EVIDENCEBASED TEACHING OF THE CLINICAL EXAM

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EVIDENCE-BASED TEACHING OF THE CLINICAL EXAM

• Dr. Rose Hatala

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OBJECTIVES

• Why bedside teaching is important
• Focus on Clinical Exam as Diagnostic Test
• Dx test
• Clinical manifestations of disease
• CPRs
• Resources for clinical exam teaching

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OBJECTIVES

• TODAY NOT FOCUS ON
• Prognosis
• Therapy
• Harm

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Sir William Osler

• There should be no teaching without a patient
  for a text, and the best teaching is that taught
  by the patients (them)selves.

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BEDSIDE TEACHING

• 75 case presentations at bedside in 1960
• 16 in 1997

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BEDSIDE TEACHING

• Lehmann LS, NEJM, 1997
• 182 patients surveyed after 24 hrs after morning
  rounds
• Medical teams cross-over design, present bedside
  or conference room weekly X 3

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BEDSIDE TEACHING

• No difference in patient satisfaction
• 10 min. vs. 6 min spent with patients
• 87 patients not upset with bedside
• 51 helped understand illness
• 46 terminology confusing
• Focus too much on trainees

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BEDSIDE TEACHING

• Rogers HD, Acad Med, 2003
• Cohort study
• 100 patients in outpatient IM clinic
• 10 attendings--60 bedside
• 68 med students

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BEDSIDE TEACHING

• Students comparing bedside v. outside
• Learned more physical diagnosis and bedside
  manner at bedside
• Learned more mechanisms of disease outside
• Preference for presentation based on where most
  commonly present

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BEDSIDE TEACHING

• Ramani S, Acad Med, 2003
• Focus groups with 6 chief residents, 16 faculty
• Regarded bedside teaching as valuable
• Barriers
• Declining bedside skills
• Aura of bedside teaching (master clinician)
• Teaching not valued by academic mission
• Erosion of teaching ethic

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Janicik RW, Med Teach, 2003
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THE SCENARIO
In your ambulatory care clinic, a final year
medical student has finished assessing a 61 y.o.
patient with SOB. Yourself, a PGY-2 resident
and the student are ready to enter the patients
room and hear the case presentation. You know
the patient is suspected of having COPD.
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The One-Minute Preceptor
Neher J, J Am Board Fam Pract, 1992
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TEACHING AGENDA

• Review the key items of history and physical
  examination for COPD with learners
• Correct examination technique
• Understanding of reliability and accuracy of COPD
  exam
• Review diagnosis, prognosis, management with
  patient and learners

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TEACHING POINTS

• Pre-test probability of COPD
• Correct physical exam technique for elements of
  COPD exam
• Inter-rater and intra-rater reliability
• Accuracy of clinical exam for COPD
• Post-clinical exam probability of COPD

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CLINICAL EXAM DX TEST
Pre-test probability (pre-clinical assessment)
Disease incidence and prevalence
History and physical examination
Post-test probability of disease (post-clinical
assessment)
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CLINICAL EXAM DX TEST

• PROPERTIES
• reliability / precision
• accuracy

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TEACHING POINTS

• Pre-test probability of COPD

• Correct physical exam technique for elements
• of COPD exam
• Inter-rater and intra-rater reliability

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COPD CLINICAL EXAM

• Laryngeal height
• Pt. sitting up, look straight ahead, hands in lap
• Palpate top of thyroid cartilage (notch), hook
  index finger over top
• Using rest of fingers, measure distance to
  sternal notch

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RELIABILITY

• agreement between examiners
• within same examiner intra-observer
• between different examiners inter-observer
• percent agreement

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RELIABILITY

• Kappa agreement beyond that expected
  by chance
• 0.00 - 0.20 slight
• 0.21 - 0.41 fair
• 0.41 - 0.60 moderate
• 0.61 - 0.80 substantial
• 0.81 - 1.00 almost perfect

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RELIABILITY

• Tracheal descent with inspiration
• Pc 31
• Po 74
• Kappa 0.62
• Stubbing D, Am Rev Resp Dis, 1982

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RELIABILITY
Holleman DR, JAMA, 1995
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TEACHING POINTS

• Pre-test probability of COPD
• Correct physical exam technique for elements
• of COPD exam
• Inter-rater and intra-rater reliability

• Accuracy of clinical exam for COPD
• Post-clinical exam probability of COPD

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LIKELIHOOD RATIO

• Conceptual definition
• A measure of how much more likely the patient
  is to have the disease because of the test result
• LR positive test result
• - LR negative test result

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ADVANTAGES OF LR

• information from perspective of clinician
• incorporates patient-specific information
• decision threshold (test or treatment)
• calculate for each level of test result
• ie. FET gt 9 s LR 4.8
• 6- 9 s LR 2.7
• lt 6 s LR 0.45

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COPD EXAM CARE STUDY

• PATIENTS
• 309 known to have COPD suspected of COPD
  neither
• INTERVENTION
• Standardized clinical exam by clinician
• Self-report of COPD, smoking history, laryngeal
  height, auscultation for wheeze
• COMPARISON
• Spirometry within 30 min., standard protocol
• OUTCOME
• Accuracy of items for diagnosis of COPD

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SENSITIVITY/SPECIFICITY

• Sensitivity
• Positive in disease
• Proportion of patients with disease who have a
  positive test result
• Specificity
• Negative in health
• Proportion of patients without disease who have a
  negative test result

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SENSITIVITY/SPECIFICITY

• LIMITATIONS
• From perspective of diagnostic test
• Difficult to calculate for levels of test
• (tend towards / - test result)

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SENSITIVITY/SPECIFICITY

• Use to calculate LRs
• LR sensitivity
• 1 - specificity
• LR - 1 - sensitivity
• specificity

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CLINICAL MANIFESTATIONS OF DISEASE
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CLINICAL MANIFESTATIONS OF DISEASE

• Stubbing D, Am Rev Resp Dis, 1982
• Regional chest and allergy clinic
• 28 pts, COPD (FEV1/FVC lt 70)
• 2 independent examiners, 4 levels of each sign

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INTEGRATING MULTIPLE FINDINGS

• Serial LRs assumes independence of items of
  clinical examination
• Least accurate strategy

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INTEGRATING MULTIPLE FINDINGS

• Holleman DR, JGIM, 1997
• Compare ROC for 4 strategies COPD

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CLINICAL PREDICTION RULES

• quantifies the individual contributions that
  various components of the history, physical
  examination and basic lab results make towards
  the diagnosis..in an individual patient

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CPRs
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Chunilal SD, JAMA, 2003
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CLINICAL GESTALT
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RESOURCES

• JAMA Rational Clinical Exam series
• (physical examination OR medical history taking
  JAMA)
• clinical examination.tw JAMA
• JAMA advanced search

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RESOURCES

• diagnosis in pre-appraised resources
• ACPJC
• Primary Literature
• physical examination AND/OR
• medical history taking
• sensitivity and specificity

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RESOURCES

• Texts
• McGee Evidence-based physical diagnosis
• ACP Annotated bibliography of literature on
  physical examination and interviewing
• Sapira Art and Science of bedside diagnosis
• Panzer Diagnostic strategies for common medical
  problems

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RESOURCES

• Internet
• www.carestudy.com
• Clinical Assessment of the Reliability of
  Examination
• www.sgim.org/clinexam.cfm
• Clinical Examination Research Interest Group

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AGAINST NIHILISM

• Reilly BM, Lancet, 2003
• Retrospective case series of 100 patients admit
  to medical ward
• Examined by attending within 7 hrs of admit
• 26 had pivotal findings that changed clinical
  care
• 7 findings not discoverable by other means

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