#13 Teaching the Physical Exam

August 9, 2022 | By Molly Heublein

With Dr André Mansoor

Physical examination guru Dr. André Mansoor, @AndreMansoor brings his expertise to effectively teach the physical examination to learners!  We discuss the power of the physical examination, how to prime learners for bedside teaching, and ways to solidify knowledge gained. 

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Credits

• Producer/Hosts/Writers: Era Kryzhanovskaya MD, Molly Heublein MD
• Cover Art/Infographic: Andrew DeLaat
• Show notes: Charlotte Chaiklin MD 
• Audio editor: Clair Morgan of Nodderly
• Guest: André Mansoor MD

CME Partner: VCU Health CE

Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner/ Best piece of advice
• Picks of the Week
• Case from Kashlak
• Value of the Physical Exam
• Teaching the Physical Examination- prework didactics
• Teaching at the bedside
• Resources to your own skills
• Roles of Technology
• Take home points 
• Outro

Physical Exam Teaching Pearls

1. We as educators must debunk the myth that physical examination is not helpful.  Educators should seek to ignite a learner’s curiosity and appreciation for the physical examination. 
2. To teach physical exams, start with didactic sessions to help frame a newly introduced physical examination finding.  Then, go to the bedside!  Teaching the physical examination must occur at the bedside for experiential learning. 
3. Have each student examine the patient on their own and then describe out loud what they observed.  Talk through the differential diagnosis for the examination finding.  If possible, have learners examine patients with different examination findings of the same organ system (Example: systolic murmur versus diastolic murmur) to solidify the differences in the physical examination findings. 

Physical Exam Notes

Importance of the Physical Examination

At times, physical examination can be more reliable than technology.  Dr Mansoor shares examples  including a patient with inflammatory arthritis who underwent surgical debridement because their psoriasis was missed. 

Performing a hypothesis driven physical examination can help you arrive at the correct diagnosis more efficiently and thus, save you, your team, and the patient time (Balighian 2016).  Avoid the shotgun approach to ordering tests and over utilizing technology (Zaman 2018).

We as educators must debunk the myth that physical examination is not helpful.  Educators should seek to ignite a learner’s curiosity and appreciation for the physical examination. 

Improve your PE Skills

Some resources Dr. Mansoor recommends to brush up on your physical examination skills include:

Physical Diagnosis PDX  

Sapira’s Art & Science of Bedside Diagnosis

Bedside Cardiac Diagnosis  

He also points out the value of having a colleague or peer that you can practice and discuss skills with.

Teaching the Physical Examination

Start with brief white board didactics followed by bedside teaching for a one-two punch.  Didactics should be based on the physical examination finding the learner is about to encounter and how we as clinicians differentiate physical examination findings.   Having the learner anticipate what they are going to see or hear allows them to be more likely to identify it (Balighian 2016).   Additionally, the differential diagnosis for each physical examination finding should be discussed.  

Then, go to the bedside!  Teaching the physical examination must occur at the bedside for experiential learning. 

Have each student examine the patient on their own and then describe out loud what they observed.  Talk through the differential diagnosis for the examination finding.  If possible, have learners examine patients with different examination findings of the same organ system (Example: systolic murmur versus diastolic murmur) to solidify the differences in findings. 

Consider modeling your approach to the physical examination maneuver for the learner if it is their first time performing the maneuver with you.  Utilize the teach back method.  For material that was already covered, quizzing learners about different physical examination findings and maneuvers can help solidify knowledge. 

Branch out beyond the patients on your team.  Take your team to see other patients with interesting physical examination findings after obtaining the patient’s permission of course.  Most patients love to be a part of the teaching experience (99% of patients in Dr. Mansoor’s experience).  

The Role of Technology

Technology can be a valuable tool to help calibrate or hone physical examination skills once you know the patient’s diagnosis.   For example, if a patient has mitral regurgitation on echocardiogram, you can evaluate the patient for a holosystolic murmur at the apex, listen to the axilla for radiation, and try the handgrip maneuver.

Videos of different physical examination findings can provide visual material for learners (check out videos on Physical Diagnosis PDX) and are used frequently in medical teaching (Uchida 2019).

Take Home Points

The physical examination is a powerful tool we can utilize to save patients time and money. 

Physical examination findings serve as clues to help us efficiently arrive at the correct diagnosis.

Links

1. Andre’s book recommendations: The Art and Craft of Stonescaping: Setting and Stacking Stones, Garden Stone Creating Landscaping with Plants and Stones, A Thousand Splendid Suns, and The Count of Monte Cristo  
2. Era’s pick of the week: Grief is Love: Living with Loss book by Marisa Renee Lee
3. Molly’s pick of the week: The Taste of Ginger book by Mansi Shah
4. Andre’s book: Frameworks for Internal Medicine 

Goal

Listeners will become familiar with ways to effectively teach physical examination.

Learning objectives

After listening to this episode listeners will…  

1. Recall the importance of teaching physical examination skills to learners
2. Describe the ideal setting for teaching physical examination skills 
3. Detail ways to evaluate a learner’s physical examination skills 

Disclosures

Dr Mansoor reports no relevant financial disclosures. The Curbsiders Teach report no relevant financial disclosures. 

Citation

Mansoor A, Kryzhanovskaya E, Heublein M. “#13 Teaching the Physical Exam.  The Curbsiders Teach Podcast. http://thecurbsiders.com/teach August 9, 2022.