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The physical examination is an essential clinical competence for all physicians. Most medical schools have students who learn the physical examination maneuvers using a head-to-toe approach. However, this promotes a rote approach to the physical exam, and it is not uncommon for students later on to fail to appreciate the meaning of abnormal finding...
Context in source publication
Citations
... The institutional ethics committees of each hospital approved our research. Action research is a research method that aims at both taking and creating knowledge or theory relating to that action [17][18][19]. The action research process involves a cyclical process of (1) planning, (2) implementing the plan (action), (3) observation, and (4) critical and self-critical reflection on the results of (1-3) and making decisions for the next cycle of (1-4) to improve the action. ...
Background
Research engagement contributes to the improvement of patient care. A systematic review is a suitable first scholarly activity because it entails summarization of publicly available data and usually requires neither rigorous ethical review nor research funding.
Methods
This study aimed to develop a model workshop for healthcare staff to acquire skills in creating systematic review protocols based on their own clinical questions at teaching hospitals. We used an action research method to create a model workshop at four hospitals in Japan from April 2015 to March 2017. To improve the program, we solicited reflections using participant questionnaires for each lecture and examined the quality of homework submitted by participants after each lecture. We administered a revised final version of the workshop at five hospitals from April 2016 to March 2017. We evaluated the participants’ scholarly productivity related to these workshops. The observation period was a minimum of 2 years following the workshops.
Results
Most participants had never developed a formal clinical research protocol and voluntarily participated in the workshop. The action research was developed and implemented at nine teaching hospitals in Japan, including one university hospital. The study developed a model nine-step workshop curriculum: 1) Research question development, 2) Search strategy development, 3) Search strategy brush-up, 4) Exclusion and inclusion criteria development, 5) Risk of bias assessment planning, 6) Meta-analysis planning, 7) Subgroup and sensitivity analysis planning, 8) Planning the presentation of results, and 9) Presentation protocols. A total of 233 participants, including medical doctors and other health professionals, produced 414 research questions. Seventy-nine participants (34%) completed the workshop, and 47 review teams accomplished systematic review protocols. The participants published 13 peer-reviewed articles as a result of the workshop.
Conclusions
We developed a structured scholarly productive model workshop for healthcare staff working at hospitals. We found healthcare staff with clinical subspecialties were able to develop an unexpectedly high number of research questions through this workshop. Medical teachers at hospitals with prior systematic review experience could teach how to develop systematic review protocols using this model. Further research is needed to increase the academic productivity of such workshops.
Trial registration
UMIN (https://www.umin.ac.jp/ctr/), UMIN000017107 (4/15/2015), UMIN000025580 (1/10/2017).
... The HPDE is a valuable educational method for teaching PE in stand-alone workshops 6 and within structured clinical skills curriculum. 7,8 At our institution, we piloted this approach in a longitudinal integrated clerkship. ...
... A second approach, called the hypothesis-driven PE (HDPE), requires a more advanced clinical reasoning ability on the part of the learner because, in it, the learner must formulate a list of appropriate PE maneuvers based on a differential diagnosis determined by the presenting history-students identify maneuvers that either support or refute these diagnoses. 9 A study by Kamel and colleagues showed that a hypothesisdriven approach to a neurologic exam yielded greater sensitivity and a trend toward faster examinations when compared with a traditional screening approach, although it yielded lower specificity, which was not surprising because neurologic findings amongst the patient population were intentionally subtle. 10 Furthermore, HDPE may be most similar to what practicing physicians are likely to do while carrying out a PE and is more likely to lead to the identification of abnormal PE signs when carried out by physicians. ...
... 10 Several educational activities focused on teaching HDPE are described in the literature. 4,9 However, to our knowledge, the existing literature does not describe purely formative instructional sessions that focus on the diagnostic approach to specific concerns and the subsequent generation of a focused PE tailored to these concerns or sessions aimed at students in the transition from the preclerkship to the clinical curriculum. ...
... The term HDPE has been used to describe many different types of educational sessions in different contexts. 4,9 Our session is unique because of its sequencing in the curriculum and the specific focus of the learning activity. Yudkowsky and colleagues 4 worked with third-year students, and their session was used more as a summative assessment during clerkships than a formative learning activity. ...
Introduction:
The head-to-toe approach to teaching the physical examination (PE) focuses on technique and performing a comprehensive PE whereas core + clusters and hypothesis-driven PE (HDPE) approaches integrate clinical reasoning into performing a focused PE. These approaches can be implemented in a developmental sequence. We report the implementation and evaluation of an HDPE educational session.
Methods:
We designed a 3-hour HDPE session as part of a transition to clerkship program. For each of five clinical vignettes, rising third-year students worked in pairs and then in small groups to generate a differential diagnosis and determine relevant PE maneuvers. Students next performed these maneuvers on peers with facilitator observation and feedback. Students completed postsession surveys on their retrospective pre- and postsession knowledge and confidence, as well as their satisfaction with the session. We completed quantitative and qualitative analyses on survey data.
Results:
One hundred ninety-two students participated, and 140 (73%) completed the survey. Students were significantly more likely to report feeling confident generating a differential diagnosis and using it to select PE maneuvers for common complaints postsession. Over 80% of respondents felt the session improved critical thinking about patient presentations and would help them in clerkships.
Discussion:
Our session increased student confidence in the progression to performing an HDPE just prior to the start of clerkships. The session is feasible and straightforward to implement. It requires a large number of faculty to facilitate, but the breadth of cases used allows inclusion of faculty from all fields.
... During bedside rounds, there are ample opportunities for clinical teachers to role-model history taking, hypothesis-driven physical examination (Nishigori et al. 2011), and stepwise clinical reasoning. As the appearance of clinicians in PPE gear is already anxiety provoking, patients should be educated on the diagnostic and management plans succinctly with emphasis on humanistic verbal and non-verbal behaviours regardless of physical distance requirements (Weissmann et al. 2006). ...
Bedside skills have been declining over the last two decades, with multiple studies reporting increasing reliance on investigations and technology in making diagnostic decisions. During the Covid-19 crisis, even less time is spent at the bedside, and physical examinations seem markedly truncated or non-existent. It is possible that cost of health care, doctor-patient relationships, and the clinical reasoning skills could be seriously impacted by ongoing decrease in bedside skills and the teaching of these skills. Careful history taking and hypothesis-driven physical examination still form the backbone of clinical reasoning and lead to parsimonious investigations. Overreliance on investigations could drive up costs of healthcare if every diagnosis depends on a head to toe scan. In this paper, we describe strategies for bedside teaching that are relevant and applicable even during the pandemic and an era of physical distancing. These strategies are categorised as: before, during and after patient interactions at the bedside. These strategies can be adapted to normal clinical teaching situations as well as challenging situations such as the current pandemic when physical distancing is mandated.
... When students perform structured clinical reasoning, they try to compare and contrast various alternate possibilities and generate nascent illness scripts. Thus, the process would enable significant 'transfer of learning' while solving similar cases in the clinical environment [33]. Jain et al. [34] conducted an open labelled randomized control experiment to test the effectiveness of a six step pneumonic centred clinical reasoning model (SNAPPS) in improving the clinical reasoning ability of postgraduates. ...
The clinical reasoning skills is often gained when the biomedical knowledge is broadened and deepened alongside
exposure to patients. The ‘ideal’ blend of axioms of clinical reasoning and case based learning would establish the pedagogical
bridges right from the first year of medical education. So this study aimed to investigate the perceived importance and
efficacy of teaching clinical reasoning skills among first year medical students, as this has not previously been described.
As a priori, two clinical reasoning skill sessions were conducted using clinico-anatomical case vignettes designed according
to the literature regarding clinical reasoning (‘serial cue’ approach and hypothetico-deduction). Students were divided into
intervention and control group and crossed over in subsequent sessions. Analysis was done by mixed method approach
including measuring proof of benefit using post-test comparison, quantitative survey and qualitative analysis by nominal
group discussion. Post test scores were compared using student’s t-test. Feedbacks were analysed using descriptive statistics.
The results showed that post test scores were significantly higher in intervention group than the control group in both
sessions (P
<
0.001, 0.016). A total of 66% students felt, diagnostic skills and lateral thinking abilities were improved and It
helped in developing problem-solving abilities for 67% students. clinico-anatomical case vignettes helped in understanding
anatomical basis of clinical conditions for 61% students. To conclude, introducing clinical reasoning has considerable effect in
improving the decision making ability of the students and if incorporated right from the first year, would better prepare the
students in successful transition to clinical learning environment.
... Consequently, since the 1970s, there have been calls to revise the instruction of the PE. Some authors (Benbassat and Schiffmann 1976;Kassirer 1983;Fagan et al. 2003;Benbassat et al. 2005;Alexander 2008;Yudkowsky et al. 2009;Kamel et al. 2011;Nishigori et al. 2011) suggested encouraging students to approach clinical problems in the same way that doctors deal with unfamiliar problems, namely, by raising diagnostic hypotheses and then performing a 'reflective' ('hypothesis-driven', 'selective', 'targeted', 'focused') PE aimed at testing these hypotheses. Other authors suggested performing a 'core' PE on every patient, and supplementing it by a reflective PE (Gowda et al. 2014). ...
Although practiced to this day, teaching the ‘head-to-toe’ physical examination (PE) does not appear to fully achieve its objective, and since the 1970s, there have been proposals to replace the traditional teaching of the head-to-toe examination by a selective PE aimed at testing diagnostic hypotheses; by a core PE to be supplemented by additional maneuvers as clinically indicated; and by limiting the number of PE maneuvers to be taught. The need to update the teaching of the PE is further indicated by the availability of hand-held pulse oximeters, spirometry and especially point of care ultrasound devices (PoCUS). This paper is a call to update the introduction of medical students into the PE by (a) teaching the PE by clinical contexts, rather than by organ systems, (b) restricting the number of PE maneuvers by discerning between a core of ‘essential’ PE signs of urgent conditions, ‘important’ signs that should supplement the core as clinically indicated, and ‘optional’ PE signs that are no longer useful, and (c) combining previously proposed alternatives of the traditional head-to-toe PE with application of hand-held ultrasound devices. We provide examples of essential, important and optional signs of the cardiovascular system.
... Nishigori et al (52). developed a model teaching session for the hypothesis-driven physical examination approach, in which students can practice physical examination in the context of diagnostic reasoning. ...
Background
Escalating demand for specialist health care puts considerable demand on hospital services. Technology offers a means by which health care providers may increase the efficiency of health care delivery.
Objective
The aim of this study was to conduct a pilot study of the feasibility, benefits, and drawbacks of a virtual clinic (VC) in the general surgical service of a busy tertiary center.
Methods
Patient satisfaction with current care and attitudes to VC were surveyed prospectively in the general surgical outpatient department (OPD; n=223). A subset of patients who had undergone endoscopy and day surgery were recruited to follow-up in a VC and subsequently surveyed with regard to their satisfaction (20/243). Other outcomes measured included a comparison of consultation times in traditional and virtual outpatient settings and financial cost to both patients and the institution.
Results
Almost half of the patients reported barriers to prospective use of VCs. However, within the cohort who had been followed-up in the VC, satisfaction was higher than the traditional OPD (100% as compared with 187/223, 83.9%). Significant savings in both time (P=.003) and financial costs to patients and the institution were found.
Conclusions
For an appropriately selected group of patients, VCs offer a viable alternative to traditional OPD. This alternative can improve both patient satisfaction and efficiency of patient care.
... We applied several educational models while to develop our curriculum. Our predominant influence was the Hypothesis Driven Physical Examination [4][5][6][7]. The emphasis on tailoring the physical examination to focus on the elements most likely to focus the differential diagnosis was one of our primary goals. ...
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In the first year of medical school, our students have a comprehensive course in history taking, physical examination skills, clinical reasoning, and patient-centered care. We have observed that first year students struggle to conduct a focused history and perform a focused physical examination on a given chief complaint. We developed an innovative program to address this concern in our Essentials of Medicine- Physical Diagnosis course.
We created an online outline and audio podcast for students to review illustrating the key elements of the history of presenting illness, review of systems, other historical patient information, and focused physical examination for 3 specific chief complaints to assist them in their approach to these patients. This resource also included the discussion of the work up and treatment plans and was created in collaboration of Internal, Family, and Emergency Medicine to account for the various approaches to the same chief complaint within the various specialites of medicine.
Students completed a brief pre- and post-session survey to assess their utilization of the resource, quality of the content, and delivery of the session materials. The preceptor’s were also surveyed regarding the students’ ability to conduct a patient encounter and discuss their assessment and plan comparing current students to those in previous years who did not use this resource. We also asked for feedback on how these resources might be improved for future use.
The resource was highly effective for first-year medical students in preparation for focused history taking and physical examination of a patient with a specific chief complaint. Students were more engaged in the critical reasoning discussion of the case assessment and plan after using this resource and preceptors were in agreement.
We believe this model we called the “Doctors’ Lounge” developed for the chief complaints of sore throat, chest pain, and abdominal pain can be replicated at any medical school desiring to introduce or enhance teaching of clinical reasoning skills to their preclinical students.
... The approach emphasizes students' abilities to anticipate which examination maneuvers will help discriminate between diagnostic considerations and to recognize diagnostically useful examination findings. A useful guide is available for implementing this method (Nishigori et al. 2011). ...
Learning to talk with a clinical vocabulary. Thinking and communicating medical language is important to relate to other clinicians and to transform patient information into medically meaningful semantic qualifiers.
... Many authors pointed out the importance of learning physical examination based on a hypothesis-driven framework. [21][22][23] Accordingly, Uchida, Farnan, Schwartz, and Heiman 24 suggested that a core physical exam should be supplemented by hypothesisdriven "clusters" of maneuvers. Having appropriate hypotheses in mind predicts success when eliciting or interpreting physical signs. ...
... Although confirming an impact on performance was beyond the scope of the present study, the relation between a hypothesis-driven learning approach and clinical performance is already established. [21][22][23][25][26][27][28] Measuring pre-assessment effects from a metacognitive perspective provides empirical evidence to redesign assessments for learning. This first demonstration of the pre-assessment effects of whole tasks in OSCEs opens an area for interventional research with other assessment methods. ...
Theory:
Models on pre-assessment learning effects confirmed that task demands stand out among the factors assessors can modify in an assessment to influence learning. However, little is known about which tasks in objective structured clinical examinations (OSCEs) improve students' cognitive and metacognitive processes. Research is needed to support OSCE designs that benefit students' metacognitive strategies when they are studying, reinforcing a hypothesis-driven approach. With that intent, hypothesis-driven physical examination (HDPE) assessments ask students to elicit and interpret findings of the physical exam to reach a diagnosis ("Examine this patient with a painful shoulder to reach a diagnosis").
Hypotheses:
When studying for HDPE, students will dedicate more time to hypothesis-driven discussions and practice than when studying for a part-task OSCE ("Perform the shoulder exam"). It is expected that the whole-task nature of HDPE will lead to a hypothesis-oriented use of the learning resources, a frequent use of adjustment strategies, and persistence with learning.
Method:
In a mixed-methods study, 40 medical students were randomly paired and filmed while studying together for two hypothetical OSCE stations. Each 25-min study period began with video cues asking to study for either a part-task OSCE or an HDPE. In a crossover design, sequences were randomized for OSCEs and contents (shoulder or spine). Time-on-task for discussions or practice were categorized as "hypothesis-driven" or "sequence of signs and maneuvers." Content analysis of focus group interviews summarized students' perception of learning resources, adjustment strategies, and persistence with learning.
Results:
When studying for HDPE, students allocate significantly more time for hypothesis-driven discussions and practice. Students use resources contrasting diagnoses and report persistence with learning. When studying for part-task OSCEs, time-on-task is reversed, spent on rehearsing a sequence of signs and maneuvers.
Conclusions:
OSCEs with similar contents but different task demands lead to opposite learning strategies regarding how students manage their study time. Measuring pre-assessment effects from a metacognitive perspective provides empirical evidence to redesign assessments for learning.
