the residents are enthusiastic about learning bedside techniques.

Conference organizer Junaid Zaman, MD, agrees there is a "real hunger" for this type of training. In his experience, residents and students complain about spending too much time in front of the computer. It is important to connect with the patient, and to that end, many of the clinicians involved with Stanford Medicine 25 have formed a Society of Bedside Medicine to further facilitate educators and provide them with resources and networking opportunities.

"We all have time pressures, and [computed tomography] scans are easy," Dr Zaman concluded. "But you have not connected with the patient."

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