The Senior Faculty Member Perspective
John Kugler’s candid and heartfelt narrative confirms what I think has happened with bedside skills: we simply are not teaching these skills where they matter most, and that is on the wards during the clerkship and subinternship years, or even in residency training. We get away with it because we use technology so abundantly.
I think a major reason for the decline in skills is that formal testing of these skills does not take place at the end of medical school. The National Board of Medical Examiners, in its USMLE Clinical Skills Exam, does not emphasize clinical skills in the sense of testing technique—can the student elicit a normal knee reflex?
Similarly, even after 3 years of internal medicine training, the physical diagnosis skills are not really tested before board certification. As Dr. Kugler describes, we make assumptions that when someone says the exam was “normal,” it was, when in fact I think trainees are nowhere as certain about physical findings as they are about the dose of Lasix or the approach to hyponatremia.
I have no doubt that if we attempted to put in place a standardized test using standardized and real patients, with examiners watching for technique as well as understanding of the methods of bedside examination, our students and residents would (much as they do in Canada and Britain) spend a lot more time mastering these skills in anticipation of the test. We would be teaching to the test.
The public would be horrified to find that a pilot gets a license without having flown a plane with an instructor sitting next to the pilot and watching every move. But in a sense that is what we do when it comes to the physical exam—there is no testing by an examiner.
I have great confidence in the clinical knowledge and patient management skills of our students and residents, but the area of bedside skills is in need of improvement, particularly if we are to practice cost-effective medicine and minimize a patient’s exposure to radiation. Recent studies have shown that a patient’s exposure to ionizing radiation as a result of imaging studies can be quite significant, and the long-term ramifications of such exposure have not been studied . Imaging tests are valuable and often necessary, but if simple bedside skills make them unnecessary, then the lack of such skills is not just costly, but dangerous. We have to be sure people can fly before we let them go solo.
- Fazel R, Krumholz HM, Wang Y, et al. Exposure to low-dose ionizing radiation from medical imaging procedures. N Engl J Med. 2009;361(9):849-857.