Monday, 30 July 2007

Let's Get Physical-- Let's Get Training

During my time in Japan I have been able to assess the medical students way of examining patients and to some extent the skills that have been taught are sometimes inadequate for finding common clinical signs.

This is a concern for me because some of the students are soon to become junior doctors.

For example, I have recently seen several medical students miss a basal pneumonia that was identifiable from loud wet crackles. The reason was the students only examined half the lungs ! Each made the same mistake.

They only placed their stethoscopes half way down the chest at the back and said they could hear no problem. Only when demonstrating the surface anatomy of where the lungs commence (at the apex) and where they finish (12th ribs posteriorly) were they able to then understand that the lungs fill the entire space and hence, they should listen at the lung bases as well.

Even after doing this, only one student was able to identify the sounds suggesting that the practical, 'hands on' ability to detect through physical examination was previously not taught to them optimally.

Moreover, one medical student started examining with his stethoscope through the patient's clothes, which must not be done as it is not possible to always differentiate the rubbing of the clothes from the sounds in the patient's chest.

So, why are some Japanese medical students unable to identify pathology / diseases through physical examination? The problem may be when they start learning physical and how they learn it.

In the UK, modern medical school teaching starts with physical examination right from the first year. This is not the case in Japan where physical only starts from 3rd/4th year onwards. Moreover, some medical students have also said to me that the opportunities to examine patients at medical school in Japan are too few.

Hence, by the time some medical students start to visit other hospitals to decide where to do their two-year residency, it becomes clear to me that some institutions training in physical examination is not optimal. Of course, this is a generalisation and on a case-by-case basis, but a final year medical student in the UK would be expected to be able to examine the three main systems (e.g. cardiovascular / respiratory / abdominal) and to pick up straight forward diagnoses such as pneumonia, pleural effusions etc...

The utility of percussion of the chest for signs of consolidation or effusion is not universally taught in Japan as some medical students have never seen this done before until they visit me at my hospital. They have been reliant on the chest xray / CT to make the diagnosis for them. Even if some students have seen percussion done, they have not fully appreciated its significance or the great utility that it has to offer until they come to this institution.

Examining simple things such as the hands and the quality of the pulse are, in my experience, not considered by medical students as important, and hence, if one were to start from the eyes, as is done in Japan, the patient's physical examination misses a vital area. Essentially, the patient has no arms as no parts of the upper limb are examined !

Things such as clubbing, splinter haemorrhages, Beau's lines, Janeway lesions, Osler's nodes, Dupytren's contracture, nerve palsies, metabolic flap, collapsing / slow rising pulses are MISSED because they are not examined for. Serious diagnoses can therefore be missed.

I also did a local seminar last weekend where I presented a case of a dissection of the aorta. I was asked whether Review of Systems questioning was necessary and worthwhile because it took so much time. I am glad that such a question was asked and of course, it is indeed very important because it is a safety net for the patient and the doctor to pick up additional information that might help with the diagnosis / diagnoses that may have been overlooked by the patient and the doctor.

Taking a little bit of extra time at the beginning might save the doctor time in the future by cutting down on unnecessary tests / scans.

Communication with the patient and thorough history taking is Essential. I am somewhat concerned that medical students do not find that this might be useful because of time constraints. This may also be because of the reliance on laboratory data, xrays and other advanced radiological studies rather than the basics of a good story of the problem and then having the appropriate skills to find the problem(s) by physical examination.

Whilst medical students come to visit here for three days only on their tour of different institutions, it is never possible to show just how the basics of being a doctor can provide quick and straight forward answers that might otherwise not be obtainable by any scan ! However, they are able to see how classical physical examination should be and how it is possible to dissect and rebuild a junior doctor's patient history so that the problem(s) can be elucidated and hence, following that, how appropriate investigations and treatment should be considered.

For those interested in improving 'level up' on history and physical, they should consider coming here for more than 3 days as it is otherwise insufficient time to obtain the true nature of what is on to offer to the medical students.

Essentially, with an ever growing elderly population and few doctors and with a large medical expenditure in Japan, I believe it will become evermore important for doctors to take more time on history and physical so that instead of doing 'blanket' blood testing and scanning otherwise referred to as the 'pan-man' scanning, the doctor will order tests related only to their considered differential diagnosis rather than doing lots of tests without really knowing what to look for and hoping to find something, as this is not efficient or cost effective.

If you are interested in an externship or a longer period than three days then please let me know on