Medical students have many good reasons for performing a physical examination. They use it to confirm diagnostic hypotheses, to monitor disease, and to connect with and reassure patients. But students—and practicing physicians—may also have flawed motives and poor approaches to the exam. They may do the exam by rote, without thinking critically or attempting to interpret their findings. They may even go through the motions of an exam in order to fulfill billing or documentation requirements. Clinical teachers recognize that in 2014 the physical exam is in danger of becoming obsolete to young medical students, who often see their preceptors rushing to complete an office encounter or an inpatient hospitalization with little time to perform, let alone process, the physical. Providers may touch and examine what Abraham Verghese1 has termed the “iPatient” (the patient’s electronic health record) far more often than the actual patient. Recent data from a multisite study have confirmed what we see every day on the wards: that the bedside teaching of the physical exam is infrequent, with only 14.6% of inpatient attending rounds addressing physical exam skills.2 Yet in masterful hands, the physical exam time and again reveals critical diagnoses that would have been otherwise missed.3
Head-to-Toe: The Traditional Approach
To revitalize the physical exam, educators have begun to reconsider the ways in which we teach it. Traditionally, physical exam skills have been taught in the first or second preclerkship years, often in an organ-based approach. Students are then generally assessed, prior to entering their clerkships, with a comprehensive “head-to-toe” examination of a standardized patient. Prior work has established that the head-to-toe model provides a reliable assessment of student skill and may serve to provide direct feedback on exam skills through the use of trained standardized patient educators.4 The stakes of the head-to-toe assessment vary from institution to institution, as well as whether or not the material is presented in the context of clinical reasoning and pathophysiology.
The head-to-toe examination is a lengthy one, and using it for assessment can be expensive. Moreover, the absence of clinical context raises questions about the authenticity of the head-to-toe. There is concern that it may be memorized for an exam but then forgotten and never performed in practice. Many worry that the head-to-toe promotes a rote approach to the physical exam that runs counter to the clinical reasoning skills we are trying to develop in medical students. These concerns have given rise to the development of other approaches to teaching the physical exam. For example, in the hypothesis-driven physical examination, physical exam maneuvers are taught in the context of a clinical reasoning problem.5 This targeted approach asks students to list and then assess for specific historical and physical exam elements in order to choose between two or more possible diagnoses. Other approaches to physical exam education include the scheme-based problem-solving method, in which the classic system-based approach is reorganized into 120 distinct clinical problem domains.6 These domains align to schemes, or mental categorizations of knowledge, which are organized to serve as frameworks for clinical problem solving.
The Core + Clusters Approach
In this issue, Gowda and colleagues7 report results of a national survey of course and clerkship directors and present a consensus, streamlined 37-item “core” exam to be performed by students on their medicine clerkships for every newly admitted patient. A similar approach recently published by Haring and colleagues8 in the Netherlands yielded a 55-item core exam. Gowda and colleagues’ core exam is intended to be supplemented by symptom-driven “clusters”—sets of questions and exam maneuvers specific to a given chief concern. For example, the core exam includes inspection of the thorax and auscultation of the chest anteriorly and posteriorly, while the examination of a patient with fever and cough would invoke a more detailed set of historical questions and an exam that would likely include tactile fremitus and egophony.
The Core + Clusters exam has many advantages. As the authors point out, with a more limited exam, cognitive load is decreased. Complexity can be added gradually within a clinical context, and, over time, this may improve learning. The condensed exam is more efficient and might also be more credible, as it more closely replicates actual practice observed by trainees. Also, more of the exam is placed in a framework of clinical reasoning, in which maneuvers are used for hypothesis testing, so that the exam is a reasoning exercise from start to finish.
Despite these advantages, there also appear to be several drawbacks to the Core + Clusters approach. Although the core exam is itemized as 37 discrete maneuvers, a number of the skills such as the motor exam of the extremities and the cranial nerves involve numerous substeps. When the substeps are enumerated, the length of the Core + Clusters begins to approximate that of the head-to-toe. In addition, the Core + Clusters will not significantly decrease cognitive load, as there may exist an infinite number of cluster exams, with their corresponding interpretations, to recall and implement correctly. Nor does the core exam completely replicate real-world clinical practice, as faculty report that they themselves perform fewer physical exam maneuvers than they expect their students to perform.8 Lastly, prior data have demonstrated the need for additional practice of certain particularly challenging skills (e.g., thyroid examination and fundoscopic examination) in order for students to achieve proficiency.9,10 A Core + Clusters approach would limit performance of these items and, in turn, stifle student practice. Gowda and colleagues acknowledge that certain items outside of the core exam may need to be designated as “educational maneuvers,” which would require additional practice.
Advantages of the Head-to-Toe
We believe that there is still a vital role for the head-to-toe exam in clinical teaching and in practice. There are few opportunities after the preclerkship years for students to learn proper exam technique in a standardized fashion, and the head-to-toe teaches a comprehensive set of maneuvers assessed in a rigorous way. Furthermore, a complete physical examination is called for in certain clinical contexts. The case of an ill patient with a vague symptom such as a fever of unknown origin, weight loss, or lymphadenopathy; a patient with multiple complaints that are not obviously related; and a cognitively impaired adult who is generally unwell—all would merit a more comprehensive exam than that found in Gowda and colleagues’ proposed core exam. Some of the maneuvers that may be warranted in the clinical scenarios above include examination of the retina, tympanic membrane, breasts, pelvis, and genitourinary system, and a more detailed examination of the heart and abdomen.
In addition, the head-to-toe exam can be taught very early in medical school, before students learn any pathophysiology. This early exposure to clinical skills can be highly motivating for students in the midst of basic science curricula and may help to engender comfort in their introductory patient-based tasks. Gowda and colleagues express concern that the physical exam is taught without a clinical context, yet early patient exposure, both within and outside the curriculum, has been called for by leaders in the field and is becoming increasingly common.11,12 The head-to-toe exam builds confidence, promotes connection with patients through physical touch, and helps novice students feel useful in the clinical environment. Moreover, where curricula strive for synergy and cohesiveness, physical exam teaching is an ideal complement to the common preclinical course work in anatomy and physiology. As students become more familiar with pathophysiology, the head-to-toe exam can serve as a platform on which they are able to build their clinical reasoning skills, gradually and deliberately. A summative head-to-toe assessment prior to clerkships ensures that students have robust and reliable exam skills to take into the patient care environment.
A Combined Approach
The task for clinical skills educators, therefore, may not be whether to teach the head-to-toe versus the Core + Clusters method but, rather, how to incorporate the best aspects of both approaches into a developmentally appropriate longitudinal curriculum. We propose a helical strategy starting with the head-to-toe exam for beginning students and then building on that foundation with a streamlined core exam and the inclusion of clinically appropriate clusters once the students have a greater knowledge of pathophysiology. Ideally, initial learning of the comprehensive head-to-toe would be linked to the basic science content, including anatomy and physiology, so that these curricular components would be mutually reinforcing. The head-to-toe would also continue to provide students with some basic physical exam skills to support their early clinical experiences and help them approach, in a comprehensive manner, patients who have undifferentiated symptoms or multiorgan diseases. Once students demonstrate proficiency in the technical aspects of the head-to-toe, the physical exam could be revisited starting with the core exam and adding clusters as students learn various disease processes. This type of physical exam instruction, which builds on itself in an iterative way, adheres to the tenets of adult learning theory by constructing new knowledge on the scaffolding of prior knowledge. This approach is also supported by the Association of American Medical Colleges Taskforce on Preclerkship Clinical Skills Education, which recommends a progressive developmental model for teaching clinical skills.13
Of course the preclerkship years are only the beginning of physical exam education. Although both the head-to-toe and Core + Clusters could be introduced in the preclerkship years, the clinical realm may be the ideal setting for fully implementing the Core + Clusters exam as students encounter patients with specific clinical problems. Integrating the Core + Clusters exam into the clerkship model could shine a much-needed spotlight on the physical exam in the clinical years.14 Reassessing students’ physical exam skills in a standardized way during clerkships would incentivize ongoing deliberate practice. Active teaching of Core + Clusters would require the entire clinical team, from third-year medical students to residents and faculty, to consider which patients require which clusters and how the physical findings influence the differential diagnosis. This hypothesis testing using the Core + Clusters approach would be built on the foundation of the head-to-toe mastered in the preclerkship years. Embracing and adopting this helical model takes advantage of the strengths of both the head-to-toe and Core + Clusters and will ensure that the physical exam again returns to the heart of clinical skills education.
Acknowledgments: The authors wish to thank the following members of the Central Group on Educational Affairs Directors of Clinical Skills Courses Special Interest Group for participating in the surveys and focus groups which led to this commentary: Christina Belmonte, DO, Carrie Bernat, MA, MSW, Angela Blood, MPH, MBA, Mary Boyle, MD, Rupel Dedhia, MD, Nate Derhammer, MD, Melanie Gordon, MD, Patricia McNally, EdD, Amy Pabst, MD, and Jim Winger, MD.
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