Pearls from Stanford 25 – Physical Exam Education

Technique matters – if you don’t have the right technique, you won’t get the results you want.
Abraham Verghese says “I don’t know” at the bedside!
Respect for the learner:  avoid “pimping,” saying “you should know this,” “here’s an easy one,” etc.
– Residents are trying to build up a rapport with their patients, and we should avoid undermining that rapport.
– Start instead with “let me show you a new technique,” or “you may not have seen this yet…”
Respect for the patient:  Be empathetic and aware of the patient’s feelings, but also understand that physical exam will inconvenience the patient in a minor way.  Two rules:  1.  The patient has to be willing – has to know it is purely educational rounds and not for medical care.  2.  Patient should be able to understand what is being said.
  1.  What is your chief complaint / what brought you to the hospital?
  2.  What physical signs should we look for to diagnose that complaint?
Recipe for successful teaching rounds at the bedside:
  1.  Set the agenda:  pre-brief with learners and, when possible, with the patient.
  2.  Learning climate:  make sure everyone knows their role and the reason for the visit.  Introduce and re-introduce.
    1. Ask the patient what has been done well and poorly in their care before, how they like to be treated…
  3.  Role model:  pay attention to body language and position, show patients the respect they deserve.
    1. Basic stuff:  ask how the patient would like to be addressed, get at eye level, ask permission prior to exam
  4.  Ask permission and explain to the patient what everyone is doing when examining the patient.
  5.  Make sure learners practice.
    1. Have an understanding of how learners often mess it up.
JVP:
– carotid comes out at you, whereas IJV is more of a depression
– IJV moves with inspiration and frequently disappears
We are not only teaching observation and technique with physical exam, but also JUDGMENT – different physicians interpret things differently, whether it’s a JVP or a CXR or a CT scan.
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