1. Welcome Assignment Write down one challenge you have experienced when teaching or learning physical exam skills in the clinical setting.

2. Integrating the Physical Exam into Teaching Resident as Teacher Presentation Arati Karnik, Sharyn Miskovitz, William Jordan Residency Program in Social Medicine Montefiore Medical Center First presentation March 30, 2010 Last updated April 18, 2011

3. Session Objectives Identify challenges to incorporating the physical exam (PE) while teaching in the clinical environment Discuss factors contributing to positive and effective PE teaching experiences Evaluate scenarios where the PE is used as a teaching point

4. Outline Why teach the physical exam? Challenges to teaching physical exam in the clinical setting Inpatient – Video & Discussion Outpatient – Video & Discussion Teaching tips

5. Why Teach PE in Clinical Setting? RRC requirements - teaching humanism and professionalism at the bedside (ACGME, 2007) Increasing evidence physicians lack physical exam skills (Jauhar, 2006) Physical exam maneuvers have known sensitivities & specificities as diagnostic tests (U Washington) Direct observation of student skills and opportunity to role model (Janicik & Fletcher, 2003)

6. Evidence Base http://depts.washington.edu/physdx/evidencebase.html

7. Example: Neck Veins http://depts.washington.edu/physdx/evidencebase.html

8. Challenges

9. Learning Climate: Managing the Room Ramani (2003), Skeff (1988) Learner (residents, interns, medical students) Patient Nurses Family Members Techs Roommate Teacher (attending, senior resident) Diagram adapted from Ramani, 2003

10. Teacher Challenges Ramani (2003), Skeff (1988), Williams et al. (2008), Kroenke et al (1997) Lack of time / space Rusty physical exam / teaching skills Managing large team of learners at different levels Lack of privacy Control of session / interruptions Student perception of value Teacher (attending, senior resident)

11. Learner Challenges Ramani (2003), Williams et al. (2008), Kroenke et al (1997) Lack of time Discomfort of learning in front of patient Fear of being put on the spot / humiliation Lack of confidence in physical exam skills Learner (residents, interns, medical students)

12. Patient Challenges Ramani (2003), Williams et al. (2008) Exclusion from medical team discussion Misunderstanding medical jargon Feeling vulnerable Discomfort of being center of attention Lack of privacy / respect Decreased confidence in trainee as caregiver Patient

13. Roadmap for PE Teaching BeforePreparation Planning Orientation DuringIntroduction Interaction Observation Instruction Summarizing AfterDebriefing Feedback Reflection Preparation Ramani (2003)

14. Inpatient Scenario Senior resident teaching medical student significance of measuring JVP on a patient Take 1 download streaming Discussion Take 2 download streaming Summary

15. Outpatient scenario Intern and senior resident evaluating a murmur in a newborn with parent present Take 1 download streaming Discussion Take 2 download streaming Summary

16. Integrating PE Teaching Tips BeforePreparation Planning Orientation Know what you’ll teach Discuss plan for rounds with learner(s) Create Goals & Objectives DuringIntroduction Interaction Observation Instruction Summarizing Yourself and team to patient Role model interaction For more learner-centered teaching Teach & challenge w/out humiliating Tell learner what they’ve been taught AfterDebriefing Feedback Reflection Preparation Questions, clarification, further study What went well and what didn’t? What would you do different? For next time… Ramani (2003)

17. Integrating PE Teaching Tips BeforePreparation Planning Orientation Know what you’ll teach Discuss plan for rounds with learner(s) Create Goals & Objectives DuringIntroduction Interaction Observation Instruction Summarizing Yourself and team to patient Role model interaction For more learner-centered teaching Teach & challenge w/out humiliating Tell learner what they’ve been taught AfterDebriefing Feedback Reflection Preparation Questions, clarification, further study What went well and what didn’t? What would you do different? For next time… Ramani (2003)

18. Integrating PE Teaching Tips BeforePreparation Planning Orientation Know what you’ll teach Discuss plan for rounds with learner(s) Create Goals & Objectives DuringIntroduction Interaction Observation Instruction Summarizing Yourself and team to patient Role model interaction For more learner-centered teaching Teach & challenge w/out humiliating Tell learner what they’ve been taught AfterDebriefing Feedback Reflection Preparation Questions, clarification, further study What went well and what didn’t? What would you do different? For next time… Ramani (2003)

19. Integrating PE Teaching Tips BeforePreparation Planning Orientation Know what you’ll teach Discuss plan for rounds with learner(s) Create Goals & Objectives DuringIntroduction Interaction Observation Instruction Summarizing Yourself and team to patient Role model interaction For more learner-centered teaching Teach & challenge w/out humiliating Tell learner what they’ve been taught AfterDebriefing Feedback Reflection Preparation Questions, clarification, further study What went well and what didn’t? What would you do different? For next time… Ramani (2003)

20. Integrating PE Teaching Tips BeforePreparation Planning Orientation Know what you’ll teach Discuss plan for rounds with learner(s) Create Goals & Objectives DuringIntroduction Interaction Observation Instruction Summarizing Yourself and team to patient Role model interaction For more learner-centered teaching Teach & challenge w/out humiliating Tell learner what they’ve been taught AfterDebriefing Feedback Reflection Preparation Questions, clarification, further study What went well and what didn’t? What would you do different? For next time… Ramani (2003)

21. Integrating PE Teaching Tips BeforePreparation Planning Orientation Know what you’ll teach Discuss plan for rounds with learner(s) Create Goals & Objectives DuringIntroduction Interaction Observation Instruction Summarizing Yourself and team to patient Role model interaction For more learner-centered teaching Teach & challenge w/out humiliating Tell learner what they’ve been taught AfterDebriefing Feedback Reflection Preparation Questions, clarification, further study What went well and what didn’t? What would you do different? For next time… Ramani (2003)

22. Integrating PE Teaching Tips BeforePreparation Planning Orientation Know what you’ll teach Discuss plan for rounds with learner(s) Create Goals & Objectives DuringIntroduction Interaction Observation Instruction Summarizing Yourself and team to patient Role model interaction For more learner-centered teaching Teach & challenge w/out humiliating Tell learner what they’ve been taught AfterDebriefing Feedback Reflection Preparation Questions, clarification, further study What went well and what didn’t? What would you do different? For next time… Ramani (2003)

23. Integrating PE Teaching Tips BeforePreparation Planning Orientation Know what you’ll teach Discuss plan for rounds with learner(s) Create Goals & Objectives DuringIntroduction Interaction Observation Instruction Summarizing Yourself and team to patient Role model interaction For more learner-centered teaching Teach & challenge w/out humiliating Tell learner what they’ve been taught AfterDebriefing Feedback Reflection Preparation Questions, clarification, further study What went well and what didn’t? What would you do different? For next time… Ramani (2003)

24. Integrating PE Teaching Tips BeforePreparation Planning Orientation Know what you’ll teach Discuss plan for rounds with learner(s) Create Goals & Objectives DuringIntroduction Interaction Observation Instruction Summarizing Yourself and team to patient Role model interaction For more learner-centered teaching Teach & challenge w/out humiliating Tell learner what they’ve been taught AfterDebriefing Feedback Reflection Preparation Questions, clarification, further study What went well and what didn’t? What would you do different? For next time… Ramani (2003)

25. Integrating PE Teaching Tips BeforePreparation Planning Orientation Know what you’ll teach Discuss plan for rounds with learner(s) Create Goals & Objectives DuringIntroduction Interaction Observation Instruction Summarizing Yourself and team to patient Role model interaction For more learner-centered teaching Teach & challenge w/out humiliating Tell learner what they’ve been taught AfterDebriefing Feedback Reflection Preparation Questions, clarification, further study What went well and what didn’t? What would you do different? For next time… Ramani (2003)

26. Integrating PE Teaching Tips BeforePreparation Planning Orientation Know what you’ll teach Discuss plan for rounds with learner(s) Create Goals & Objectives DuringIntroduction Interaction Observation Instruction Summarizing Yourself and team to patient Role model interaction For more learner-centered teaching Teach & challenge w/out humiliating Tell learner what they’ve been taught AfterDebriefing Feedback Reflection Preparation Questions, clarification, further study What went well and what didn’t? What would you do different? For next time… Ramani (2003)

27. Integrating PE Teaching Tips BeforePreparation Planning Orientation Know what you’ll teach Discuss plan for rounds with learner(s) Create Goals & Objectives DuringIntroduction Interaction Observation Instruction Summarizing Yourself and team to patient Role model interaction For more learner-centered teaching Teach & challenge w/out humiliating Tell learner what they’ve been taught AfterDebriefing Feedback Reflection Preparation Questions, clarification, further study What went well and what didn’t? What would you do different? For next time… Ramani (2003)

28. Conclusion PE should be taught in clinical setting evidence physicians lack skills evidence of utility Teacher, learner, and patient challenges Tips prepare, plan, orient introduce, interact, observe, instruct, summarize debrief, feedback, reflect, prepare

29. ACGME (2007). ACGME Program Requirements for Graduate Medical Education in Family Medicine. Retrieved from http://www.acgme.org/acWebsite/downloads/RRC_progReq/120pr07012007.pdf http://www.acgme.org/acWebsite/downloads/RRC_progReq/120pr07012007.pdf Janicik, R. W., & Fletcher, K. E. (2003). Teaching at the bedside: A new model. Medical Teacher, 25 (2), 127-30. Jauhar, Sandeep (2006). The Demise of the Physical Exam. NEJM, 354, 548-551. Kroenke, K., Omori, D.M, Landry, F. J., & Lucey, C. R. (1997). Bedside Teaching. Southern Medical Journal, 90 (11), 1069-74. Ramani, Subha (2003). Twelve Tips to Improve Bedside Teaching. Medical Teacher, 25 (2):112-115. Ramani, Subha (2008). Twelve tips for excellent physical examination teaching. Medical Teacher, 30, 851-856. http://informahealthcare.com/doi/abs/10.1080/01421590802206747 http://informahealthcare.com/doi/abs/10.1080/01421590802206747 Skeff, KM (1988). Enhancing teaching effectiveness and vitality in the ambulatory setting. J Gen Intern Med., 3 (2 Suppl):S26-33. University of Washington. Advanced Physical Diagnosis. Retrieved from http://depts.washington.edu/physdx/ http://depts.washington.edu/physdx/ Williams, K, N., Ramani, S., Fraser, B., & Orlander, J.D. (2008). Improving bedside teaching: Findings from a focus group study of learners. Academic Medicine, 83 (3), 257-64. References

30. Acknowledgment This publication was made possible by Physician Faculty Development in Primary Care Grant Number D55HP08354 from the Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the HRSA.