RESTORING CARDIAC PHYSICAL DIAGNOSIS: TOOLS FOR TEACHING

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1 RESTORING CARDIAC PHYSICAL DIAGNOSIS: TOOLS FOR TEACHING STUDENTS, RESIDENTSANDFACULTY Subha Ramani, MBBS, MMed, MPH Associate Professor of Medicine Boston University School of Medicine Jasminka Criley, MD, FACP, FHM Associate Program Director Medicine Clerkships and Electives Site Director St. Mary Medical Center and UCLA David Geffen School of Medicine AGENDA I. Introduction and learning goals II. Interactive group discussion about curricula, techniques, teaching andtesting methods currently utilized III. Review of the Literature IV. CE curricula for medical students and residents OSCE as needs assessment Bedside rounds Virtual patients V. Cardiac Examination Workshops for Faculty: a. Case based basedinstruction b. Using cardiac examination validated testing tools VI. Panel Discussion: a. Pros and cons of different approaches. b. Implementation into your own program: next steps and overcoming barriers

2 Workshop objectives By the end of the workshop, participants will be able to: Be able to cite the current literature about the state of the cardiac physical examination and its teaching and assessment. Know different tools available for teaching and testing cardiac examination skills and understand advantages and validity of each of the tools Be inspired to structure curricula in their own Institutions to improve cardiac examination skills among medical student, residents and/or faculty OSCE as curriculum needs assessment and teaching tool

3 PGY1 OSCE Boston University Medical Center Mandatory for all categorical residents House staff rotate through 5 stations Heart, lung, abdomen, joint, neuro Real patients 10 minutes per station 70 min total duration for eachhouse house officer Faculty observer at each station will direct what exam to perform, score and give feedback ul ad e L ro s u os dm t n lk i g oe an s gl ca t ye la x et ea x i m xl a o am n me x a m 10 min 10 min E2 E6 12 housestaff, 2 sets of stations: 60 minutes + 8 min change time 10 min 10 min E3 10 min E5 10 min E4

5 Teaching Medical Student Stanford University Medical Center Program Design: Cardiac Exam Tutorial CE Curriculum Design: Fall, winter, spring blocks Cardiac Computer Lab Final Exam: cardiac station mini OSCE Teaching Medical Student Stanford University Medical Center Critical factors for success: Administrative buy in Faculty/Physicians development

group (n=18) Tested at the beginning and end of IM clerkship

6 Teaching MS 3 and MS 4 Harbor UCLA Medical Center Operation Heart Sounds (Harbor UCLA) Students: Intervention group (n=21) Control group (n=18) Tested at the beginning and end of IM clerkship rotations Vukanovic-Criley, JM. Et al. Clinical Cardiology. 2008; 31 (7): 334-9

7 CE Competency Third Year Medical Students Vukanovic-Criley, JM. Et al. Clinical Cardiology. 2008; 31 (7): Teaching MS1 MS4 Longitudinal Cardiac Exam Curriculum (Dr. Rebecca Shunk at UCSF)

8 Cardiac Exam Competency Interns Vukanovic-Criley JM et al. J Hosp Med. 2008; 3(2) Teaching Students and Residents Online homework and classroom teaching Pre test and Post test Survey Results

9 Challenges: Design issues: Frequency and duration of Teaching Frequency of Testing Crowded curriculum Lack of teaching resources Evaluations on Live patients Variability of findings Availability of patients Scheduling Students/Residents

10 Evaluations on Virtual patients Findings are objective and reproducible All patients Dx confirmed by cath Availability of patients Always available Scheduling Students/Residents Cardiac exam Workshop for Faculty Cardiac exam Workshop for Faculty A Case based approach

11 Objectives Discuss best techniques to elicit common physical lfindings seen in Mdii Medicine wards and clinics Interpretation and clinical significance of common findings Discuss strategies to teach physical diagnosis Discuss reported sensitivity and specificity of findings Case 1 A 78 year old man with no past cardiac history presents with recent onset shortness of breath on exercise with tightness in his chest. Last fall he nearly passed out while working in his garden. On examination, his blood pressure is 120/90, and his carotid upstrokes are diminished. His apical impulse is in the 5th intercostal space and is sustained. S1 is normal, S2 is single. The clinical diagnosis is:

12 Case 2 A 53 yr old man is day 3 following an acute myocardial infarct, suddenly becomes acutely short of breath and develops pulmonary edema. On examination, his heart rate is 130/minute, his blood pressure is 100/70 and examination of his lungs reveals rales 2/3 up both lung fields. Cardiac exam: The likely diagnosis is: Clinical significance of systolic murmurs Is this murmur functional or organic? 90% of young and 50% of older adults have innocent murmurs. A well established combination of findings indicate an organic murmur LR 38.3 What is the responsible lesion? Is this lesion severe?

14 Does the patient have aortic stenosis Prolonged carotid pulse 95% Sp Pl Palpate for brachio radial, apical carotid delays dl Intensity and Splitting of S2 Intensity of murmur: Sn 29%, Sp 90% Does murmur radiate: Right clavicle Right carotid artery Dynamic auscultation Stand to squat Passive leg raise Clinical predictors of severe AS Effort syncope effectively rules in AS Carotid upstroke delay and decrease (positive LR 130) Late peaking of the murmur (positive LR 101) Decreased or absent A2 (positive LR 50) Apical carotid or brachio radial delay (positive LR 6.8)

15 Does the patient have MR Murmur in mitral area (positive LR 3.9) Late or holosystolic murmur (positive LR 1.8) Any murmur during acute MI (positive LR 4.7) Increase in intensity with transient arterial occlusion (positive LR 7.5) Dynamic auscultation Passive leg raise, inspiration, abdominal pressure: increase venous return Squatting, transient arterial occlusion: increase afterload Standing: decreases afterload Valsalva phase 2: decreasesvenous return, therefore stroke volume

16 12 tips for teaching physical exam Physical exam should be reflective guided by diagnostic hypotheses The most skilled clinicians should be recruited for PEx teaching Establish a structured and longitudinal curriculum Integrate simulation with bedside learning Teach it well: use a systematic approach Make it fun The clinical detectives 12 tips for teaching physical exam Increase and improve bedside clinical teaching Technology can help not hinder physical exam teaching Apply basic sciences to clinical exam Assessment drives curriculum Staff development: Teach the teachers clinical skills Integrate into the institutional values

Virtual Patient Examinations: Teaching Cardiac Clinical Skills to Medical Students and Residents

Virtual Patient Examinations: Teaching Cardiac Clinical Skills to Medical Students and Residents Workshop Faculty Coordinator: Jasminka Vukanovic-Criley, MD, FACP, FHM Additional Faculty: Preetha Basaviah,