Synopses of Rational Clinical Exam Series: Teaching the Science of the Clinical Exam M. Lee Chambliss MD MSPH Associate Professor Moses Cone Family Medicine Residency UNC Dept of Family Medicine

Handout/Presentation Will upload to FMDRL Email me – address is in handout

Outline Introduction to the Rational Clinical Exam Series RCE Synopsis Project Goals Methods Example Discussion

Rational Clinical Exam Series Regular series systematic reviews on the precision and accuracy of specific elements of the clinical examination Science of medicine can be applied to the clinical exam “Intended to inform not to reassure”

The Rational Clinical Exam Series Journal of the American Medical Association Began in May 1992 Editors Simel DL (1994-), Sackett DL (1992-1994), and Rennie D (1992-),

More than 50 systematic reviews “Is the patient taking the treatment as prescribed?” “Does this patient have appendicitis?” “Is the patient dead, vegetative or severely neurologically impaired?”

RCE Series Format The Patient Scenario. The Prevalence of disease How to elicit symptoms and signs Literature Review Methods for literature searching, inclusion criteria for articles qualitative and quantitative results of the search. The Precision of the symptoms and signs Accuracy of the symptoms and signs The "Bottom Line"

Online Collections

A valuable resource but not very accessible Long and Dense

RCE Project Each of our interns choose an article from the series, review it, and create a 2-3 page archival synopsis highlighting the most useful findings for diagnosing a condition

Goals Improve residents knowledge of the evidence based assessment of diagnostic tests Promote the Strength of Recommendation Taxonomy (SORT) Criteria Increase awareness of the RCE Series Perform a critique of a systematic review and individual studies of diagnostic tests Produce a user friendly synopsis of the information in the RCE articles

RCE Project Read introduction and background articles Choose a topic and update the search Write a synopsis using a template Rewrite the synopsis after edits 4 half days

RCE Project 1. Read the introduction to the RCE series   1.      Read the introduction to the RCE series A primer on the precision and accuracy of the clinical examination; J Amer Med Assoc.; 267(19):2638-44, 1992 May 20 The science of the art of the clinical examination J Amer Med Assoc.  267(19):2650-2, 1992 May 20.         

RCE Project 2. Read the User's Guide to the Medical Literature about   Diagnostic Tests How to use an article about a diagnostic test A. Are the results of the study valid? JAMA 1994 Feb 2; 271 (5) : 389-391 How to use an article about a diagnostic test  B. What are the results and will they help me in caring for my patients? JAMA 1994; 271 : 703-707 Evaluating Review Articles Users' guides to the medical literature. VI. How to use an overview. JAMA. 1994 Nov 2;272(17):1367-71 Guidelines for Meta-analyses Evaluating Diagnostic Tests. Ann Intern Med 1994;120: 667-676 (Primarily review Table 1)

RCE Project Read about Likelihood Ratios Using the Likelihood Ratio. JFP 2005:54:127-28 Simplifying the Likelihood Ratio. J Gen Int Med 2002;17:64-649

Accuracy Sensitivity/Specificity Likelihood Ratios Probability of finding in pt with disease = -------------------------------------------------------- Probability of finding in pt without disease Must convert pretest probabilities to odds to use LRs

Likelihood Ratios Positive LR increases the probability of disease 1 No change in probability 2 15% increase in probability 5 30% increase in probability 10 45% increase in probability Negative LR decreases the probability of disease 0.5 15% decrease in probability 0.2 30% decrease in probability 0.1 45% decrease in probability

Precision Kappa – correlation coefficient of agreement between clinicians 0 chance agreement 0 - 0.2 Slight 0.2-0.4 Fair 0.4-0.6 Moderate 0.6-0.8 Substantial 0.8-1 Nearly Perfect

RCE Project 3. Review the RCE Series of Articles and choose one 4. Perform a literature search to find any more current articles on your topic   Go to http://www.sgim.org/clinexam.cfm

RCE Project Review studies for: relevance (is it about the topic) and validity (is it a good study) and discuss with your preceptor

RCE Project 5. Use the template to create a Synopsis of the Clinical Exam topic. What is clinically useful What is not clinically useful Quantify Level of Evidence Updated Information Other practical information

RCE Project Template -Summary Question  Original Citation  Bottom Line What you would want to know as a clinician  SORT Grade of Recommendation: Give Grade of Recommendation. (See SORT Criteria)  Comments/Hints/Suggestions Other useful information contained in the review

Template - Usefulness Prevalence (best if can give the pretest probability when a patient presents to a physician with a particular sign or symptom Accuracy of Exam  Symptoms /Signs LRs and Sensitivity/Specificity Prediction Rules (Combinations of Symptoms, Signs and simple Labs)  

Template - Usefulness Description of how symptoms elicited or defined Description of how exams were done or scoring of prediction rules  Precision Give Kappas

Template -Evidence Studies description from RCE article Inclusion criteria Search Date from Article Number Found and Reviewed Quality/Limitations Gold Standards

Template - Update Reviewer Updated Search Article citation: Description: (brief) Findings (may include under Accuracy section) Critique (use SORT LOE for individual study) Level of Evidence (SORT) Fit (how does this article compare to the RCE review)

RCE Project Currently Plans Have completed five synopses Positive informal feedback Plans Pre/Post testing starting in July

RCE Synopses Use with medical student clinical reasoning sessions Use for bedside teaching rounds and precepting Make available on handhelds and intranet ? Available on FMDRL

Does this patient have Influenza? Recent Illustrates that the clinical exam isn’t particularly useful Issue of Point of Care Testing and Cost Effective Analysis Updated Search found a trial

Does this patient have Influenza? What would be important to be in the Synopsis? What is the best format?

Thank You Suggestions? Questions?