The physical exam is often a patient’s introduction to a physician. It is a valuable tool of clinical measurement and emotional connection between a patient and physician. Still, the way it is taught has lacked focus in physician training.
The AMA and its partner programs in the AMA Reimaging Residency initiative are working to change that. During a recent episode of “AMA Moving Medicine,” AMA Chief Academic Officer Sanjay V. Desai, MD, discussed the importance of the physical exam and how training related to the skill is evolving.
A key interaction
The physical exam is a touchstone for treatment of a patient, Dr. Desai said.
“Medically, this is central to our care,” he said. “It is crucial to develop, to determining the accuracy of a diagnosis that you have. It's crucial for us to reduce diagnostic error. It helps us reduce unnecessary testing that we may reach for because technology is easily available. However, testing is expensive, and we should be judicious and use those technologies only when they're appropriate.”
Beyond the actual clinical benefits, the exam offers a key point of connection between a patient and physician.
“When we're with patients, it's often at moments of vulnerability,” Dr. Desai said. “And the physical connection that you are able to nurture through the practice of a physical exam is invaluable and I think facilitates those connections that are so important to healing.”
Refocusing physical exam training
Numerous factors have caused a shift away from an emphasis on the physical exam in residency training. Dr. Desai listed regulatory shifts, operational changes within training institutions and the burden of documentation on residents among them.
Dr. Desai highlighted work being done at a trio of institutions partnering with the AMA Reimagining Residency initiative as key to remaking the way residents are trained to administer the physical exam.
Stanford’s model, based on doing an exam in five minutes, is one key framework.
“They teach you how to do [a physical] properly, and what information you can yield from that to better care for your patient,” he said. “And there's a series of these now. And so these are meant to be bite-sized moments that can be scaled across any institution really in the world who choose to look at it and teach it. And hopefully, as you do this more and more, those students that then learn it can teach it on to the next generation.”
Dr. Desai also touted the work of Johns Hopkins in studying how residents are using their time on the wards. The findings indicate that too much time is being spent away from patients.
“It's about 13% of the time is spent in direct patient care, which is—we don't know what the right amount of time is, but I think that there is largely consensus and concern that that is an inadequate amount of time,” Dr. Desai said. “And so how do we determine how much time is effective? The first step is to measure it. And so once we're able to measure it, we can both look at the amount of time but also look at the quality of that time, and then, again, correlate it to outcomes, which will be the most important part.”
Understanding is a key step in reshaping training, according to Dr. Desai. “That's really the goal in the end, to learn what interventions, practices, processes will allow us to cultivate the skills that we think are most important to learn in physical examination. And then bring that evidence to demonstrate that, in fact, these skills improve the clinical care a physician can provide, improve the well-being a physician can provide and then ultimately improve patient outcomes,” he said.
“AMA Moving Medicine” highlights innovation and the emerging issues that impact physicians and public health today. You can catch every episode by subscribing to the AMA’s YouTube channel or the audio-only podcast version, which also features educational presentations and in-depth discussions.
