These excellent teachers helped me realize what strong clinicians do when examining a child with a focused complaint: they use clinical reasoning to guide the physical exam so it can best serve to confirm or exclude diagnoses. This article bridges the gap between those educators who exhorted you to “do a full physical exam,” and the attending ward physician who only wanted to hear about the few relevant positive, and even more challenging, relevant negative physical exam findings during a busy morning rounds.
Both the preclinical educator and the ward attending want the best for their student and the patient, but neither has actually cued the student or given them a skill set with which to do the job. While we expect students to do “a full physical,” we also want them to identify relevant findings, not simply produce an endless monologue of normal findings, the reporting of which mainly engenders fidgeting and interrupting.
The approach that Drs. Balighian and Barone describe integrates the purpose of the physical exam with the exam itself. Educators have the unique ability to give learners of every level that “eureka” moment: of course we do the physical exam to nail down the diagnosis! We examine the child to identify clues that support or refute our diagnostic thinking. The physical exam, then, is not a rote exercise, but rather a mental game in which we jump back and forth between potential diagnoses, looking for the key findings that will push our thinking forward. As soon as students (and we) realize this, the exam becomes a lot more enjoyable and more keenly focused because it is being done for a clear and interesting reason.
The case example offered by Drs. Balighian and Barone is ideal: a 4 year old boy with a petechial rash. Since a petechial rash has the potential to be the clue to a medical urgency or alternately, to a more common non-urgent condition, the history (what questions should we ask?) and the physical exam are crucial. The authors then give strategies for integrating the “hypothesis driven physical exam” into all aspects of teaching, from the specific clinical encounter, to review of the write up, to small group teaching. Enjoy this easy-to-read article-- it’s just plain fun to revisit “the why we do what we do” of our everyday practice.