Letters to the Editor
the process of creating, receiving, reviewing, and evaluating residency as well as fellowship application materials. As always, when deliberate and intentional inaccuracies are found which jeopardize the integrity of the process, we encourage programs to report these incidents to ERAS for investigation of a possible breach to ERAS’s Integrity Promotion policy. Disclosures: None reported. B. Renee Overton, MBA Senior director, Electronic Residency Application Service, Association of American Medical Colleges, Washington, DC; [email protected].
Reference 1 Grimm LJ, Maxfield CM. Ultimate publication rate of unpublished manuscripts listed on radiology residency applications at one institution. Acad Med. 2013;88:1719–1722.
Addressing Concerns About a “Core + Clusters” Physical Exam To the Editor: We appreciate Uchida and colleagues’ commentary1 regarding our study2 on a core physical exam for medical students based upon a national survey of clinical skills educators. We wish to respond to the concerns raised by Uchida and colleagues about our proposed “Core + Clusters” approach and emphasize the potential advantages to this approach to teaching physical exam skills. A strength of the core exam is that enough of the head-to-toe exam (HTT) is retained to remain comprehensive, while being considerably leaner than the typical HTT. For instance, the core contains only 65% of the maneuvers in Columbia’s HTT checklist and took an average of 20 minutes for preclerkship students in our schools to perform. The maneuvers removed offer little clinical or educational value when performed on every patient (e.g., Romberg test). Importantly, all the maneuvers in the HTT that are not part of the core would still be taught in the curriculum within clinically situated clusters. Uchida and colleagues’ concern that the Core + Clusters curriculum would require students to learn “an infinite number” of clusters suggests a misunderstanding of our curriculum. We do not propose developing clusters
834
for every clinical scenario that students might encounter. Rather, students would be taught a limited set of clusters covering common and important presentations. For example, the Romberg and other pertinent neurological tests not in the core could be taught within a cluster on frequent falls. We disagree with Uchida and colleagues’ assertion that students need the HTT to evaluate presentations such as fever of unknown origin (FUO), for which many elements of the HTT are not relevant. An evidence-based “FUO cluster” added to the core would better teach advanced students which maneuvers should be done (e.g., tympanic membranes, spleen) and which should not (e.g., pronator drift) when evaluating FUO. We also feel that technically difficult maneuvers such as the fundoscopic exam would be practiced more, not less, in clerkships if students learned them within clusters. We believe that learning a streamlined, meaningful core exam (to be performed routinely on clinical rotations) alongside a manageable set of clusters will result in increased confidence, better retention, and more appropriate use of the exam in clinical settings. Uchida and colleagues propose teaching Core + Clusters after the HTT is learned. We feel it is most developmentally appropriate to teach the core exam first, followed by teaching clinically relevant clusters. This sequence may render teaching the HTT completely unnecessary; further research is needed in this area. Lastly, we enthusiastically concur that the Core + Cluster approach could reinforce and advance the teaching of the physical examination in the clerkship years, where it is much needed. Disclosures: None reported. Deepthiman Gowda, MD, MPH Assistant professor of medicine, Department of Medicine, Columbia University, College of Physicians and Surgeons, New York, New York; dg381@ columbia.edu.
Benjamin Blatt, MD Professor of medicine, Department of Medicine, George Washington University School of Medicine, Washington, DC.
Lynn Y. Kosowicz, MD Associate professor of medicine, Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut.
Ronald C. Silvestri, MD Assistant professor of medicine, Department of Medicine, Harvard Medical School, and physician, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
References 1 Uchida T, Farnan JM, Schwartz JE, Heiman HL. Teaching the physical examination: A longitudinal strategy for tomorrow’s physicians. Acad Med. 2014:89;373–375. 2 Gowda D, Blatt B, Fink MJ, Kosowicz LY, Baecker A, Silvestri RC. A core physical exam for medical students: Results of a national survey. Acad Med. 2014:89:436–442.
To the Editor: Gowda and colleagues1 suggest replacing the traditional head-to-toe (HTT) physical exam (PE) with teaching a core PE plus clusters of maneuvers appropriate for specific complaints (Core + Clusters). In the accompanying commentary, Uchida and colleagues2 suggest a longitudinal curriculum in which students begin by learning the HTT to gain basic PE skills, followed by learning the Core + Clusters to incorporate the clinical reasoning component of the PE. However, the concern with the HTT is that students are introduced to the PE through decontexualized rote learning and practice—a habit that may be hard to break. Early exposure to the PE does not need to be context-free. By breaking up the HTT into clinically relevant chunks, the Core + Clusters approach facilitates learning the PE as a purposeful hypothesisdriven activity in the context of a clinical challenge.3 Challenges for novice students can be appropriately limited and linked to anatomy and physiology—for example, learning to auscultate the heart (a core maneuver) in the context of determining whether a murmur is systolic or diastolic. The more complex task of using the PE to help distinguish between competing etiologies of chest pain can be taught subsequently as a cluster. I agree with Uchida and colleagues’ suggestion that the PE be taught and practiced longitudinally in a progressive developmental fashion. Perhaps the longitudinal curriculum should begin with the core items, taught as purposeful maneuvers, followed by hypothesis-driven clusters. Only after students acquire the habit of conducting a thoughtful and purposive PE would the full set of PE maneuvers be integrated into an HTT exam—avoiding at any stage the
Academic Medicine, Vol. 89, No. 6 / June 2014
the process of creating, receiving, reviewing, and evaluating residency as well as fellowship application materials. As always, when deliberate and intentional inaccuracies are found which jeopardize the integrity of the process, we encourage programs to report these incidents to ERAS for investigation of a possible breach to ERAS’s Integrity Promotion policy. Disclosures: None reported. B. Renee Overton, MBA Senior director, Electronic Residency Application Service, Association of American Medical Colleges, Washington, DC; [email protected].
Reference 1 Grimm LJ, Maxfield CM. Ultimate publication rate of unpublished manuscripts listed on radiology residency applications at one institution. Acad Med. 2013;88:1719–1722.
Addressing Concerns About a “Core + Clusters” Physical Exam To the Editor: We appreciate Uchida and colleagues’ commentary1 regarding our study2 on a core physical exam for medical students based upon a national survey of clinical skills educators. We wish to respond to the concerns raised by Uchida and colleagues about our proposed “Core + Clusters” approach and emphasize the potential advantages to this approach to teaching physical exam skills. A strength of the core exam is that enough of the head-to-toe exam (HTT) is retained to remain comprehensive, while being considerably leaner than the typical HTT. For instance, the core contains only 65% of the maneuvers in Columbia’s HTT checklist and took an average of 20 minutes for preclerkship students in our schools to perform. The maneuvers removed offer little clinical or educational value when performed on every patient (e.g., Romberg test). Importantly, all the maneuvers in the HTT that are not part of the core would still be taught in the curriculum within clinically situated clusters. Uchida and colleagues’ concern that the Core + Clusters curriculum would require students to learn “an infinite number” of clusters suggests a misunderstanding of our curriculum. We do not propose developing clusters
834
for every clinical scenario that students might encounter. Rather, students would be taught a limited set of clusters covering common and important presentations. For example, the Romberg and other pertinent neurological tests not in the core could be taught within a cluster on frequent falls. We disagree with Uchida and colleagues’ assertion that students need the HTT to evaluate presentations such as fever of unknown origin (FUO), for which many elements of the HTT are not relevant. An evidence-based “FUO cluster” added to the core would better teach advanced students which maneuvers should be done (e.g., tympanic membranes, spleen) and which should not (e.g., pronator drift) when evaluating FUO. We also feel that technically difficult maneuvers such as the fundoscopic exam would be practiced more, not less, in clerkships if students learned them within clusters. We believe that learning a streamlined, meaningful core exam (to be performed routinely on clinical rotations) alongside a manageable set of clusters will result in increased confidence, better retention, and more appropriate use of the exam in clinical settings. Uchida and colleagues propose teaching Core + Clusters after the HTT is learned. We feel it is most developmentally appropriate to teach the core exam first, followed by teaching clinically relevant clusters. This sequence may render teaching the HTT completely unnecessary; further research is needed in this area. Lastly, we enthusiastically concur that the Core + Cluster approach could reinforce and advance the teaching of the physical examination in the clerkship years, where it is much needed. Disclosures: None reported. Deepthiman Gowda, MD, MPH Assistant professor of medicine, Department of Medicine, Columbia University, College of Physicians and Surgeons, New York, New York; dg381@ columbia.edu.
Benjamin Blatt, MD Professor of medicine, Department of Medicine, George Washington University School of Medicine, Washington, DC.
Lynn Y. Kosowicz, MD Associate professor of medicine, Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut.
Ronald C. Silvestri, MD Assistant professor of medicine, Department of Medicine, Harvard Medical School, and physician, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
References 1 Uchida T, Farnan JM, Schwartz JE, Heiman HL. Teaching the physical examination: A longitudinal strategy for tomorrow’s physicians. Acad Med. 2014:89;373–375. 2 Gowda D, Blatt B, Fink MJ, Kosowicz LY, Baecker A, Silvestri RC. A core physical exam for medical students: Results of a national survey. Acad Med. 2014:89:436–442.
To the Editor: Gowda and colleagues1 suggest replacing the traditional head-to-toe (HTT) physical exam (PE) with teaching a core PE plus clusters of maneuvers appropriate for specific complaints (Core + Clusters). In the accompanying commentary, Uchida and colleagues2 suggest a longitudinal curriculum in which students begin by learning the HTT to gain basic PE skills, followed by learning the Core + Clusters to incorporate the clinical reasoning component of the PE. However, the concern with the HTT is that students are introduced to the PE through decontexualized rote learning and practice—a habit that may be hard to break. Early exposure to the PE does not need to be context-free. By breaking up the HTT into clinically relevant chunks, the Core + Clusters approach facilitates learning the PE as a purposeful hypothesisdriven activity in the context of a clinical challenge.3 Challenges for novice students can be appropriately limited and linked to anatomy and physiology—for example, learning to auscultate the heart (a core maneuver) in the context of determining whether a murmur is systolic or diastolic. The more complex task of using the PE to help distinguish between competing etiologies of chest pain can be taught subsequently as a cluster. I agree with Uchida and colleagues’ suggestion that the PE be taught and practiced longitudinally in a progressive developmental fashion. Perhaps the longitudinal curriculum should begin with the core items, taught as purposeful maneuvers, followed by hypothesis-driven clusters. Only after students acquire the habit of conducting a thoughtful and purposive PE would the full set of PE maneuvers be integrated into an HTT exam—avoiding at any stage the
Academic Medicine, Vol. 89, No. 6 / June 2014
