Abstract
To the Editor:
Throughout medical school, education of students in the art of the physical exam has been an experience of mixed messages. Early on we are meticulously taught the nuances of examination findings and their significance to diagnosing disease. Educators spend hours emphasizing the sensitivity, thoroughness, and tact that this unique interaction requires. Armed with the foundation of diagnostics, we head to the wards ready to put our new skills to work. There we find that the reality of a busy, modern teaching hospital offers a very different message. We quickly realize that our discovery of heart sounds, abdominal tenderness, and pronator drifts are merely a prelude to echocardiogramss, computed tomography scans, and magnetic resonance images. Our preceptors applaud our enthusiasm, but any therapeutic consideration from our discoveries is trumped for the certainty of gold standards. Exam findings are shrugged off as interesting anomalies, a means to justify further testing rather than significant in and of themselves. Thus encouraged to think efficiently and move quickly through the standard algorithms, medical students wonder if the physical exam is actually a vestigial skill, akin to a history class providing context for a modern political science course.
An interesting counterpoint may lie in Wilderness Medicine education. This discipline, a rapidly growing area of medical education, offers not only a fresh environment for teaching but also a rationale for the premise that the physical exam remains an indispensable part of being a physician.
The observations above reflect a growing trend seen in medical education, and the diminished proficiency of these skills is a well-published phenomenon. 1 -4 Time pressures on the teachers have been likewise noted to contribute to this issue. While direct bedside observation and critique of the student-patient interaction seems to be the best method to teach, physicians have little time to adhere to these practices.5,6 Instead, other obligations and teaching points take precedence over bedside lessons, such as discussion of diagnostic imaging and lab results. 7 These aspects of education are essential to learn and require dedicated teaching but have a very different emphasis than physical diagnosis. The physical exam encourages an overview independent from instrumentation, to more successfully ensure a broad differential and rule out unnecessary testing. It emphasizes personal and lengthy contact with the patient, allowing the establishment of a rapport and further revelation of clinical issues. These elements are understandably difficult to sustain in a hurried hospital setting busy with readily available diagnostic equipment. An environment away from the pressures found in hospitals may paradoxically facilitate the teaching of physical exam skills.
Wilderness Medicine education is an area of medical teaching that necessarily underscores the importance of physical diagnosis. Practicing the physical exam in a wilderness setting ensures a location away from the hospital, without the presence of the technology that undermines the necessity of examination techniques. In the outdoors, students cannot forego attention to a finding because an echocardiogram or magnetic resonance image is available. Both physicians and students are free from the distractions and obligations that normally hurry them through exams. Already, students of Wilderness Medicine recognize the practicality of learning care without the technology of a hospital. 8 Emphasizing this capability of Wilderness Medicine education can restore a sense of confidence and reliance in physical diagnosis, highlight the importance of these skills, and garner interest in this growing field.
Teaching the physical exam in a wilderness setting is all the more useful when considering scenarios in which physical diagnosis is particularly essential, such as disaster or rural medicine. Disaster situations, as in natural or terrorist events, have forced physicians and medical administrators recently to look at preparedness and their ability to handle emergencies. Findings indicate that a thorough and skilled physical examination allows for quick allocation of needed resources, including tests and imaging that might be overwhelmed. 9 In settings with austere resources, such as practice in rural areas or developing countries, the scarcity of diagnostic technology forces a greater reliance on these clinical skills. 10 One of the hallmarks of Wilderness Medicine teaching programs has been the use of scenario-based learning with an emphasis on real-time decision making with live “victims,” a technique that translates well to these areas of medicine. Wilderness Medicine education, therefore, can meet a growing interest in and necessity for practicing in limited-resource situations, through its focus on the physical exam and other advantages of its location.
Wilderness Medicine education cannot provide everything essential to learning these skills. Exposure to pathology necessitates real patients—one will not find a cirrhotic liver or a third heart sound in a wilderness-teaching scenario. Yet understanding that technology enhances but does not substitute for a physician's acumen is imperative to mastering the physical exam, and becoming a mature physician.
Students must reconcile the necessity of the physical exam with the necessity of technology. Capability in both ends of the clinical spectrum allows the practitioner to act as a mediator, emotionally and intellectually, between the patient and the probing medical technology—an “essential filter . . . for the proper use and interpretation of the laboratory.” 11 The rapid innovations in our world today suggest much of how we practice medicine will soon become obsolete. Likewise, by innovating our medical school teaching strategy to incorporate Wilderness Medicine education we can ensure appreciation of and proficiency in physical diagnosis for future generations of physicians.