r
i
I SPECIALARTICLE
Teaching Physical Diagnosis in the Nursing Home MICHAELJ. GRADY,M.D., F.A.C.P.,JERRYM. EARLL, M.D., F.A.C.P., Washington, D.C.
Physical diagnosis has traditionally been taught in the inpatient hospital setting. ChAnges in hospital reimbursement, as well as a shift to outpatient directed care, has resulted in a sicker inpatient prof'fle. These patients are less amenable to the needs of the student first learning how to take a history and perform a physical examination. The outpatient setting ha~ not been found to be a practical setting for teaching physical diagnosis either. We have developed a program using an academic university-affillated nursing home in the teaching of a physical diagnosis course. Nursing home patients are predesignated according to physical f'mdings or chronic-care complaints characteristic of a specific pathologic process. Patients developing acute problems while in the nursing home are identified on a daily basis as well. These constitute the patients seen by the second-year students during the physical diagnosis course. Overall, the program was well received by both faculty and students. The spectrum of findings on beth history and physical examination was broad. Many of the pitfalls found in beth the inpatient and outpatient settings were minimized. We believe that the teaching nursing home can become a useful tool in the teaching of a physical diagnosis program.
From the Division of Internal Medicine and Geriatrics, Georgetown University School of Medicine, Washington, D.C. Requests for reprints should be addressed to Michael J. Grady, M.D., Spring Valley Primary Care, 4910 Massachusetts Avenue, N.W., Washington, D.C. 20016. Manuscript submitted August 11, 1989, and accepted in revised form February 8, 1990.
he ability to take an informative history and perform a thorough physical examination are fundaT mental to the practice of medicine. Teaching of physical diagnosis in medical schools is becoming more difficult for a number of reasons. Such courses have traditionally been taught with inpatients as teaching models in university hospitals. The profile of the inpatient, however, has changed considerably over the past several years in response to evolving trends in modern medicine. Hospital stays are shorter and patients now represent a sicker population with more complicated end-stage medical problems. Many of the less ill patients previously hospitalized and used for teaching purposes are now being managed on an outpatient basis. The expansion of diagnostic and therapeutic procedures (e.g., endoscopy, outpatient surgery) now available in the outpatient setting, as well as the growing involvement of health maintenance organizations and preferred provider organizations in the health care system, will direct more care to the outpatient setting. Diagnosis-related groups are also contributing to shorter hospital stays. The inpatient's days are tightly scheduled around diagnostic tests, therapeutic interventions, and consultants' appointments. All this leaves little time for the student to probe uninterrupted into the history of the illness and conduct a physical examination that is not prejudiced by the results of previous diagnostic tests or consultants' findings. These beginning students may require 1 to 2 hours of uninterrupted time with patients who are tired, ill, and busily scheduled. Inpatients often have complicated histories of which a substantial and essential part may include previous hospital records and diagnoses that the patient cannot verbally contribute to the student. Teaching physicians often are not familiar with the patients they are using for instructional purposes and seldom have time to review a complete history and physical findings prior to seeing the patient with the students. Although these concerns practically mandate a shift in training of physical diagnosis to the outpatient setting, the feasibility of such has not been without its own difficulties. Perkoff [1] identified efficiency and cost as the principal impediments to successful teaching in the ambulatory setting. Clinic space is seldom available to be used by students to conduct a thorough history and physical on a patient, and patients seldom have time or wish to spend such time in the clinic. The cost of ambulatory care teaching is also noted to be high. Stern et al [2] estimated the marginal cost for training a first-year resident in 1977 in the ambulatory care setting to be about $15,000 per year. The cost of teaching learners with less experience such as medical students can be expected to be higher from both time and financial perspectives. Outpatients being managed for chronic medical problems may be a poor choice for teaching purposes if the student is to have only a single exposure to their ongoing care. In response to the difficulties inherent in both the inpatient and outpatient settings, many innovations May 1990 The American Journal of Medicine
Volume 88
519
TEACHING PHYSICAL DIAGNOSIS IN THE NURSING HOME / GRADYAND EARLL
TABLE I Common DiseaseStates of Patients Identified Numberof Patients Category I Cerebralvascularaccidents Parkinson'sdisease Chronic lung disease Thyroid disease Aortic stenosis Aortic insufficiency Peripheralvasculardisease Hernias Abnormal liver examinations Tardive dyskinesia Varietyof skin diseasesand others
11 11 8 7 7 3 3 3 3 3 8
CategoryII Degenerativejoint disease Chronic lung disease Cerebralvascularaccidents Diabeticneuropathy Rheumatoidarthritis Parkinson'sdisease Edema Falls Syncope Angina Peripheralvasculardisease
CategoryIII (AcuteComplaintsEvaluated) Falls Cough/dyspnea Abdominalpain Dysuria Nausea/vomiting Weight loss Headache Urticaria Foot pain/swelling Backache
7 5 4 4 3 3 3 2 2 2 2
5 5 3 2 2 l 1 1 1 1
have been tried by directors of physical diagnosis courses to make the experience more meaningful to students and to ease these burdens. The use of professional actors as patients and computer-assisted history taking have been tried [3,4]. Again, cost and efficiency factors need consideration here as well. The loss of reality is sensed by students in these artificial situations. Style, rather than the content of the process, may be viewed as emphasized. Modularization of courses with teaching components of history taking and physical examination using a number of patients again makes the encounters less real. It also requires a large number of patients to be provided by the course directors. Several models of the teaching nursing home have been devised [5-9]. They differ in scope, methods, and goals. As a model for teaching physical diagnosis, the nursing home seems uniquely suited. The nursing home presents itself as a setting distinctly different and free from many of the problems that arise in teaching physical diagnosis in either the inpatient or ambulatory care settings. It also has some of the advantages that make these settings preferable. Patients are usually available at any time of the day and can be interviewed and examined in their rooms, thus obviating the need for more clinic space. These patients often enjoy the attention and conversation of the students. A wealth of physical findings and complaints specific for many pathologic entities are present in 520
May 1990 The American Journal of Medicine Volume 88
such a population. The average length of stay of a patient in a long-term nursing facility is generally 2 to 3 years. The same patients can be used repeatedly at the discretion of the medical director. Attending physicians at the nursing home can use their own patients for instruction. They will be familiar with the histories and physical findings of these patients specifically and can make instruction more individualized to their patients' problems. The instructors will, therefore, require less preparation time other than to briefly update themselves on their patients' course, thus making more efficient use of instructors' time. Demographics are now showing a "graying of America" and many common problems seen in the elderly population can be addressed in this setting as well [10]. We have developed a program using an academic university-affiliatednursing home to assist in teaching of the physical diagnosis course.
RESOURCES The Wisconsin Avenue Nursing Home is a 355-bed, private skilled nursing home facility located in the northwest section of Washington, D.C., approximately 1.5 miles from Georgetown University Hospital. It has been affiliated with Georgetown University since 1985. The faculty members of Georgetown's Division of Internal Medicine serve as the medical directors of the nursing home and are the primary attending physicians for approximately 175 residents of the facility. Georgetown University Hospital serves as the main hospital resource for the nursing home. At any given time, there are approximately 10 to 12 nursing home residents on the inpatient services at Georgetown University Hospital. Members of the Division of Internal Medicine evaluate and update charts of their individual patients on a monthly basis or as needed. A detailed history and physical update is required annually on every patient. When a patient is admitted to the nursing home, readmitted from the hospital, or evaluated for an annual history and physical, the attending physician completes a form designed to identify patients to be used in the physical diagnosis program. Information obtained includes the patient's diagnoses, mental status, pertinent positive or negative physical findings, specific chronic complaints for which the patient can give a coherent history, and any collaborative diagnostic studies performed in the past evaluation of this patient (e.g., electrocardiogram, echocardiogram, radiologic procedures). A coordinator of the nursing home physical diagnosis program collates these forms as outlined below. These forms are useful if the instructor that day is not the primary attending for the patient. As medical directors of the nursing home, a member of the internal medicine division makes daily rounds at the nursing home and evaluates patients with acute problems identified by nursing supervisors on each floor. IMPLEMENTATION
The designated patients are categorized by the physical diagnosis coordinator into three groups: (1) Patients demonstrating findings on physical examination that are characteristic of a specific pathologic entity (e.g., Parkinson's disease, aortic stenosis, chronic liver disease). These patients may be included in the following categories also.
TEACHING PHYSICAL DIAGNOSIS IN THE NURSING HOME / GRADY AND EARLL
(2) Patients capable of relating a coherent history for a specific chronic medical problem. These patients may or may not have physical findings consonant with the problem for which the history is given (e.g., exertional angina, intermittent claudication, diabetic neuropathy). These patients may be included in categories I and/or 3 as well. (3) Patients here include those who have the cognitive capability to relate a history for a specific acutecare complaint, should such develop during the course of the physical diagnosis program. Such patients are identified by the nursing supervisor as problem patients and are reviewed with the medical director daily. Complaints in this category include such common ones as diarrhea, fever, falls, and cough, to name a few.
DATA In category 1, as noted earlier, 103 patients were identified. In category 2, 58 patients were identified, whereas 78 patients were identified in category 3. The most common disease states found in patients in these categories are included in T a b l e I.
IMPLEMENTATION OF COURSE The patient evaluation component of the physical diagnosis course is conducted during the second half of the second academic year. There are 200 students in that class. The same 16 students were assigned to the nursing home for their weekly physical diagnosis session. This consisted of 10 weekly 2-hour sessions. A brief orientation lecture to this nursing home as well as a series of didactic lectures on geriatrics conducted earlier in the academic year introduced the students to the concept of long-term care. Before the students' arrival at the nursing home, the course director identified patients to be interviewed and examined by students that day. Patients with acute complaints could be utilized if they appeared in category 3 (able to give a coherent history) of the course director's patient log. The patient's consent was always obtained before a student's visit. A running week-to-week list of patients seen by individual students was kept by the nursing home physical diagnosis course director to ensure that students did not see the same patient more than once, to ensure that a variety of patients from different categories were seen, and to ensure that a spectrum of disease processes was seen throughout the course by each student. Eight patients per week were seen by the 16 students (two students per patient per week). Approximately four of the eight patients seen per session were patients with acute-care complaints. These acute-care patients were frequently included in category 1 as well as category 3, thus offering physical diagnostic findings in addition to those relative to the acute complaint. The remaining four patients were derived from categories 1 and 2 as noted earlier. Each student saw approximately 10 different patients (one per session) during the course. Repeat visits to the same patients w e r e k e p t to a m i n i m u m to p r e v e n t p a t i e n t dissatisfaction.
COURSE EVALUATION Even though the objective of a physical diagnosis course may be adequately outlined, the outcome of this type of course is difficult to evaluate. Student evaluations were determined by their individual instructors after the completion of the course. Oral quizzes and patient case discussions with the students convinced the instructors that this was certainly as effective a method for teaching physical diagnosis as the traditional hospital-based approach. Overall satisfaction with the program was high. Students felt they were well received, appreciated, and not intimidated by patients. They indicated that they had ample time to evaluate patients in a comfortable setting. The patients overall enjoyed the program very much. They felt they were given undivided attention from the students. The nursing home can be a major resource for the student learning physical diagnosis.
FUTURE DIRECTION The use of the nursing home as a major instrument in the teaching of physical diagnosis could be further refined by the computerization of the data described. Histories, physical findings, diagnoses, and supporting radiographic and laboratory data could be stored and cross-referenced for accessibility among different instructors. Such data could also be a potentially excellent resource for teaching medicine and geriatrics at all levels of expertise, such as nurse practitioners, physician assistants, students, housestaff, and fellows. When common acute-care complaints from category 3 are identified as being used repeatedly, algorithms could be made up for these complaints to assess the student's accuracy in looking for pertinent points on history and physical for that complaint. This could also be used by students in such a way that self-evaluation and examination could be conducted. We hope that other universities might be encouraged by our approach in the application of the teaching nursing home for teaching physical diagnosis.
REFERENCES 1. Perkoff GT: Teaching clinical medicine in the ambulatory care setting: an idea whose time may have finally come. N Engl J Med 1986; 314: 27-31. 2. Stern RS, Jennings M, Delbanco TL, Dorsey JL, Stoechle JD, Laurence RS: Graduate education in primary care: an economic analysis. N Engl J Med 1977; 297: 638-643. 3. Nardone DA, Schriver CL, Guyer-Kelly P, Kositch LP: Use of computer simulations to teach history-taking to first year medical students. J Med Educ 1987; 62: 191-193. 4. Stillman PL, Swanson DB, Sydney S, et al: Assessing clinical skills of residents with standardized patients. Ann Intern Med 1986; 105: 762-771. 5. Pawlson LG: Clinical medical education in the nursing home: opportunities and limits. J Med Educ 1982; 57: 787-791. 6. Wooliscroft JO, Calhoun JG, Maxim BR, Wolf FM: Medical education in facilities for the elderly: impact on medical students, facility, staff and residents. JAMA 1984; 252: 3382-3385. 7. Butler RN: The teaching nursing home. JAMA 1981; 245: 1435-1437. 8. Riesenberg D: The teaching nursing home: a golden annex to the ivory tower (editorial). JAMA 1987; 257: 3119-3120. 9. Garrell M: The organization of a teaching nursing home: an eight year experience. J Med Educ 1983; 58: 482-483. 10. Federal Council on Aging: The need for long term care: information and issues (DHHS publication no. [OHDS] 81-20704). Washington, DC: Government Printing Office, 1981.
May 1990 The American Journal of Medicine Volume 88
521
i
I SPECIALARTICLE
Teaching Physical Diagnosis in the Nursing Home MICHAELJ. GRADY,M.D., F.A.C.P.,JERRYM. EARLL, M.D., F.A.C.P., Washington, D.C.
Physical diagnosis has traditionally been taught in the inpatient hospital setting. ChAnges in hospital reimbursement, as well as a shift to outpatient directed care, has resulted in a sicker inpatient prof'fle. These patients are less amenable to the needs of the student first learning how to take a history and perform a physical examination. The outpatient setting ha~ not been found to be a practical setting for teaching physical diagnosis either. We have developed a program using an academic university-affillated nursing home in the teaching of a physical diagnosis course. Nursing home patients are predesignated according to physical f'mdings or chronic-care complaints characteristic of a specific pathologic process. Patients developing acute problems while in the nursing home are identified on a daily basis as well. These constitute the patients seen by the second-year students during the physical diagnosis course. Overall, the program was well received by both faculty and students. The spectrum of findings on beth history and physical examination was broad. Many of the pitfalls found in beth the inpatient and outpatient settings were minimized. We believe that the teaching nursing home can become a useful tool in the teaching of a physical diagnosis program.
From the Division of Internal Medicine and Geriatrics, Georgetown University School of Medicine, Washington, D.C. Requests for reprints should be addressed to Michael J. Grady, M.D., Spring Valley Primary Care, 4910 Massachusetts Avenue, N.W., Washington, D.C. 20016. Manuscript submitted August 11, 1989, and accepted in revised form February 8, 1990.
he ability to take an informative history and perform a thorough physical examination are fundaT mental to the practice of medicine. Teaching of physical diagnosis in medical schools is becoming more difficult for a number of reasons. Such courses have traditionally been taught with inpatients as teaching models in university hospitals. The profile of the inpatient, however, has changed considerably over the past several years in response to evolving trends in modern medicine. Hospital stays are shorter and patients now represent a sicker population with more complicated end-stage medical problems. Many of the less ill patients previously hospitalized and used for teaching purposes are now being managed on an outpatient basis. The expansion of diagnostic and therapeutic procedures (e.g., endoscopy, outpatient surgery) now available in the outpatient setting, as well as the growing involvement of health maintenance organizations and preferred provider organizations in the health care system, will direct more care to the outpatient setting. Diagnosis-related groups are also contributing to shorter hospital stays. The inpatient's days are tightly scheduled around diagnostic tests, therapeutic interventions, and consultants' appointments. All this leaves little time for the student to probe uninterrupted into the history of the illness and conduct a physical examination that is not prejudiced by the results of previous diagnostic tests or consultants' findings. These beginning students may require 1 to 2 hours of uninterrupted time with patients who are tired, ill, and busily scheduled. Inpatients often have complicated histories of which a substantial and essential part may include previous hospital records and diagnoses that the patient cannot verbally contribute to the student. Teaching physicians often are not familiar with the patients they are using for instructional purposes and seldom have time to review a complete history and physical findings prior to seeing the patient with the students. Although these concerns practically mandate a shift in training of physical diagnosis to the outpatient setting, the feasibility of such has not been without its own difficulties. Perkoff [1] identified efficiency and cost as the principal impediments to successful teaching in the ambulatory setting. Clinic space is seldom available to be used by students to conduct a thorough history and physical on a patient, and patients seldom have time or wish to spend such time in the clinic. The cost of ambulatory care teaching is also noted to be high. Stern et al [2] estimated the marginal cost for training a first-year resident in 1977 in the ambulatory care setting to be about $15,000 per year. The cost of teaching learners with less experience such as medical students can be expected to be higher from both time and financial perspectives. Outpatients being managed for chronic medical problems may be a poor choice for teaching purposes if the student is to have only a single exposure to their ongoing care. In response to the difficulties inherent in both the inpatient and outpatient settings, many innovations May 1990 The American Journal of Medicine
Volume 88
519
TEACHING PHYSICAL DIAGNOSIS IN THE NURSING HOME / GRADYAND EARLL
TABLE I Common DiseaseStates of Patients Identified Numberof Patients Category I Cerebralvascularaccidents Parkinson'sdisease Chronic lung disease Thyroid disease Aortic stenosis Aortic insufficiency Peripheralvasculardisease Hernias Abnormal liver examinations Tardive dyskinesia Varietyof skin diseasesand others
11 11 8 7 7 3 3 3 3 3 8
CategoryII Degenerativejoint disease Chronic lung disease Cerebralvascularaccidents Diabeticneuropathy Rheumatoidarthritis Parkinson'sdisease Edema Falls Syncope Angina Peripheralvasculardisease
CategoryIII (AcuteComplaintsEvaluated) Falls Cough/dyspnea Abdominalpain Dysuria Nausea/vomiting Weight loss Headache Urticaria Foot pain/swelling Backache
7 5 4 4 3 3 3 2 2 2 2
5 5 3 2 2 l 1 1 1 1
have been tried by directors of physical diagnosis courses to make the experience more meaningful to students and to ease these burdens. The use of professional actors as patients and computer-assisted history taking have been tried [3,4]. Again, cost and efficiency factors need consideration here as well. The loss of reality is sensed by students in these artificial situations. Style, rather than the content of the process, may be viewed as emphasized. Modularization of courses with teaching components of history taking and physical examination using a number of patients again makes the encounters less real. It also requires a large number of patients to be provided by the course directors. Several models of the teaching nursing home have been devised [5-9]. They differ in scope, methods, and goals. As a model for teaching physical diagnosis, the nursing home seems uniquely suited. The nursing home presents itself as a setting distinctly different and free from many of the problems that arise in teaching physical diagnosis in either the inpatient or ambulatory care settings. It also has some of the advantages that make these settings preferable. Patients are usually available at any time of the day and can be interviewed and examined in their rooms, thus obviating the need for more clinic space. These patients often enjoy the attention and conversation of the students. A wealth of physical findings and complaints specific for many pathologic entities are present in 520
May 1990 The American Journal of Medicine Volume 88
such a population. The average length of stay of a patient in a long-term nursing facility is generally 2 to 3 years. The same patients can be used repeatedly at the discretion of the medical director. Attending physicians at the nursing home can use their own patients for instruction. They will be familiar with the histories and physical findings of these patients specifically and can make instruction more individualized to their patients' problems. The instructors will, therefore, require less preparation time other than to briefly update themselves on their patients' course, thus making more efficient use of instructors' time. Demographics are now showing a "graying of America" and many common problems seen in the elderly population can be addressed in this setting as well [10]. We have developed a program using an academic university-affiliatednursing home to assist in teaching of the physical diagnosis course.
RESOURCES The Wisconsin Avenue Nursing Home is a 355-bed, private skilled nursing home facility located in the northwest section of Washington, D.C., approximately 1.5 miles from Georgetown University Hospital. It has been affiliated with Georgetown University since 1985. The faculty members of Georgetown's Division of Internal Medicine serve as the medical directors of the nursing home and are the primary attending physicians for approximately 175 residents of the facility. Georgetown University Hospital serves as the main hospital resource for the nursing home. At any given time, there are approximately 10 to 12 nursing home residents on the inpatient services at Georgetown University Hospital. Members of the Division of Internal Medicine evaluate and update charts of their individual patients on a monthly basis or as needed. A detailed history and physical update is required annually on every patient. When a patient is admitted to the nursing home, readmitted from the hospital, or evaluated for an annual history and physical, the attending physician completes a form designed to identify patients to be used in the physical diagnosis program. Information obtained includes the patient's diagnoses, mental status, pertinent positive or negative physical findings, specific chronic complaints for which the patient can give a coherent history, and any collaborative diagnostic studies performed in the past evaluation of this patient (e.g., electrocardiogram, echocardiogram, radiologic procedures). A coordinator of the nursing home physical diagnosis program collates these forms as outlined below. These forms are useful if the instructor that day is not the primary attending for the patient. As medical directors of the nursing home, a member of the internal medicine division makes daily rounds at the nursing home and evaluates patients with acute problems identified by nursing supervisors on each floor. IMPLEMENTATION
The designated patients are categorized by the physical diagnosis coordinator into three groups: (1) Patients demonstrating findings on physical examination that are characteristic of a specific pathologic entity (e.g., Parkinson's disease, aortic stenosis, chronic liver disease). These patients may be included in the following categories also.
TEACHING PHYSICAL DIAGNOSIS IN THE NURSING HOME / GRADY AND EARLL
(2) Patients capable of relating a coherent history for a specific chronic medical problem. These patients may or may not have physical findings consonant with the problem for which the history is given (e.g., exertional angina, intermittent claudication, diabetic neuropathy). These patients may be included in categories I and/or 3 as well. (3) Patients here include those who have the cognitive capability to relate a history for a specific acutecare complaint, should such develop during the course of the physical diagnosis program. Such patients are identified by the nursing supervisor as problem patients and are reviewed with the medical director daily. Complaints in this category include such common ones as diarrhea, fever, falls, and cough, to name a few.
DATA In category 1, as noted earlier, 103 patients were identified. In category 2, 58 patients were identified, whereas 78 patients were identified in category 3. The most common disease states found in patients in these categories are included in T a b l e I.
IMPLEMENTATION OF COURSE The patient evaluation component of the physical diagnosis course is conducted during the second half of the second academic year. There are 200 students in that class. The same 16 students were assigned to the nursing home for their weekly physical diagnosis session. This consisted of 10 weekly 2-hour sessions. A brief orientation lecture to this nursing home as well as a series of didactic lectures on geriatrics conducted earlier in the academic year introduced the students to the concept of long-term care. Before the students' arrival at the nursing home, the course director identified patients to be interviewed and examined by students that day. Patients with acute complaints could be utilized if they appeared in category 3 (able to give a coherent history) of the course director's patient log. The patient's consent was always obtained before a student's visit. A running week-to-week list of patients seen by individual students was kept by the nursing home physical diagnosis course director to ensure that students did not see the same patient more than once, to ensure that a variety of patients from different categories were seen, and to ensure that a spectrum of disease processes was seen throughout the course by each student. Eight patients per week were seen by the 16 students (two students per patient per week). Approximately four of the eight patients seen per session were patients with acute-care complaints. These acute-care patients were frequently included in category 1 as well as category 3, thus offering physical diagnostic findings in addition to those relative to the acute complaint. The remaining four patients were derived from categories 1 and 2 as noted earlier. Each student saw approximately 10 different patients (one per session) during the course. Repeat visits to the same patients w e r e k e p t to a m i n i m u m to p r e v e n t p a t i e n t dissatisfaction.
COURSE EVALUATION Even though the objective of a physical diagnosis course may be adequately outlined, the outcome of this type of course is difficult to evaluate. Student evaluations were determined by their individual instructors after the completion of the course. Oral quizzes and patient case discussions with the students convinced the instructors that this was certainly as effective a method for teaching physical diagnosis as the traditional hospital-based approach. Overall satisfaction with the program was high. Students felt they were well received, appreciated, and not intimidated by patients. They indicated that they had ample time to evaluate patients in a comfortable setting. The patients overall enjoyed the program very much. They felt they were given undivided attention from the students. The nursing home can be a major resource for the student learning physical diagnosis.
FUTURE DIRECTION The use of the nursing home as a major instrument in the teaching of physical diagnosis could be further refined by the computerization of the data described. Histories, physical findings, diagnoses, and supporting radiographic and laboratory data could be stored and cross-referenced for accessibility among different instructors. Such data could also be a potentially excellent resource for teaching medicine and geriatrics at all levels of expertise, such as nurse practitioners, physician assistants, students, housestaff, and fellows. When common acute-care complaints from category 3 are identified as being used repeatedly, algorithms could be made up for these complaints to assess the student's accuracy in looking for pertinent points on history and physical for that complaint. This could also be used by students in such a way that self-evaluation and examination could be conducted. We hope that other universities might be encouraged by our approach in the application of the teaching nursing home for teaching physical diagnosis.
REFERENCES 1. Perkoff GT: Teaching clinical medicine in the ambulatory care setting: an idea whose time may have finally come. N Engl J Med 1986; 314: 27-31. 2. Stern RS, Jennings M, Delbanco TL, Dorsey JL, Stoechle JD, Laurence RS: Graduate education in primary care: an economic analysis. N Engl J Med 1977; 297: 638-643. 3. Nardone DA, Schriver CL, Guyer-Kelly P, Kositch LP: Use of computer simulations to teach history-taking to first year medical students. J Med Educ 1987; 62: 191-193. 4. Stillman PL, Swanson DB, Sydney S, et al: Assessing clinical skills of residents with standardized patients. Ann Intern Med 1986; 105: 762-771. 5. Pawlson LG: Clinical medical education in the nursing home: opportunities and limits. J Med Educ 1982; 57: 787-791. 6. Wooliscroft JO, Calhoun JG, Maxim BR, Wolf FM: Medical education in facilities for the elderly: impact on medical students, facility, staff and residents. JAMA 1984; 252: 3382-3385. 7. Butler RN: The teaching nursing home. JAMA 1981; 245: 1435-1437. 8. Riesenberg D: The teaching nursing home: a golden annex to the ivory tower (editorial). JAMA 1987; 257: 3119-3120. 9. Garrell M: The organization of a teaching nursing home: an eight year experience. J Med Educ 1983; 58: 482-483. 10. Federal Council on Aging: The need for long term care: information and issues (DHHS publication no. [OHDS] 81-20704). Washington, DC: Government Printing Office, 1981.
May 1990 The American Journal of Medicine Volume 88
521
