Letters to the Editor
We thank Gowda et al and Yudkowsky for engaging with us in a dialogue about the optimal approach to teaching and assessing the physical exam. It is clear we all agree that the physical exam requires renewed focus and curriculum development, and we hope this discussion contributes to returning the physical exam to a place of prominence in the clinical realm. We appreciate the opportunity to reply to their comments.
First, we continue to assert that the Core + Clusters approach is unlikely to significantly decrease the cognitive load of learning the physical exam. Gowda et al write that they envision a “limited set of clusters,” and yet, since the clusters are still in development, the number and scope of necessary clusters is still unknown. We believe the list will turn out to be quite extensive. Also, we do not advocate the performance of unnecessary physical exam maneuvers, but we feel that the head-to-toe is a prudent approach to assessing patients with vague and/or numerous symptoms. Pronator drift, for example, could be helpful in assessing for occult brain abscess in a patient with a fever of unknown origin. We are also concerned that the Core + Clusters approach will not encourage practice of challenging maneuvers like the fundoscopic exam, since the majority of the time students will be performing the core exam, which does not include such skills.
We agree with Yudkowsky that we do not want to promote the rote performance of physical exam maneuvers devoid of clinical reasoning, yet we believe that the head-to-toe examination serves a vital role for novice students who have limited knowledge of pathophysiology. Students have to know that a valve can be stenotic or incompetent before they can understand murmurs, and the head-to-toe exam provides students with a “toolbox” of physical exam maneuvers that they can draw upon as they progress in their underlying medical knowledge. In this way the head-to-toe exam can serve an important function in the developmental approach to learning and assessing the physical exam.
In the end we all agree with Yudkowksy that this is an area “ripe for research,” and we look forward to partnering with our colleagues in such an endeavor.
Toshiko Uchida, MD
Director of clinical skills education, Northwestern University Feinberg School of Medicine, Chicago, Illinois; firstname.lastname@example.org.
Jeanne M. Farnan, MD, MHPE
Director of clinical skills education, University of Chicago Pritzker School of Medicine, Chicago, Illinois.
Jennifer E. Schwartz, MD
Statewide course director, Introduction to Clinical Medicine II, Indiana University School of Medicine, Indianapolis, Indiana.
Heather L. Heiman, MD
Medical director, Clinical Education Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois.