Introduction

This blog is about medical education in the US and around the world. My interest is in education research and the process of medical education.



The lawyers have asked that I add a disclaimer that makes it clear that these are my personal opinions and do not represent any position of any University that I am affiliated with including the University of Kansas, the KU School of Medicine, Florida International University, or the FIU School of Medicine.



Friday, December 27, 2013

Feedback or Compliments? Which is better?

I was getting ready to do journal club a couple of weeks ago and I came across an interesting study from a couple of years ago. Boehler and colleagues at the Southern Illinois University School of Medicine, decided to do a study of feedback (1), which happens to be one of my favorite topics.

Feedback is an old term that actually comes from rocketry and missiles. Radio signals came from the rocket back to the control tower on Earth. The direction of the rocket is then controlled by sending signals back to the rocket. Those signals are the feedback.

But it is hard! Faculty do not give students feedback often enough. At the University of Michigan, medical students were asked about the third year Surgery clerkship.(2) When asked (did you always get feedback?), students were more likely to Disagree or Strongly Disagree (p<0.001). Medical students thought that feedback was poor when compared with the opinions of faculty and residents (p<0.002). And 50% of the medical students believed that they were an inconvenience to the clinical service that they were a part of.

And faculty do not give good enough feedback. At the University of Missouri-Columbia, I did a study of PGY-1 residents who had been evaluated by faculty and senior residents.(3) We looked at the end of block written feedback comments. What we found was that 82% of all the comments were positive. 38% of all comments fell into two categories. The first category was generic comments such as “did a great job” or “is a pleasure to work with.” The second category was personal attributes, such as “has a great sense of humor.” The level or gender of the evaluator did not affect the comments (p = 0.17)

Feedback is really important in clinical skills acquisition. It helps students to learn about their own strengths and deficiencies. It offers insight into what he or she actually did and the consequences of actions. There is a dissonance between the intended result and the actual result, which hopefully becomes an impetus for change in the learner.

So Boehler’s project had two hypotheses: 1) medical students receiving compliments would be more satisfied than those receiving feedback, and 2) medical students receiving feedback would demonstrate improved performance, whereas those receiving compliments would not. They took a group of second and third year medical students at the medical school and studied their ability to learn to tie a knot. More specifically, a two-handed square surgical knot. This is a basic skill that all medical students need to learn.

The authors video-taped all of the students tying a knot. Then they gave all the students knot-tying instruction by an expert academic surgeon who was well-respected, supportive, credible, and trustworthy. They video-taped the students tying a knot again. Then the students were randomly assigned to two groups. One group received specific feedback about their knot tying skills (ie: this hand needs to be in this position), the other group received generic compliments about their technique (ie: you are doing a great job). After this, the students were video-taped a third time as they were tying a knot.

Each of the knot-tying videos were evaluated by three experienced surgeons who were blinded to the students. They used a validated knot-tying scale to score the skill of the students. They also asked the students how satisfied they were with the instruction given by the surgeon (feedback versus compliments).

What do you think they found?

As you might have guessed, the students liked the compliments better. They were more satisfied (p=0.005). But more importantly, the group that received specific feedback did a better job with their knot tying than the group that just got compliments (21.9 vs 17.0, p=0.008).

It is interesting (to me at least) that both groups got better with practice. This is known as the time on task effect. The longer you work at something the better you get. The group that got feedback just got better at a faster rate, than the group that only got compliments.

There is often a tension between what a learner perceives as their deficit and what an objective observer sees as the deficit. As a teacher, when we do a good job of pointing out the deficits, it can help the learner to improve at a faster rate. But importantly, the learner may not be as satisfied with this method. It is a strong statement for limiting the use of student satisfaction data in evaluating teacher performance. Students can be less satisfied but have improvement in their performance on a task.

References

Wednesday, December 11, 2013

General Surgery and Family Medicine are in the same boat

In its 21st Report, Improving Value in GraduateMedical Education (1), the Council on Graduate Medical Education made an important recommendation. COGME looked at all of the data regarding the physician workforce and predictions of student specialty choice. Their Recommendation 2 states that “GME funding should be prioritized to accelerate physician workforce alignment with population and health delivery needs.” And even more specifically, that “increases in GME funding should be directed toward the following high priority specialties: Family medicine, Geriatrics, General internal medicine, General surgery, High priority pediatric subspecialties, Psychiatry. I have written a lot about family medicine and primary care, but why is general surgery on this list?

General surgery has been facing many of the same pressures that have afflicted family medicine over the past twenty years.(2) Between 1987 and 2002, the percentage of US allopathic seniors choosing general surgery declined from 7.8% to 5.8%. This occurred while the percentage of students choosing surgical fields remained fairly constant around 12%. This coupled with a 20% attrition from surgical residency programs is leading to a shortage of general surgeons.(3) And compounding the problem is that up to 80% of general surgery residents plan on completing a specialty fellowship after residency.(4) 

Why is this happening? When I was in medical school, the General Surgeons were to gods of the wards. They were terrible to behold—striking fear in medical students, residents, nurses, and staff alike. Their position was lofty. When we needed something important done, we could always count on the surgeons.  So, what happened?

In some ways, it is similar to what has happened to primary care. You could call them the primary care surgeons. (I would not want to offend them with this, but I mean it as a compliment). Those surgeons were true generalists. A good general surgeon could operate in the abdomen, the thorax, the breast, the extremities, even in the gynecologic organs. But then general surgery was picked apart. Graduating residents wanted to confine their practice to a particular area. Maybe they did not like doing breast biopsies and mastectomies, so they limited themselves to the abdomen. Maybe, their friend was the gynecologist in town and did not like them doing hysterectomies because it took away some of their business. Maybe, they did not do enough vascular surgeries to remain competent. Over time, all of these factors, and others (reimbursement, hospital privileging, and local politics) led to general surgeons who were more limited in their scope of practice.

The interesting thing about academic medicine is that residents tend to practice like their teachers. So, when academic general surgery started to fragment, residents and students started to see that as the norm. If you look at a Department of Surgery in a major academic medical center, there are surgeons who operate only on the colon, who only do transplants, who only operate on the liver, and who only do trauma. If you step back a bit, there are now Departments of Urology, Orthopedics, Neurosurgery, etc.  In the past, those were all part of the Department of Surgery. Dean’s offices at medical schools around the nation are happy with things this way. Each time they created a new department, the dean had another department and chair to tax for more money for the Dean’s office. Recruitment is easier too. It is getting pretty hard to find the surgeons that want to do everything.

I used to joke that someday we would have Left Pinky Finger Doctors, but now I am worried that may really happen. It has already happened in other specialties. More than 80% of graduates of Internal Medicine residencies choose to complete further specialty fellowship training, in endocrinology, nephrology, infectious diseases, and others. Most of those doctors only practice in their sub-specialty area without any general medicine. Pediatrics, has seen this also in a smaller way (only 40-50% of graduates sub-specialize). And now, General Surgery is going the same way.

I think it is a great loss to our profession! When all of those “old” guys have died out, we will have lost something important.

References
(1)  The Council on Graduate Medical Education. 2008. 21st Report, Improving Value in Graduate Medical Education. http://www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/Reports/twentyfirstreport.pdf
(2)  http://usatoday30.usatoday.com/news/health/2008-02-26-doctor-shortage_N.htm
(3)  Newton D, Grayson M. Trends in Career Choice by US Medical School Graduates. JAMA. 2003; 290(9): 1179-1182.
(4)  Fischer J. How to rescue general surgery. Am J Surgery. 2012; 204(4): 541–542.]            

Monday, November 18, 2013

Why do students not choose primary care?

This is a re-post of a great article written last month by Dr. Joshua Freeman and posted on his blog Medicine and Social Justice.  It is re-posted with his permission here on Education in Medicine. 

Enjoy!

Joshua Freeman, MD

We need more primary care physicians. I have written about this often, and cited extensive references that support this contention, most recently in The role of Primary Care in improving health: In the US and aroundthe world, October 13, 2013. Yet, although most studies from the US and around the world suggest that the optimum percent of primary care doctors should be 40-60%, the ratio in the US is under 30% and falling. A clear reason for this is that relative lack of interest of US medical students in entering primary care at the rates needed to maintain, not to mention increase, our current primary care ratio. In addition, the ratio of primary care to other specialty residency positions is too low. Here we confront the fact that the large majority of medical students completing Internal Medicine residencies enter subspecialty fellowships rather than practicing General Internal Medicine. At the Graduate Medical Education level, a simple way of estimating the future production of primary care doctors would be to add the number of residency positions in Internal Medicine (IM), Pediatrics (PD), Family Medicine (FM), and combined Internal Medicine-Pediatrics (IMPD) and subtract the number of fellowship positions they might enter. This still overestimates the number of general internists, however, since it does not account for doctors who practice as “hospitalists” after completing their residency because such a role does not currently require a fellowship (as does, say cardiology). Estimates are now that 50% or more of IM graduates who do not pursue fellowship training become hospitalists.

Thus, we welcome the research report from the Association of American Medical Colleges (AAMC) “The role of in medical school culture inprimary care career choice” (1), by Erikson et al. that appears in the December 2013 issue of AAMC’s journal Academic Medicine. The authors surveyed all 4th-year medical students from a random sample of 20 medical schools to assess both student and school level characteristics that were associated with greater likelihood of entering primary care. The first, and arguably most important finding, was that only 13% of these final-year medical students were planning on primary care careers. This is despite the fact that 40% were planning to enter the “primary care” residencies of IM, PD, FM, and IMPD, with most of the fall-off in internal medicine and least in family medicine. This finding strongly supports my assertions above, and makes clear that the historically AAMC-encouraged practice of medical schools reporting “primary care” rates by entry into residencies in those fields is not valid. It also, even more important, shows the extent of our problem – a 13% production rate will not get us from 30% to 40% or 50% primary care no matter how long we wait; obviously it will take us in the other direction.

The primary outcome variable of the study was entry into primary care, and it specifically looked at two school level (but perceived by students, as reported in the survey) characteristics: badmouthing primary care (faculty, residents or other students saying it is a fall back or something that is a “waste of a mind”) and having greater than the average number of positive primary care experiences. It turns out that both were associated with primary care choice (in the case of badmouthing, students from schools with higher than average reported rates were less likely to be planning primary care careers, while students who were planning such careers reported higher rates of badmouthing), but, after controlling for individual student and school characteristics, accounted for only 8% of the difference in primary care choice. Characteristics of the student (demographics such as sex, minority status or rural origin, academic performance defined as the score on Step 1 of USMLE, as well as expectation of income and feeling of a personal “fit” with primary care) and of the school (research emphasis, private vs. public,  selectivity) accounted for the rest. Interestingly, debt was not a significant factor in this study.

I would argue that many of these individual and school characteristics are highly correlated. A school that prides itself on being selective (taking students with high scores) and producing subspecialists and research scientists does not have to badmouth primary care; the institutional culture intrinsically marginalizes it. On the other side, the students selected at those schools are more likely to have those characteristics (particularly high socioeconomic status and urban or suburban origin) not associated with primary care choice. It is worth noting that the measure of academic performance in this study was USMLE Step 1, usually taken after the first 2 years and focusing more on the basic science material covered in those years, rather than USMLE Step 2, which covers more clinical material (perhaps because not all 4th-year students studied have taken Step 2 yet). This biases the assessment of academic qualification; many studies have demonstrated high levels of association of pre-medical grades and scores on the Medical College Admissions Test (MCAT) with pre-clinical medical school course grades and USMLE Step 1 scores, but not with performance in any clinical activity, not to mention primary care. Perhaps most students improve their scores from Step 1 to Step 2, but it is particularly true for FM and primary care. A quick look at our KU students applying to our family medicine program shows an average increase of nearly 30 points in these scores.

So the problem is in the overall culture of medical schools, in their self-perception of their role (creating research scientists vs. clinicians, creating subspecialists vs. primary care doctors) and in their belief that taking students with the highest grades is equivalent to taking the best students. This culture, simply put, is bad, defined as “it has undesirable outcomes for the production of the doctors America needs”, and must change. Erikson and colleagues acknowledge that schools could do a better job of taking rural students, offer more opportunities to engage in public health and community outreach activities, and have more experiences in primary care, all of which were somewhat associated with primary care career choice. These are tepid, but coming from the AAMC, a reasonably significant set of recommendations. I say we need an immediate change in every single medical school to recruit at least half of every class with students whose demographic and personal characteristics are strongly associated with primary care choice, present a curriculum that has much less emphasis on “basic science” and more on clinical, especially public health, community health, and primary care. One of the primary bases for assessing the quality of a medical school should be its rate of primary care production, and this is going to require a major qualitative shift in their practices and the beliefs of many of their faculty and leaders.

I am NOT saying is that we don’t need subspecialists or research scientists. We do. I AM saying that the emphasis on production of these doctors compared to primary care doctors is out of whack, not just a little but tremendously so, and can only be addressed by a major sea change in attitudes and practices in all of our medical schools. I do not expect that all schools should produce the same percent of primary care physicians. Some might be at 70%, while others are “only” at 30%, but ALL need a huge increase, by whatever means it takes. Even if we produce 50% primary care physicians on average from all schools it will be a generation before we get to their being 50% of the workforce. At less than that it will take longer, and at less than 30% we will not even maintain where we are.

13% is not just “insufficient”, it is a scandalous abrogation of the responsibility of medical schools to provide for the health care of the American people. They should be ashamed, should be shamed, and must change.


References
(1) Erikson CE, Danish S, Jones KC, Sandberg SF, Carle AC, “The role of in medical school culture in primary care career choice”, Acad Med December2013;88(12) published online before print.

Tuesday, November 5, 2013

The ROAD less traveled or why don’t med students choose primary care?

A recent article in AcademicMedicine by Kimberly Clinite and colleagues (1) is an important addition to the growing body of literature around specialty choice. For those of you who are not familiar with the subject, let me give you a bit of background.

Many countries in the world have better health outcomes than we do here in the United States. There are many reasons for these differences, but one that is often pointed to, is the lack of a strong primary care infrastructure as compared to other developed nations. For instance, our neighbors to the North, the Canadians, have a national health system that is built around having about 40 percent of the physician workforce in primary care and 60 percent in specialty care. (2) The Canadians rank higher than the US in almost every health outcome category, except cost. They spend less per capita than we do, and we get worse health outcomes as our reward!

The problem is that students in the US are choosing primary care specialties less often than they are choosing other specialties. (3) The ROAD in the title refers to a (not-so-funny) joke amongst medical students. The joke goes: if you do well enough in medical school, you can hit the ROAD (Radiology, Ophthalmology, Anesthesiology, Dermatology) when you graduate. Why those four specialties?  Primarily, because they are high-paying specialties that have the “best” lifestyles.

In the most recent residency selection match (4), US seniors (4th year medical students applying for residency) applying to Internal Medicine, Pediatrics, and Family Medicine filled 6,327 of 26,392 total spots that were offered (23.97%). Now 23.97% is lower than we need (at 40%) but the true picture is even bleaker. Of the 3,135 students that matched into Internal Medicine, about 80 percent will go on to do specialty training (for example Cardiology or Rheumatology) and another 10 percent will practice as hospitalists. This leaves about 314 students in primary care practice. For Pediatrics it is a bit better, only about 45 percent go on to specialty training, leaving about 1,010 in primary care. And for Family Medicine, about 90 percent end up in primary care practice (1,220).

This means that the actual number of US Seniors in the 2013 Match that will end up practicing primary care is 2,544 or 9.6 percent of the total. On the flip side, 2,710 students matched into positions on the ROAD, which accounts for 10.3% of US Seniors. That number should scare all of us in medical education! If the American public knew the implications of that number to the health of our nation, they would be scared as well. Twice as many students will become Radiologists as will become General Internists.

Don’t get me wrong, we need some Radiologists. I have no problems with that. But this “market-driven” system has been skewed to the point that the product of our medical schools is no longer meeting the needs of our country.

So, the survey by Clinite, et al (1) looked at first-year medical students’ views on the importance of lifestyle and specialty characteristics. They surveyed 11 allopathic (MD) schools across the country. The schools including public and private schools and even included the military’s school (the Uniformed Services University). 60 percent of the students that were surveyed responded.

The students rated, “enjoying the type of work that I am doing” highest in importance for lifestyle characteristics. For specialty characteristics, they rated “being satisfied with the job” highest. Students were also asked to declare their interest in practicing in a primary care field after graduation. The groups were split fairly evenly between four groups (primary care first, primary care second, primary care least, and no opinion). And here is where it starts to get interesting…

Financial compensation of the specialty overall was not ranked as that important. But in students who ranked primary care first and those that ranked it as least, the ranking was significantly different (2.8 to 3.7; p ≤ 0.01). Looking at specialty characteristics, “average salary earned by attending physicians in the specialty” ranked 2.7 (SD 0.9) for the primary care first group but was up to 3.6 (SD 0.8) in the primary care least group. The effect size for this difference was large (0.94).

All of this suggests that the number of students who choose primary care specialties will continue to shrink unless something is done. Some students are making a financial, lifestyle, and long-term investment decision to choose specialties with higher pay and “better” lifestyles. The only way to change this is to change the lifestyle, change the pay or bring in a different group of students. I can’t really control the high pay differential with specialists or make a difference in the lifestyle of primary care doctors. But we can definitely bring in students who value different characteristics of the physician lifestyle.

References

(1)   Clinite KL, et al. Primary Care, the ROAD Less Traveled: What First-Year Medical Students Want in a Specialty. Academic Medicine  2013;88(10):1522-1528.
(2)   Association of Faculties of Medicine of Canada. The Future of Medical Education in Canada: a collective vision for MD Education. 2010
(3)   Chen C, et al. Toward Graduate Medical Education (GME) Accountability: Measuring the Outcomes of GME Institutions. Acad Med  2013; 88(9):1267–1280.

(4)   Results and Data 2013 Main Residency Match. National Residency Matching Program.  http://b83c73bcf0e7ca356c80-e8560f466940e4ec38ed51af32994bc6.r6.cf1.rackcdn.com/wp-content/uploads/2013/08/resultsanddata2013.pdf

Sunday, September 29, 2013

Diversity in Medical Education, Part II

Do we need diversity in our medical schools? Let me say again. The answer is emphatically and non-equivocally YES!

In my last blog, (I know it was several months ago. We moved, so I got busy with all that involves) I talked about why a diverse medical student body is important and how the admissions process works against diversity.

The MCAT can be biased against some student groups in several subtle ways. Let’s start with the cost? It is a major investment to take the MCAT ($270 for most students, but to be fair a fee waiver program can lower the cost to $100). Many students take an MCAT prep course, such as the type that Kaplan or Princeton Review offers. Those course are really pricey ($1,699 for Kaplan). How about taking the MCAT more than once? Who can afford that? It is not that uncommon for me to see a med school applicant who got a 30 on their first take who has retaken the MCAT in order to raise their score.

Students from some racial and ethnic groups score lower on the MCAT. Mean total MCAT scores for black students are lower than for white students (20.0 vs. 26.3). The same difference is seen in Hispanic students (21.6 vs. 26.3) There are many reasons for these differences. The authors of this study (1) were quick to point out that just having a difference in means does not equate to test bias. The differences may be related to differences in the students themselves. The problem with this view is that students do not all have the same background, experiences, and opportunities. So, even if the individual items on the test are not biased, there may still be inherit bias in the system that keeps black or Hispanic students from performing at the same level. And if a test is used to decide on admission of students to medical school (or graduate school or business school or law school) students with differing performance will be admitted at different rates.

How about rural students? Performance on the MCAT is somewhat related to amount of higher level science courses that are taken prior to the test. Students from rural counties are more likely to attend community colleges and regional state colleges and universities. These students may not have the same access to upper level Biology and Chemistry classes. (This may also put them at risk in the beginning of the medical curriculum.) I remember having a discussion about requiring undergraduate Biochemistry several years ago. There were several small colleges that did not offer Biochemistry. I asked a simple question—is there any difference in medical school performance for students who have had Biochemistry versus those who had not had it? The interesting response at the time from several of the basic science faculty was-yes, students who take Biochemistry do better.  But it was interesting because they had no real data to back up the statement.  When we actually studied it, we found that there was some very slight improvement their grades in the first module, but it did not affect GPA or USMLE Step 1 scores. (2)

What about students from lower family income brackets? Many schools put emphasis on having a service attitude. One of the ways that we measure this attitude is looking at the amount of service (specifically nonpaid) that a students has done. Not a specific hourly amount but the engagement and commitment to service. Many of our students from poorer families may have difficulty doing this. They are often working two jobs just to survive and they really do not have time to volunteer somewhere. There are reasons that most medical students come from the top quintile of family income. Lower income students do not have the same access to opportunity the richer students have when they apply to medical school.

So, what can we do?  Schools should adopt admissions processes that minimize the inherent advantages that white, urban, wealthy students have.

Blind the admissions committee to MCAT scores.  Set you bar and then only tell the Admissions committee if the student is over that bar.

Give credit to students from lower socioeconomic groups for paid work, particularly when it is done in medical fields. Working as a nurse’s aide in a nursing home is far more useful to an applicant that shadowing a radiologist or orthopedic surgeon.

Give the Admissions committee the explicit charge to seek out the unique characteristics that will bring diversity to the class. The Dean has to tell them, “I don’t care how high their MCAT score is, I want them to make a lasting difference in the world.”

The Admissions process should seek out a diverse student body. Don’t use a set minimum MCAT or GPA that might eliminate amazing students before you even get to interview them.  The school’s average MCAT may be 32, but students with a much lower MCAT will still pass Step 1 and may be the students that will make the difference.

Develop pipeline programs. These must start in junior high and high school. They have to be available to students from a variety of backgrounds. The timeline is very long-12 to 14 years sometimes from when they enter the pipeline until you actually turn out a doctor. That requires a true long-term view.

Lastly, get the right people on the Admissions Committee. You have to stack the committee with passionate voices that will speak out for diversity and a diverse medical student class.

References

1. Davis D, Dorsey K, Franks RD, et al. Do Racial and Ethnic Group Differences in Performance on the MCAT Exam Reflect Test Bias? AcademicMedicine 2013;88(5): 593-602


2. Delzell J, Chumley H. Does Prematriculant Biochemistry Exposure Predict Preclinical or Clinical Performance? Family Medicine 2013; 45(Supp 3)

Friday, July 26, 2013

Diversity in Medical Education, Part I

Do we need diversity in our medical schools? Let me say right at the beginning. The answer is emphatically and non-equivocally YES!

One of the important values inherent in this discussion is that the medical school class and then subsequently the graduating physicians should look like the general population of the United States. Right now it does not. Medical students are richer (or at least their families are), more suburban, and they are much more white than the overall population.

Why is this important?  Well for one reason, students may not have had exposures to people that are different than they are when they were growing up. A survey in Academic Medicine  from two medical schools (Harvard and UCSF) found that only 27% of medical students reported having frequent contact with people of different races or ethnicities when they were “growing up”(1). The number increased to 41% by the time they got to college, but the message is clear. Students rarely had contact during their formative years with people that looked or sounded or saw the world differently than they did.

A diverse medical school class will be a better class of students. I would like to define diverse very broadly. It is not just about having more than just white students. Yes, it is important to have black students, and hispanic students, and asian students, and native american students. But other aspects of diversity are important. We need students from rural counties, who grew up on a farm. We need students from low income brackets. We need students from other countries, who see the world differently than I do. We need gay and lesbian students, and older students, and women..... And so on. You get the idea?

But, it does not happen by chance. Every school has to work constantly to make their class diverse.

I have heard many discussions about this during the admissions process. It is not overt racism or classism or urbanism. No, it is more subtle. There are suggestions that it is unfair to put students into a situation where they might fail. There is a suggestion that the students are less prepared or less able to handle the academic rigor of medical school. There is a reminder of other students that have struggled. All of this is said by well-meaning faculty, but the reality is that the variables that they are talking about do not have much to do with how good a doctor a student is going to be. Does the MCAT predict that? Absolutely not! Does USMLE Step I predict that? Again, no. How about performance in their college courses? Still, no.

I heard Darrell Kirsch, MD, the president of the AAMC talking about the new MCAT a while back. The most important statement that he made (from my perspective) was that schools that continue to emphasize the MCAT and GPA will by that very act be anti-diverse. That is a pretty bold statement, but completely defensible. If the admissions committee only looks at numbers (GPA, MCAT) the admissions process is going to be biased against non-white, non-urban, non-wealthy students. I would put forth that for most schools much of the admissions process is biased against minority, rural, and lower income students. 

I will talk about each of these in my next blog and put forth some ideas to make the admissions process better.

References

Monday, June 17, 2013

The value of teaching the History and Physical Examination

Students learn many things during their time in medical school. Some things that they learn are soon forgotten (think: the Kreb's cycle). But other things stay with them forever. I can still remember learning how to ask about thyroid symptoms from one of my family medicine mentors. I still use the same words when I ask patients about thyroid symptoms.

Many schools start to teach about taking a history from a patient at the very beginning of medical school. These courses are often called an Introduction to Clinical Medicine.  There are many techniques used to teach students to do an appropriate history and physical examination, but students really start to hone this skill when they complete their clinical clerkships in the third year. The more experience that a student gets in taking a history, the better they get at this skill.

So, an article (1) in JAMA Internal Medicine (the Journal of the American Medical Association's specialty journal for Internal Medicine) caught my eye. In this study, the authors prospectively evaluated patients that were admitted from the emergency room to an academic hospitalist service of Internists. Each patient was interviewed and examined by an experienced senior resident. The patients received a full history and physical examination, and the resident reviewed laboratory tests and xrays done in the emergency room. The resident was then forced to put her nickel down. She recorded her most likely diagnosis and identified the things that were the most helpful in making the diagnosis.

The patients’ were also evaluated by a “senior” clinician, someone with at least twenty years of experience. The senior clinician was a hospitalist who had no knowledge of the senior resident’s diagnosis. The senior resident spent more time (ave 40 minutes per patient) than the senior hospitalist (ave 25 minutes). In this study, 80 percent of the patients admitted were given the correct diagnosis at admission. I think that is really high! 90 percent of the correctly diagnosed patients only received a history, physical examination, and some basic tests.  A few CT scans of the head in the ED, but most did not get anything more than a chest xray or an electrocardiogram.

The senior resident and the senior clinician missed the diagnosis completely on ten percent of the patients but that is consistent with or even lower than other studies of diagnosis. The author wrote, “Our results do not mean that sophisticated studies need not be used after admission, but they do suggest that their choice should be guided by the clinical data on presentation.” That should be a duh, but it is worth repeating. Many studies are ordered by reflex. They are coming into the orthopedic clinic they need an xray of the joint or they are coming in to the cardiologist so they need an electrocardiogram.  It is worse in the hospital. This study supports that a good physical examination and a thorough history are still very sensitive tests. Maybe more sensitive than the CT scan that I am about to order.

Two other quotes that I thought were memorable. From the Editor (of JAMA Internal Medicine) “The (study) by Paley et al reminds us of the value of lower-tech ways of making a diagnosis of patients seen in the emergency department (ED), as technology increases in availability and complexity and because ED health professionals now routinely order imaging tests, not uncommonly without even examining patients.”  The other was from an invited commentary, who said (possibly without actually knowing what he was talking about) that auscultation of the heart was less effective than echocardiography.

So, keep teaching the physical examination and history skills. Your students need them!

References

(1)   Paley L, et al. Utility of Clinical Examination in the Diagnosis of Emergency Department Patients Admitted to the Department of Medicine of an Academic Hospital.  Arch Intern Med  2011;171(15):1393-1400.