Letters to the Editor
performance of a rote PE. Determining the most effective sequence would seem to be a testable question! The best way to teach and assess PE skills, with the goal of producing students who conduct thoughtful, effective, and efficient PEs in real clinical settings, remains an area ripe for research. Disclosures: None reported. Rachel Yudkowsky, MD, MHPE Associate professor, Department of Medical Education, University of Illinois at Chicago College of Medicine, Chicago, Illinois; [email protected].
References 1 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. 2 Uchida T, Farnan JM, Schwartz JE, Heiman HL. Teaching the physical examination: A longitudinal strategy for tomorrow’s doctors. Acad Med. 2014;89:373–375. 3 Yudkowsky R, Otaki J, Lowenstein T, Riddle J, Nishigori H, Bordage G. A hypothesis-driven physical examination learning and assessment procedure for medical students: Initial validity evidence. Med Educ. 2009;43:729–740.
In Reply to Gowda et al and to Yudkowsky: 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-totoe 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
Academic Medicine, Vol. 89, No. 6 / June 2014
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 headto-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; [email protected].
into an HTT exam. However, it is our impression that if the Core + Clusters curriculum is learned, there would be no need for students to perform the HTT in clinical settings. The Core + Clusters curriculum is designed to allow students to identify and perform maneuvers relevant to their particular patient, without the rote learning that the HTT perpetuates. We agree with Dr. Yudkowsky that determining which of these approaches to learning the PE is most effective is testable, and we look forward to further contributions to this area of research. 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
Jeanne M. Farnan, MD, MHPE
Assistant professor of medicine, Department of Medicine, Harvard Medical School, and physician, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
Director of clinical skills education, University of Chicago Pritzker School of Medicine, Chicago, Illinois.
Reference
Jennifer E. Schwartz, MD Statewide course director, Introduction to Clinical Medicine II, Indiana University School of Medicine, Indianapolis, Indiana.
1 Yudkowsky R, Otaki J, Lowenstein T, Riddle J, Nishigori H, Bordage G. A hypothesis-driven physical examination learning and assessment procedure for medical students: Initial validity evidence. Med Educ. 2009;43:729–740.
Heather L. Heiman, MD Medical director, Clinical Education Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
In Reply to Yudkowsky: We agree with Dr. Yudkowsky’s statement that by breaking up the head-to-toe exam (HTT) into clinically relevant chunks, the Core + Clusters approach facilitates learning the physical exam (PE) as a purposeful, clinically contextualized activity. This approach is consistent with the previous work that she and others have done in the hypothesisbased PE.1 She proposes that after students acquire the habit of conducting a thoughtful and purposive PE, the full set of PE maneuvers could be integrated
While We Advocate for Integrated Electronic Medical Records, Continue to Empower Patients and Families To the Editor: Medical students everywhere sympathize with, and likely can unanimously relate to, Mr. Ehrmann’s1 account of his recent futile attempts to obtain a transfer patient’s medical records that were critical to ongoing treatment. Disjointed systems and unavailable archives regularly drive frustration and delay patient care. With each failed attempt to obtain records, the cycle of redundant diagnostic medicine repeats, as it is currently the only way to serve our patients in real time. I
835
Letters to the Editor
recall one patient with seasonal allergies and a benign murmur who had four echocardiograms in the span of one week as he drove across country, using different health systems along his trip, each having to obtain new “baseline” data because no previous study could be obtained. I applaud Mr. Ehrmann for shedding a direct light on these frequently occurring but often ignored incidents and his call for advocacy amongst young providers. Although no structured plans currently exist to standardize the electronic medical record interface, or require the universal use of these digital records at all practices, I argue that both patient and family empowerment must play a prominent role in making patient data more readily available to providers. Challenged as a clerkship student to provide patients with copies of new diagnostic data prior to discharge, I soon saw the value in placing information directly into the hands of the patient consumer to enable direct access for future reference. To maximize on this information handoff, and to address the ongoing need for clear and directed patient education at the time of discharge, methods of teach-back can be employed to ensure further patient and family understanding.2 Not only does this create patient autonomy and grant full disclosure regarding recent medical care but, in the event of readmission, this material may be more readily available to the patient and/or family. There are clearly limitations to this practice, as some patients do not have the capability, desire, or support system to receive and retain detailed diagnostic information. While we shouldn’t hold our breath advocating for seamless and integrated electronic medical records, perhaps equipping our patients and their families with vital and highly sought-after medical
836
data may provide ease of transition, safety, and better use of resources during subsequent health care interactions. Disclosures: None reported. John Daggett, Jr. Fourth-year medical student, Tufts University School of Medicine, Boston, Massachusetts; john.daggett@ tufts.edu.
References 1 Ehrmann DE. Overwhelmed and uninspired by lack of coordinated care: A call to action for new physicians. Acad Med. 2013;88: 1600–1602. 2 Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: A review of key issues for hospitalists. J Hosp Med. 2007;2:314–323.
In Reply to Daggett: I appreciate the argument posited by Mr. Daggett in relation to my commentary. His premise—that physicians can empower patients by providing them copies of their important medical data upon hospital discharge—is certainly important. This is often the best we can do at the present time, and indeed, many institutions utilize this practice. However, in itself, this practice fails to foster the culture change I argue for in my commentary. Progress in care coordination can only be realized if we view the problem through the lens of partnership. In a culture of partnership, providers and patients equally accept the responsibility for facilitating optimally coordinated care. Providing patients with copies of their medical records upon discharge, although empowering, does not achieve true partnership. It places the responsibility entirely on patients to coordinate their
own future care. Although some patients are up to this arduous task, many simply are not. Even when patients maintain all of their health care documentation and verify understanding of their condition prior to recent discharge, there is often an inefficient transfer of information to new providers. New providers often find themselves digging through mounds of progress notes from three prior prolonged admissions. At best, this approach is inefficient. At worst, it promotes an enormous strain on the brand new patient–physician relationship. Perhaps a bigger step toward optimal care coordination—one that is consistent with the culture of partnership—is the use of online patient portals that are becoming more popular with electronic health record implementation. In theory, providers and patients work together to make sure that accurate information is available to patients in a user-friendly format. Patients can then be maximally empowered to transfer the information (in part or full) to anyone they wish at any time. Although there are many limitations to the use of online patient portals in their current form, we should not be dissuaded from envisioning their enormous potential. Imagine established providers working with patients to send specific documents to new specialists across the country in preparation for upcoming consultations. Imagine new providers and patients being able to peruse a recent discharge summary from a computer in an emergency room anywhere in the world. This is true empowerment, and it is only possible through a shared commitment to true partnership in care coordination. Daniel E. Ehrmann, MS Fourth-year medical student, University of Michigan Medical School, Ann Arbor, Michigan, at the time this was written; [email protected].
Academic Medicine, Vol. 89, No. 6 / June 2014
performance of a rote PE. Determining the most effective sequence would seem to be a testable question! The best way to teach and assess PE skills, with the goal of producing students who conduct thoughtful, effective, and efficient PEs in real clinical settings, remains an area ripe for research. Disclosures: None reported. Rachel Yudkowsky, MD, MHPE Associate professor, Department of Medical Education, University of Illinois at Chicago College of Medicine, Chicago, Illinois; [email protected].
References 1 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. 2 Uchida T, Farnan JM, Schwartz JE, Heiman HL. Teaching the physical examination: A longitudinal strategy for tomorrow’s doctors. Acad Med. 2014;89:373–375. 3 Yudkowsky R, Otaki J, Lowenstein T, Riddle J, Nishigori H, Bordage G. A hypothesis-driven physical examination learning and assessment procedure for medical students: Initial validity evidence. Med Educ. 2009;43:729–740.
In Reply to Gowda et al and to Yudkowsky: 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-totoe 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
Academic Medicine, Vol. 89, No. 6 / June 2014
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 headto-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; [email protected].
into an HTT exam. However, it is our impression that if the Core + Clusters curriculum is learned, there would be no need for students to perform the HTT in clinical settings. The Core + Clusters curriculum is designed to allow students to identify and perform maneuvers relevant to their particular patient, without the rote learning that the HTT perpetuates. We agree with Dr. Yudkowsky that determining which of these approaches to learning the PE is most effective is testable, and we look forward to further contributions to this area of research. 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
Jeanne M. Farnan, MD, MHPE
Assistant professor of medicine, Department of Medicine, Harvard Medical School, and physician, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
Director of clinical skills education, University of Chicago Pritzker School of Medicine, Chicago, Illinois.
Reference
Jennifer E. Schwartz, MD Statewide course director, Introduction to Clinical Medicine II, Indiana University School of Medicine, Indianapolis, Indiana.
1 Yudkowsky R, Otaki J, Lowenstein T, Riddle J, Nishigori H, Bordage G. A hypothesis-driven physical examination learning and assessment procedure for medical students: Initial validity evidence. Med Educ. 2009;43:729–740.
Heather L. Heiman, MD Medical director, Clinical Education Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
In Reply to Yudkowsky: We agree with Dr. Yudkowsky’s statement that by breaking up the head-to-toe exam (HTT) into clinically relevant chunks, the Core + Clusters approach facilitates learning the physical exam (PE) as a purposeful, clinically contextualized activity. This approach is consistent with the previous work that she and others have done in the hypothesisbased PE.1 She proposes that after students acquire the habit of conducting a thoughtful and purposive PE, the full set of PE maneuvers could be integrated
While We Advocate for Integrated Electronic Medical Records, Continue to Empower Patients and Families To the Editor: Medical students everywhere sympathize with, and likely can unanimously relate to, Mr. Ehrmann’s1 account of his recent futile attempts to obtain a transfer patient’s medical records that were critical to ongoing treatment. Disjointed systems and unavailable archives regularly drive frustration and delay patient care. With each failed attempt to obtain records, the cycle of redundant diagnostic medicine repeats, as it is currently the only way to serve our patients in real time. I
835
Letters to the Editor
recall one patient with seasonal allergies and a benign murmur who had four echocardiograms in the span of one week as he drove across country, using different health systems along his trip, each having to obtain new “baseline” data because no previous study could be obtained. I applaud Mr. Ehrmann for shedding a direct light on these frequently occurring but often ignored incidents and his call for advocacy amongst young providers. Although no structured plans currently exist to standardize the electronic medical record interface, or require the universal use of these digital records at all practices, I argue that both patient and family empowerment must play a prominent role in making patient data more readily available to providers. Challenged as a clerkship student to provide patients with copies of new diagnostic data prior to discharge, I soon saw the value in placing information directly into the hands of the patient consumer to enable direct access for future reference. To maximize on this information handoff, and to address the ongoing need for clear and directed patient education at the time of discharge, methods of teach-back can be employed to ensure further patient and family understanding.2 Not only does this create patient autonomy and grant full disclosure regarding recent medical care but, in the event of readmission, this material may be more readily available to the patient and/or family. There are clearly limitations to this practice, as some patients do not have the capability, desire, or support system to receive and retain detailed diagnostic information. While we shouldn’t hold our breath advocating for seamless and integrated electronic medical records, perhaps equipping our patients and their families with vital and highly sought-after medical
836
data may provide ease of transition, safety, and better use of resources during subsequent health care interactions. Disclosures: None reported. John Daggett, Jr. Fourth-year medical student, Tufts University School of Medicine, Boston, Massachusetts; john.daggett@ tufts.edu.
References 1 Ehrmann DE. Overwhelmed and uninspired by lack of coordinated care: A call to action for new physicians. Acad Med. 2013;88: 1600–1602. 2 Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: A review of key issues for hospitalists. J Hosp Med. 2007;2:314–323.
In Reply to Daggett: I appreciate the argument posited by Mr. Daggett in relation to my commentary. His premise—that physicians can empower patients by providing them copies of their important medical data upon hospital discharge—is certainly important. This is often the best we can do at the present time, and indeed, many institutions utilize this practice. However, in itself, this practice fails to foster the culture change I argue for in my commentary. Progress in care coordination can only be realized if we view the problem through the lens of partnership. In a culture of partnership, providers and patients equally accept the responsibility for facilitating optimally coordinated care. Providing patients with copies of their medical records upon discharge, although empowering, does not achieve true partnership. It places the responsibility entirely on patients to coordinate their
own future care. Although some patients are up to this arduous task, many simply are not. Even when patients maintain all of their health care documentation and verify understanding of their condition prior to recent discharge, there is often an inefficient transfer of information to new providers. New providers often find themselves digging through mounds of progress notes from three prior prolonged admissions. At best, this approach is inefficient. At worst, it promotes an enormous strain on the brand new patient–physician relationship. Perhaps a bigger step toward optimal care coordination—one that is consistent with the culture of partnership—is the use of online patient portals that are becoming more popular with electronic health record implementation. In theory, providers and patients work together to make sure that accurate information is available to patients in a user-friendly format. Patients can then be maximally empowered to transfer the information (in part or full) to anyone they wish at any time. Although there are many limitations to the use of online patient portals in their current form, we should not be dissuaded from envisioning their enormous potential. Imagine established providers working with patients to send specific documents to new specialists across the country in preparation for upcoming consultations. Imagine new providers and patients being able to peruse a recent discharge summary from a computer in an emergency room anywhere in the world. This is true empowerment, and it is only possible through a shared commitment to true partnership in care coordination. Daniel E. Ehrmann, MS Fourth-year medical student, University of Michigan Medical School, Ann Arbor, Michigan, at the time this was written; [email protected].
Academic Medicine, Vol. 89, No. 6 / June 2014
