1. Bridging the Gap
Integrating Hypothesis-Driven Physical Exam and Clinical Reasoning to Mold the 21st Century Physician
Sirisha Narayana, Joshua Stein*, Anita Richards, Allison Ishizaki, Heather Nye, Susannah Cornes and Anna Chang
University of California, San Francisco School of Medicine
WGEA Conference, Salt Lake City, UT
February 26, 2017
*presenting

2. Roadmap
Describe current state of physical exam (PE) teaching and identify gaps in this model
Define purpose of our new curriculum
Elaborate key steps in building this curriculum
Highlight evaluation strategy
Share general conclusions and lessons learned
Context of physical exam teaching today  identifying the gaps  defining our objective  elaborating key steps in building this curriculum  evaluation strategy  conclusions and discussion points
Picture is Skyline Blvd (touch of NorCal to UT!)

3. Context
Physical exam (PE) has traditionally been taught in a head-to-toe manner
Experts advocate for a hypothesis-driven approach
Variations have arisen to adapt the approach to best serve early medical students
PE curriculum is an ideal location to incorporate instruction in clinical reasoning
1) The physical exam (PE) is a core skill set through which physicians gather patient data to help make clinical decisions. Inaccuracies in PE, including failure to perform key parts of the PE and misinterpretation of physical findings, contribute to medical error. PE has traditionally been taught in a “head-to-toe” comprehensive manner, favoring memorization and a sequential approach without clinical context. With students’ knowledge organized in this fashion, decision-making is less aligned with the multi-faceted way expert clinicians process clinical information.
2) Many experts advocate learning PE maneuvers in a more diagnosis-focused (“hypothesis-driven”) and contextually-relevant fashion to better facilitate retention of techniques while fostering appropriately focused exams during real patient encounters.
3) There is debate as to the exactly appropriate way to teach hypothesis driven approach given concern that early medical students may not have enough knowledge to learn PE skills in this manner. Uchida et al have advocated for a core+cluster approach (Uchida et al). But another recent study (Allen et al 2016) demonstrated that first year students were ready to learn in this manner and performed well with HDPE.
The PE curriculum thus serves as an ideal place to incorporate instruction in clinical reasoning and bridge the gap of integration.

4. Objective
Design and implement case-based standardized patient (SP) sessions in which first year medical students apply history-taking and hypothesis-driven PE skills, while integrating the clinical reasoning principles of data acquisition, problem representation, and building illness scripts.

5. Identified key chief complaints
Fatigue/Weight loss (“Undifferentiated” patient) x 2
Shortness of breath (CV/Pulm)
Vision Loss (HEENT/Ophtho)
Loss of consciousness (Neuro)
Shoulder pain (MSK)
Abdominal Pain (Abd)
Falls and functional/cognitive decline (Geriatric Assessment)
Using input from established curricula on hypothesis-driven PE and from local clinical experts, we identified the following essential “chief complaints:” fatigue, weight loss, shortness of breath, vision loss, loss of consciousness, shoulder pain, abdominal pain, falls and functional and cognitive decline.
We then created EIGHT modules based on these chief complaints and identified faculty leads for each module, with our first and last module being the undifferentiated patient so that students can practice the PE skills for all systems.

6. Breakdown for each 4 hour session
Session-oriented didactic (30-60 min)
History and Physical (SP) + Skills Feedback (2-2.5 hrs)
Student A: Performs clinical skills
Student B: Keeps time, prompts Student A
Student C: Fills out clinical reasoning worksheet
Clinical Reasoning Exercise and Debrief (30 min)
Each session begins with a didactic from their preceptor about essential concepts related to the students’ upcoming SP encounter (e.g. cardiac sounds, how to take vital signs, how to hold the otoscope, etc). Students then obtain a focused history and complete a physical examination (data acquisition). While one student is performing these clinical skills, another functions as a time-keeper and prompts her peer with possible exam maneuvers from a comprehensive checklist developed by local content area experts. Meanwhile, the third student in the room is developing an evolving problem representation and differential diagnosis as information is obtained from the history and the physical exam. At the end of the session, students regroup with their preceptor to discuss their problem representation and differential.
During each session, students received focused feedback from their preceptor on their history-taking and physical exam technique. They also receive feedback from their SP’s on communication, basic exam technique, and flow of the clinical encounter.

7. Simulation
Try to Add Images with the 4 examples above for the Simulation we incorporated into the sessions.
SAM II (Card/Pulm)
Lymphnods (Derm)
Hazard Room (Geriatric Assessment)
Ultra Sound (Abdomen)

8. Clinical Reasoning
Sample clinical reasoning worksheet – hand out to audience??

9. Student and Faculty Preparation
Students:
Watched skills-based videos or read content-relevant material
Completed online pre-session self-assessment
Faculty:
Facilitator guide
In-person faculty development session with module lead faculty week prior to SP session
Access to all student preparation materials
Prior to each session, students are expected to watch skills-based videos or read content-relevant material and complete an online self-assessment as preparation.
Preceptors were trained through a developed facilitator guide, in-person faculty development sessions the week prior to the SP session.

10. Evaluation: Kirkpatrick’s Four Levels of Outcomes
Results
Transfer
Evaluation of preceptor perception of student readiness for clinical preceptorships
Learning
Mid year MS1s > 80% accuracy in clinical checklists developed by faculty clinicians in the medical history, PE, and communication.
Reactions
Random sample of students (46/152) rated sessions at 4.54 (SD 0.75) after the first four months of the curriculum.
Only five months into medical school, our MS1s have demonstrated outstanding direct patient care skills, at and beyond the MS2 and MS3 level from prior years.
Attitude (bottom of pyramid): On a scale of 1 (poor) to 5 (excellent), a random sample of students (46/152) rated these SP clinical skills sessions at 4.54 (SD 0.75) after the first four months of the curriculum (August to December 2016). Superlative comments include "I highly enjoyed the clinical skills Kanbar sessions,” "I really enjoy the CMC curriculum and love the Kanbar sessions,” and "I would like to spend more time in Kanbar learning clinical skills."
Knowledge/Skills (level two): As a class, mid-year first year medical students scored on average great than 80% accuracy in clinical checklists developed by faculty clinicians in the medical history, physical examination, and communication skills. The score is higher than outcomes from comparable examinations administered in a prior curriculum to end of second year students.
Level 3 is transfer (i.e. clinical environment
PREVIOUS NOTES FROM MEETING:
Interstation exercises
Kirkpatrick’s pyramid: attitude (students liked these session: student feedback), knowledge (show a write up or checklist etc), skills (we could watch every student do this via B line video), don’t have how they use this in a clinical setting.
Student feedback – comments present vs focus groups (Anna) [focus groups]
Knowledge – checklist (communication, history, pe: overall score), mention other components (note writing, etc)  numbers for the clinical reasoning station, PE and history (comparisons from previous years). Note writing (only ask H&PE here) and clinical reasoning: use these a new innovations to set a standard (meet our standard)
Skills – Review B line videos ourselves as clinicians to balance (Susannah)
Use in the clinical setting – milestone-based question? Week of 4/25, capstone as end of ICS  “how well did the ics sessions prepare students for preceptorships in clinical setting Jan – May” “At what level is your student performing (MS3?)”; look at notes, etc. (Everyone)
Other evaluation opps:
1. Pose questions to students

11. Conclusions
A clinical skills curriculum incorporating focused history-taking, hypothesis-driven physical exam, and clinical reasoning principles, is feasible and may address the gap of integration of previously isolated clinical skill techniques.

12. Acknowledgements
Anna Meyer, MD Jacque Duncan, MD Nikki Schroeder, MD Derek Harmon, MD Kim Topp, PhD, PT Emma Webb, MD Jacklyn Lee, MD
Sneha Daya, MD
Kanade Shinkai, MD
Wes Cayabyab
Marika Smally
Denise Connor, MD
Catherine Lucey, MD
UCSF Class of 2020 Students and Faculty

13. [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
7/30/2018