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Do You Hear What I Hear?

teaching physical diagnosis

By Leslie Hill
February 2013

Photo by Susan Urmy

Photo by Susan Urmy

Michael Fowler, M.D., assistant professor of Medicine, teaches the Physical Diagnosis course to second-year medical students, which develops the skills for taking a thorough history and physical – from learning to use a stethoscope and otoscope to practicing patient interviewing and clinical observation.

Students are put through practice scenarios with standardized patients in the Center for Experiential Learning and Assessment (CELA), often with a hidden bit of information the student must tease out. For example, a “patient” with a bronchitis-like cough, the students discover, does not believe in vaccinations and has not been immunized against whooping cough.

While CELA is a safe environment for learning, Fowler believes real-life scenarios are most salient for students who are divided into small groups under a mentor and assigned patients to visit to practice history and physical exam skills.

A recent session had Fowler accompanying three students to visit a 71-year-old male who had surgery for obstructed renal arteries at an outside hospital, and had been transported to Vanderbilt after developing pneumonia and fluid in the abdomen. The patient was on contact isolation, so Fowler helped the students don their gowns, gloves and masks and reassured them that if they worked slowly around the trach and tubes, there was no danger for pulling them out.

Fowler told the students to listen for upper airway congestion (“a loud popping noise”) and demonstrated how to percuss the abdomen to assess fluid levels. (“Start anterior and go laterally and listen for the sound to change from resonant to dull.”)

As each student stepped up for a turn, Fowler told the patient he could start charging a quarter to listen to his heart. Student Dan Balikov continued the joke: “Do you take credit cards?”

“This was one of the most extreme cases – wearing gowns and gloves and listening to the heart and lungs and tapping the abdomen,” Balikov said.

“I will always remember those sounds now,” medical student Sarah Coggins added.

By the time these students reach their internal medicine rotation during their third year, they have learned the basics of the patient exam and are ready to put those skills to the test in the evaluation of patients in the hospital. The students are responsible for a patient’s full workup, from which they create a written assessment and plan, along with daily notes of the patient’s progress.

“That’s where their gathering of all the information, prioritizing, sequencing and reasoning of it all comes together. It is one important means of how students develop and demonstrate their emerging ‘Sherlock Holmes’ and care-giving abilities,” said Anderson Spickard III, M.D., M.S., associate professor of Medicine and director of the Third-Year Medicine Clerkship.

“They change so much during this year, I joke that their short coats get longer before my eyes.”

Once a week, the 30 students on the rotation gather for “Morning Report,” where three students informally present recent cases and the students practice making a diagnosis.

The students throw out every potential diagnosis, and then Spickard has them narrow the list to the most likely scenarios.

“We’re trying to get them to think about two to four things, not 12, and definitely not one,” he explained.


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