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Not confident in Physical Exam Skills


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Other than OSCEs, there's no objective evaluation of my physical exam skills - we go see patients every week, but it's just me and the patient so I can't even gauge how my skills are.

It just feels like I'm doing the motions (i.e. placing a stethoscope on the chest, lungs, listening to sounds that all sound the same to me, not being able to tell the difference between dull and resonant on percussion to find organ borders, palpating the spleen but I never know what I'm actually feeling), I can never find the JVP

Any tips? 

 

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Until you see real patients that's how it will feel like. For preclerkship OSCEs just focus on learning what's normal and getting the points so you can pass.

As for the JVP, you can watch a few online videos on how to get it but to be honest I'm pretty sure most people make it up to some extent. If you don't plan on going into IM then it doesn't matter. If you plan on going into IM then you'll have plenty of time to practice. IMO it ranks around the same level as bowel sounds and diaphragmatic excursion percussion in terms of actual clinical utility.

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23 minutes ago, 1D7 said:

Until you see real patients that's how it will feel like. For preclerkship OSCEs just focus on learning what's normal and getting the points so you can pass.

As for the JVP, you can watch a few online videos on how to get it but to be honest I'm pretty sure most people make it up to some extent. If you don't plan on going into IM then it doesn't matter. If you plan on going into IM then you'll have plenty of time to practice. IMO it ranks around the same level as bowel sounds and diaphragmatic excursion percussion in terms of actual clinical utility.

thank you that makes me feel better! interesting about the clinical utility part, i've heard the same! I was shadowing an internist, and all they did was palpation of the abdomen, and auscultation of the lungs and heart during the physical exam.

I guess percussion really gets thrown out the window in clinical practice haha

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Don`t worry. You`ll learn and practice more than enough when you are in clerkship.

Many of the physical examinations they teach are pretty much useless.

examples: thyroid bruits (more of an urban legend than anything else), renal bruits, lung percussion etc... when you have ultrasound, liver size scratch test, spleen castel sign or whatever that is

You`ll realize that often, doing an exam doesn`t change the management anyways. e.g. A patient comes with pneumonia. You don`t hear the lung bases. You suspect a pleural effusion. You can do your different physical exam manoeuvers, but you`ll ask the x-ray anyways or see it with ultrasound if you have one. Therefore, doing low sensitivity and specificity physical exams at a time when we have technology is truly a waste of time.

BTW I don`t ever percuss anything nor check for the JVP. In fact, I was never able to see the JVP on physical exam.

Learn that kind of stuff for exams/OSCEs and old staff who will pimp you on that kind of stuff, but keep in mind that many of the physical exams taught are basically obsolete or useless.

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5 minutes ago, Arztin said:

Don`t worry. You`ll learn and practice more than enough when you are in clerkship.

Many of the physical examinations they teach are pretty much useless.

You`ll realize that often, doing an exam doesn`t change the management anyways. e.g. A patient comes with pneumonia. You don`t hear the lung bases. You suspect a pleural effusion. You can do your different physical exam manoeuvers, but you`ll ask the x-ray anyways or see it with ultrasound if you have one. Therefore, doing low sensitivity and specificity physical exams at a time when we have technology is truly a waste of time.

BTW I don`t ever percuss anything nor check for the JVP. In fact, I was never able to see the JVP on physical exam.

Learn that kind of stuff for exams/OSCEs and old staff who will pimp you on that kind of stuff, but keep in mind that many of the physical exams taught are basically obsolete or useless.

Most of the physical examination is garbage. Still, some manoeuvres are well validated and can help you a lot. The JAMA rational of clinical examination is a great resource to know what to look for and how findings and symptoms can help rule in or rule out things. 

Plus, we get extremely bad physical examination teaching. It is an art that is being lost.

I don`t buy the JVP assessment for volume status in most of the hospitalized patients. I think the money is the US guided IVC assessment.

If you haven't seen any JVP yet, I am sure you will. Acute heart failure is a common presentation to ER and the ones who get NIPPV will have their neck veins are bulging out.

 

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1 hour ago, brady23 said:

Other than OSCEs, there's no objective evaluation of my physical exam skills - we go see patients every week, but it's just me and the patient so I can't even gauge how my skills are.

It just feels like I'm doing the motions (i.e. placing a stethoscope on the chest, lungs, listening to sounds that all sound the same to me, not being able to tell the difference between dull and resonant on percussion to find organ borders, palpating the spleen but I never know what I'm actually feeling), I can never find the JVP

Any tips? 

 

Look up the sensitivity and specificity of physical exams...

Two real reasons we do the physical exam: 1) So the patient feels like you're doing something for them     and... 2) To distance ourselves from the algorithm driven world that can be done by an AI/midlevel

 

Overall though, murmurs/basic resp findings/msk findings are of value. 

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1 hour ago, Arztin said:

Don`t worry. You`ll learn and practice more than enough when you are in clerkship.

Many of the physical examinations they teach are pretty much useless.

 examples: thyroid bruits (more of an urban legend than anything else), renal bruits, lung percussion etc... when you have ultrasound, liver size scratch test, spleen castel sign or whatever that is

 You`ll realize that often, doing an exam doesn`t change the management anyways. e.g. A patient comes with pneumonia. You don`t hear the lung bases. You suspect a pleural effusion. You can do your different physical exam manoeuvers, but you`ll ask the x-ray anyways or see it with ultrasound if you have one. Therefore, doing low sensitivity and specificity physical exams at a time when we have technology is truly a waste of time.

 BTW I don`t ever percuss anything nor check for the JVP. In fact, I was never able to see the JVP on physical exam.

Learn that kind of stuff for exams/OSCEs and old staff who will pimp you on that kind of stuff, but keep in mind that many of the physical exams taught are basically obsolete or useless.

I've definitely heard both sides of the coin - physical exams are really important and the other being that it isn't that useful. I'm leaning towards the side that it isn't useful, but I realize I still need to learn it.

But in clerkship, I've heard they expect you to know how to do a physical exam/history independently on your first day.  And with patients with fluid volume issues, won't they expect you to perform and comment on JVP, etc. 

From what people have told me, JVP is one of the few skills that is incredibly useful and the family doc I shadowed mentioned how useful percussion of the lungs is when you don't have tools in the hospital. 

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44 minutes ago, samy said:

Most of the physical examination is garbage. Still, some manoeuvres are well validated and can help you a lot. The JAMA rational of clinical examination is a great resource to know what to look for and how findings and symptoms can help rule in or rule out things. 

Plus, we get extremely bad physical examination teaching. It is an art that is being lost.

I don`t buy the JVP assessment for volume status in most of the hospitalized patients. I think the money is the US guided IVC assessment.

If you haven't seen any JVP yet, I am sure you will. Acute heart failure is a common presentation to ER and the ones who get NIPPV will have their neck veins are bulging out.

 

Omg I couldn't agree more. The way my school does it, they'll teach a skill relevant to the lungs such as ausculating them, by making us pre-read material, then coming to class and practising on each other and then go out to the wards and interview patients - there's minimal guidance by the clinical skills leader.

But I feel like a better way of doing things would be having a clinical teacher find a patient, demonstrate it on the patient, and have each of us practice on that patient under their guidance. 

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Actually, I do percuss teeth for certain dental conditions, and I do percuss sinuses for acute rhinosinusitis.

And @samy, yeah when it's blatantly obvious, it's easy to see. Otherwise on a regular patient, I was never able to see it, and I don't bother looking for it.

Something that is very important though, is history taking. That is actually very important. 

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When you do your internal medicine rotation they should teach you how to look for the JVP. Also its pretty helpful if its abnormally high (Elevated JVP has a + LR of 5, for CHFe which is pretty decent). For the JVP specifically, no medical student (and some Junior residents) ever actually see it. Even staff have a hard time seeing it at times. Change the position of the bed, press down on the abdomen (HJR), palpate. These things should help... and if not then just move on and say you didn't see it. It'll come with practice.

Do I make any clinical decisions based off of JUST my physical exam findings... no. But do I use them to corroborate my history and in my gestalt... yes absolutely.

Just like investigations/tests. I don't treat numbers or images (even though sometimes I might be very tempted to), I treat patients. That means History + physical + investigations = A/P

There are some specialties/sub specialties that are highly dependent on physical exams, like neurology, rheumatology, Dermatology (skin exam)

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22 hours ago, brady23 said:

I've definitely heard both sides of the coin - physical exams are really important and the other being that it isn't that useful. I'm leaning towards the side that it isn't useful, but I realize I still need to learn it.

Physical exam costs only time and patient comfort. It is usually useful for guiding further investigation and in certain scenarios it can be diagnostic when combined with the history. The basics like inspection, lung auscultation, abdominal palpation, and neuro/MSK screens are extremely useful for any clinical specialty. The 'useless' exams are generally those that have such low sensitivity and specificity that clinical judgement should almost never rely on them.

With regards to the JVP, I think it's near useless not because it has poor sensitivity/specificity (IIRC it actually correlates reasonably well with right atrial pressures when doing by attending IM docs), but because it's difficult to actually perform well and adds little to the overall.

Quote

And with patients with fluid volume issues, won't they expect you to perform and comment on JVP, etc. 

In clerkship you are expected to go into each rotation as if you want to go into that specialty. Thus, you must still learn and attempt it, since IM docs love it.

 

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On 7/25/2018 at 8:54 PM, brady23 said:

Other than OSCEs, there's no objective evaluation of my physical exam skills - we go see patients every week, but it's just me and the patient so I can't even gauge how my skills are.

It just feels like I'm doing the motions (i.e. placing a stethoscope on the chest, lungs, listening to sounds that all sound the same to me, not being able to tell the difference between dull and resonant on percussion to find organ borders, palpating the spleen but I never know what I'm actually feeling), I can never find the JVP

Any tips? 

 

A lot of the OSCE is going through the motions. They want you to know how to do these things so that you don't forget when it comes to real life, because in real emergencies you are likely to blank on things you don't really firmly have in your head. The truth is, most of us don't actually know how to properly palpate a spleen until we've felt a huge spleen in real life. The first time i felt a splenomegaly that stretched all the way past the umbilicus, i realized i'd never miss a spleen that big again.

With that being said, physical exam in modern day Canadian hospitals is honestly almost useless, it is at best used to guide you on what investigations you might order, but you almost never make decisions based on physical exam alone. Percussion if you ask me is almost useless because in real hospital settings you can barely hear percussion over the background noise of the hospital. In real life if you suspected anything u'd probably image them. 

The best advice is to just "go through the motions" accept that when you do your OSCE you don't need and shouldn't really be confident in your skills, you just need to know how to do them for when the time comes. 

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If I might add on, it seems training for a lot of various things, whether it’s St. John’s, or my past career, that the testing is thorough and “going through the motions”. In real life you will gather information in a way that directs how you progress and don’t need to do half the things you memorized how to do. Looks like

medicine is just the same as other things in life.

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Thanks everyone! I know everyone says do imaging in the hospital, but what about for specialties not based in the hospital like Family Medicine?

And on clerkship, when they make you do a physical exam on a patient on your first day - do people just not bother doing JVP and all that stuff and just put a stethoscope on a patient's heart and lungs and touch their abdomen and call it a day? :/

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I remember in med school doing a sports med elective.  Even those docs didn't really base much on the exam, aside from "can the patient point directly to where the problem is."  Stuff like Lachmann's wasn't really used--if they suspected an ACL tear based on the mechanism and the knee was swollen you were gonna get an MR reguardless of maneuvers.  

Similarly Im now in neurology, where physical exam is supposedly really important--but I only make decisions based on really really obvious physical exam stuff if at all, and as you may point out, almost all my patients come to me with brain imaging anyway.

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5 minutes ago, goleafsgochris said:

I remember in med school doing a sports med elective.  Even those docs didn't really base much on the exam, aside from "can the patient point directly to where the problem is."  Stuff like Lachmann's wasn't really used--if they suspected an ACL tear based on the mechanism and the knee was swollen you were gonna get an MR reguardless of maneuvers.  

Similarly Im now in neurology, where physical exam is supposedly really important--but I only make decisions based on really really obvious physical exam stuff if at all, and as you may point out, almost all my patients come to me with brain imaging anyway.

and to add, well, to be clear it isn't just that the signs don't always mean what they classic training tell you, it is that the complete and utter lack of the sign can be present with raging disease. 

As an example since I got at my new job - 100% negative result for all PE studies in people with pleuritic chest pain (ha, small 3 week sample). Multiple examples of major PE with nothing more than mild short of breath. I don't know who gets pleuritic chest pain but it isn't these people so far. 

RUQ pain? Issue is in the RLQ, or LUQ or even once the LLQ - basically even broad point to the general area of pain was wrong a rather large number of the times. Nerves are weird, bellies are weird.....

We don't use it yet but we can even now do functional imaging to on imaging show where the pain is. 

Point is we are advancing in many many areas of medicine but these physical findings are stuck with their limitations and are as good as they ever are going to be. It makes sense that the older ones will in many cases be left behind - doesn't mean they are useless or that people shouldn't try to use them, but only that you would never use them alone anymore for anything important. 

 

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31 minutes ago, sangria said:

Soon to be clerk here. 

I’m not sure how to transfer what we learned for OSCE into real life. Like IRL what is dropped and what isn’t?

I don't think you should honestly worry about that too much right now - first off clerkship you are going to have to develop all of the clinical OSCE skills for your likely final clinical exam and also LMCC part 2 - all osce land stuff, and you cannot take any "real world" cuts with anything - cuts is probably the wrong word, it is more that we have access to the right test normally so you would use that - like an echocardiogram rather than a million murmours. In the real world if the heart sounds funny you can the next test. 

More than that those all these osce style physical exams on all your patients really are teaching you what normal is. You need to hear a huge number of "normal X" to be very good at knowing it isn't normal in subtle cases. 

Residency will prepare you for the real world. Clerkship for the basics. Don't worry you will have time for all things - ha, trust the system

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5 hours ago, sangria said:

Soon to be clerk here. 

I’m not sure how to transfer what we learned for OSCE into real life. Like IRL what is dropped and what isn’t?

Go by the book but keep it relatively concise and to the point. 

 

5 hours ago, rmorelan said:

I don't think you should honestly worry about that too much right now - first off clerkship you are going to have to develop all of the clinical OSCE skills for your likely final clinical exam and also LMCC part 2 - all osce land stuff, and you cannot take any "real world" cuts with anything - cuts is probably the wrong word, it is more that we have access to the right test normally so you would use that - like an echocardiogram rather than a million murmours. In the real world if the heart sounds funny you can the next test. 

More than that those all these osce style physical exams on all your patients really are teaching you what normal is. You need to hear a huge number of "normal X" to be very good at knowing it isn't normal in subtle cases. 

Residency will prepare you for the real world. Clerkship for the basics. Don't worry you will have time for all things - ha, trust the system

The physical exam is super superrr important for one thing: Patient satisfaction. I don't care what anyone says, doing a rapid physical beyond cardioresp ausc. is critical for the patient feeling like you "did enough." We can talk all day about how patients don't know medicine blah blah and so on, but patient satisfaction IS important and 1 star negative reviews on ratemd DO hurt. Not to mention bad reviews tend to accumulate once a nasty few read what others are saying... starts a domino effect essentially. 

 

What I like to do in addition to cardioresp is carotid ausc, abdominal ausc & palpation, occasionally a quick percussion in the abd, and checking for leg edema. Really doesn't take up time and the patient feels far more satisfied at the end when you tell them everything is normal. 

 

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1 hour ago, medigeek said:

The physical exam is super superrr important for one thing: Patient satisfaction. I don't care what anyone says, doing a rapid physical beyond cardioresp ausc. is critical for the patient feeling like you "did enough." We can talk all day about how patients don't know medicine blah blah and so on, but patient satisfaction IS important and 1 star negative reviews on ratemd DO hurt. Not to mention bad reviews tend to accumulate once a nasty few read what others are saying... starts a domino effect essentially. 

What I like to do in addition to cardioresp is carotid ausc, abdominal ausc & palpation, occasionally a quick percussion in the abd, and checking for leg edema. Really doesn't take up time and the patient feels far more satisfied at the end when you tell them everything is normal. 

 

Yeah, especially when your job is mostly "reassurance". 

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