The Stanford 25: Reviving the Art of the Physical Exam. Physician Revives a Dying Art: The Physical

Transcription

1 The Stanford 25: Reviving the Art of the Physical Exam Physician Revives a Dying Art: The Physical

2 1891- Luke Fildes: The Doctor Fildes s ambition: To put on record the status of the doctor in our time. The Doctor in our time? Verghese A. Culture Shock: Patient as icon, icon as patient. NEJM 359:26; 2008

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4 Changing a Culture Stanford25: An Initiative to Revive the Culture of Bedside Medicine 25 technique-dependent physical diagnosis maneuvers Stanford25.wordpress.com A culture of bedside rounds with students Morning reports to cover the Stanford25 A reflex hammer & ophthalmoscope for every resident

5 Technique Driven Stanford Symposium on Bedside Medicine Provided dda forum for leaders to come together and discuss the future of bedside medicine Input from these leaders as well as the myriad Stanford faculty helped to define what twenty-five exam techniques were included in the final list. Thyroid Exam Gait Abnormalities Techniques Precordial Movements Cardiac Second Sounds Examination of the Spleen Examination of the Liver Liver Disease, Head to Foot Ascites & Venous Patterns Knee Exam Shoulder Exam Lymph Node Exam Deep Tendon Reflexes Cerebellar Exam Fundoscopic Exam Neck Veins & Wave Forms BP & Pulsus Paradoxus Ankle Brachial Index The Hand in Diagnosis Bedside Ultrasound Rectal Exam Pupillary Responses Involuntary Movements Internal Capsule Stroke The Tongue in Diagnosis Pulmonary Exam

6 Dissemination Hour long sessions with multiple instructors and standardized di d patients t Each session covers one or two techniques Focus of the session is on resident practice Strive to keep a nonthreatening, low stakes environment to allow residents to be comfortable asking questions or demonstrating ignorance The map is not the territory stanford25.wordpress.com

7 Not just residents! Residents are not the only ones who are interested in and in need of more physical exam training. i Both community and faculty physicians have been able to attend special sessions for practicing physicians to receive additional training on bedside skills, most recently at the regional ACP. Educational Migration Finding protected time to provide this education to every resident with sufficient i instructors t is a major undertaking. The goal of the education session is more than mastery of the skill. Goal is to provide a teaching tool, to give residents something to teach at the bedside. d Instrumental in changing the culture at the bedside

8 Follow Up Residents have responded via survey to the experience of the Stanford 25 and response has been positive. >85% felt they needed additional training on their physical exam >90% felt that their exam skill improved as a result of a session >80% said they were more likely to teach physical exam skills at the bedside as a result of attending a Stanford 25 teaching session Thyroid Exam Gait Abnormalities Techniques Precordial Movements Cardiac Second Sounds Examination of the Spleen Examination of the Liver Liver Disease, Head to Foot Ascites & Venous Patterns Knee Exam Shoulder Exam Lymph Node Exam Deep Tendon Reflexes Cerebellar Exam Fundoscopic Exam Neck Veins & Wave Forms BP & Pulsus Paradoxus Ankle Brachial Index The Hand in Diagnosis Bedside Ultrasound Rectal Exam Pupillary Responses Involuntary Movements Internal Capsule Stroke The Tongue in Diagnosis Pulmonary Exam

9 Thyroid Exam Gait Abnormalities Examination of the Spleen Examination of the Liver Techniques Precordial Movements Cardiac Second Sounds Neck Veins & Wave Forms BP & Pulsus Paradoxus Liver Disease, Head to Foot Ascites & Venous Patterns Knee Exam Shoulder Exam Lymph Node Exam Deep Tendon Reflexes Cerebellar Exam Fundoscopic Exam Pulmonary Exam Ankle Brachial Index The Hand in Diagnosis Bedside Ultrasound Rectal Exam Pupillary Responses Involuntary Movements Internal Capsule Stroke The Tongue in Diagnosis Bedside Ultrasound

10 NEJM 2011: Point of Care Ultrasonography Challenges Defining useful and teachable exams Medical legal issues Adequate faculty for training Access to equipment Quality control and follow up

11 Opportunities Potential for diagnosis and evaluation of conditions poorly evaluated by traditional PE skills, such as LV function Clear opportunity to improve safety of bedside procedures Brings the physician back to the bedside The Future of the Stanford 25 Study the effects of an increased presence at the bedside Refine teaching methods and incorporate technology Expand faculty participation Establish point of care ultrasound within Internal Medicine New Website Ipad App