1. 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

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

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

4. 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”

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

6. 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?”

7. 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"

8. Online Collections

9. A valuable resource but not very accessible
Long and Dense

10. 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

11. 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

12. 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

13. 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): , 1992 May 20
The science of the art of the clinical examination J Amer Med Assoc.  267(19):2650-2, 1992 May 20.  
      

14. 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) :
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 :
Evaluating Review Articles
Users' guides to the medical literature. VI. How to use an overview. JAMA Nov 2;272(17):
Guidelines for Meta-analyses Evaluating Diagnostic Tests. Ann Intern Med 1994;120: (Primarily review Table 1)

15. 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

16. 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

17. 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

18. Precision
Kappa – correlation coefficient of agreement between clinicians
0 chance agreement
Slight
Fair
Moderate
Substantial
Nearly Perfect

19. 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

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

22. 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

23. 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

24. 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)

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

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

27. 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)

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

29. 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

30. 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

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

32. Thank You
Suggestions?
Questions?