Stanford Medicine Newsletter Updates For the Local Community

 

Back to the bedside

A renewed focus on the practice of physical exams

   

“What do you notice about this patient?” Abraham Verghese, MD, asked the four students as he nudged them closer to the bed. The patient, a 44-year-old woman, smoothed her blondish hair and adjusted her hospital gown to cover herself.

Well, her sclera (the whites of her eyes) look a bit yellow, one volunteered. Verghese, a professor of medicine, nodded. He gently picked up the patient’s hand and pointed to a curious pattern on her palm—islands of intense redness on a background of pale white skin. “That’s palmar erythema,” he said.

He helped a student locate a distinct raised and thickened tendon in the palm, a condition called Dupuytren’s contracture, which occurs in patients with liver disease. Next he noted that the patient’s pulse could be felt by holding the wrist as if trying to pull her up; the forceful beat is known as a “bounding” pulse, a sign of a wide pulse pressure that can occur with liver dysfunction.

These are common observations, Verghese said later, and though students may know about them in theory, they may not have observed them in practice.

The professor, with the patient’s permission, exposed the skin just under the collarbones, revealing red, star-shaped markings—spider angiomas fanning out like the threads of a spider web. The students leaned in to glimpse the unusual blood vessel patterns, which they had never seen before.

These and a host of other findings are classic signs of liver disease, said Verghese, the senior associate chair for the theory and practice of medicine.

“It would be unfortunate to use technology to tell us something that’s clear on the first blush,” he told the trainees. “That’s why this bedside practice is so useful. It helps us ask better questions of the tests we order.”

Bedside interactions

These weekly bedside teaching sessions are part of an effort by the Department of Medicine to resuscitate the vanishing art of the bedside exam. As doctors increasingly rely on imaging and other new technologies, they have strayed away from the practice of diagnosing disease on the basis of a physical exam.

What has been lost in the process, Verghese said, is not only the time-honored, meaningful ritual of the doctor–patient encounter, which can be therapeutic in itself, but critical information about the patient’s condition, which may be apparent days before a test (if ordered) reveals the same result.

Verghese, who considers the skilled exam a form of basic medical literacy, has made it his mission to revive the use of the physical exam nationwide. He credits Ralph Horwitz, MD, professor and chair of the Department of Medicine, who recruited him to Stanford three years ago, for giving momentum to the effort to help reshape the way medicine is practiced.

“We order tests so easily because, as my colleague [health economist] Alan Garber, MD, PhD, has said, our health care system feels like a ‘menu without prices’—we can order filet mignon every night. No one really stops to consider what a test costs or who is paying,” Verghese said. Reversing the trend is a daunting challenge, but he believes no effort is more important for medicine’s future.

“We make huge errors of oversight because certain conditions are staring us in the face—and we miss them,” he said.

Tools of the trade

After Verghese’s arrival at Stanford in 2007, he and Horwitz introduced the Stanford 25, an immensely popular “grand experiment” in which trainees in internal medicine receive focused instruction on 25 essential exam skills.

Each monthly session, part of the required curriculum, focuses on a single bedside diagnostic technique and what it can reveal. Sessions include examination of the thyroid, liver, spleen, neck veins, pupils, lungs and other organs.

Verghese uses real patients and standardized patients (actors) for some sessions, and occasionally students practice on each other. All trainees have been taught these techniques or know them in theory, he said, but the sessions emphasize hands-on practice.

Verghese also organized a national conference, the first Symposium on the Bedside Exam, at Stanford last fall, bringing together approximately 40 master clinicians from around the country who are interested in rejuvenating bedside skills.

Speaking nationally on the issue, he has struck a chord. More than 1,000 physician educators attended a talk on the bedside exam at the annual meeting of the Association of American Medical Colleges last November.

“I was mobbed by people wanting more details,” Verghese said. “The irony is that these skills have been around for at least a hundred years. The problem is that they have fallen into disuse.”

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