Physical examination teaching for the 21st century:
How to incorporate bedside ultrasound into clinical
teaching rounds
Maral Nadjafi, Jordan Chenkin,
Rodrigo Cavalcanti, David Frost
October 19, 2012
Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Presenters
• Maral Nadjafi, MD, FRCP(C) – staff general internist, North
York General Hospital, Toronto
• Jordan Chenkin, MD, FRCP(C)- staff emergency physician,
Sunnybrook Health Sciences Centre, Toronto
• Rodrigo Cavalcanti, MD, FRCP(C)- staff general internist,
University Health Network, Toronto
• David Frost, MD, FRCP(C)- staff general internist,
University Health Network, Toronto
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We do not have an affiliation
(financial or otherwise) with
a pharmaceutical, medical
device or communications
organization.
Nous n’avons aucune affiliation
(financière ou autre) avec une
entreprise pharmaceutique, un
fabricant d’appareils médicaux
ou un cabinet de
communication.
Maral Nadjafi, Jordan Chenkin,
Rodrigo Cavalcanti, David Frost
October 19, 2012
Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Disclosures
1) None of the presenters have ever received compensation
from companies in the bedside ultrasound industry
2) Sonosite, Inc. has provided the use of point of care
ultrasound machines for this workshop
3) The entire content of this workshop was created by the
authors without any involvement of Sonosite, Inc.
4) The people who have kindly agreed to serve as models
in the hands-on component are being compensated for
their time by the Centre for Excellence in Education and
Practice (University of Toronto)
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Objectives for this workshop
1) Appreciate the value of bedside teaching and
reasons why its frequency has declined
2) Gain basic understanding of point of care
ultrasound and its uses
3) Create a lesson plan and practice teaching a
bedside session utilizing point of care
ultrasound
4) Analyze the benefits and challenges to using
ultrasound in bedside teaching
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
What this workshop is not
1) Instruction on how to perform point-of-care
ultrasound
2) For development of an ultrasound curriculum
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Plan for workshop
1) Review literature on bedside rounds and
introduction to point of care ultrasound (20
minutes)
2) Small group task: Develop a plan and practice
teaching examination for ascites incorporating
point-of-care ultrasound (40 minutes)
3) Re-convene: Discuss small group task and
share benefits, challenges and solutions (20
minutes)
4) Wrap up and conclusions
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Introduction
1) Review current state of bedside physical
examination rounds
2) Rationale for point of care ultrasound and
basics in its performance
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Why is teaching the physical
examination important?
1) It is an inexpensive, accurate diagnostic test
-shown in many contexts
-accuracy is dependent on correct, reproducible
performance of the examination
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Why is teaching the physical
examination important?
1) It is an inexpensive, accurate diagnostic test
-shown in many contexts
-accuracy is dependent on correct, reproducible
performance of the examination
2) Patients often expect a physical examination,
may enhance the patient-doctor relationship
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Why is teaching the physical
examination important?
1) It is an inexpensive, accurate diagnostic test
-shown in many contexts
-accuracy is dependent on correct, reproducible
performance of the examination
2) Patients often expect a physical examination,
may enhance the patient-doctor relationship
3) Leads to rational ordering of subsequent tests
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Bedside teaching- Definition
• Teaching and learning focused on, and usually
directly involving, patients and their problems
(Spencer BMJ 2003)
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
“In what may be called the natural method
of teaching, the student begins with the
patient, continues with the patient and
ends with the patient, using books and
lectures as tools, as means to an end. For
the junior student in medicine and surgery,
it is a safe rule to have no teaching without
a patient for a text, and the best teaching
is that taught by the patient himself” (Sir
William Osler, Address to the New York Academy of
Medicine, 1903)
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
“Empathy”
Artist: Dr. Ken Robb
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
“Epidemiology” – Temporal Trends
• In 1960s, bedside teaching = 70% of teaching
time, 1978 = 16%, even lower now
• 77% of patients enjoy bedside teaching, 83%
reported it did not cause anxiety
• Validity and utility supported by students,
trainees, and teachers in a variety of surveys
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
The Pros
• Face validity
• Meets needs of students, trainees, and
faculty
• Allows teaching of many physician roles
that are otherwise difficult
• Vital for skills like physical exam and
procedures
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
The Pros
• Learning is enhanced by direct
observation and performance
• Opportunity for faculty to demonstrate
correct performance
• Patient participation
• Improved understanding of patient
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Challenges of bedside teaching
Unanticipated events occur frequently
Ward team has varying levels of learners
Patients too sick or unwilling to participate
Trainees and teachers insecure about admitting
errors in front of patient and team
• Tendency by clinical teachers to lecture rather
than practice interactive learning
• Engaging all learners simultaneously can be
difficult
•
•
•
•
AMEE Guide no. 34: Teaching in the Clinical
Environment
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Ways to improve bedside teaching
•
•
•
•
•
•
•
•
Set clear, realistic expectations
Teach to learners’ needs
Observe performance and give specific feedback
Encourage independent learning and reflection
Vary your teaching methods in different contexts
Create a positive learning environment
Reflect upon and improve your teaching
Make learning memorable and fun
Parsell, G; Bligh, J. Recent perspectives on clinical teaching Medical
Education Volume 35, Issue 4, pages 409–414, April 2001
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Potential impact of incorporating ultrasound
•
•
•
•
•
•
•
•
Set clear, realistic expectations
Teach to learners’ needs
Observe performance and give specific feedback
Encourage independent learning and reflection
Vary your teaching methods in different contexts
Create a positive learning environment
Reflect upon and improve your teaching
Make learning memorable and fun
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Our challenge
• It has been proposed that “learners [being]
distracted by technology” is a hindrance to
bedside teaching*
• We believe this need not be the case
• We’ll see whether you agree at the end of the
workshop!
*Nair BK et al, University of Newcastle
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Technology in bedside teaching
Current situation?
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Introduction
1) Review current state of bedside physical
examination rounds
2) Rationale for point of care ultrasound and
basics in its performance
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Why do we need it?
• Clinical examination alone unreliable for many
important diagnoses
• Can lead to adverse patient outcomes
• Enhances accuracy of the physical examination
• Adds another point of data to clinical picture
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
How has it changed practice?
•
•
•
•
Free fluid in trauma
Ruptured AAA
Ectopic pregnancy
Cardiac tamponade
• Improved patient outcomes due to rapid and
accurate diagnosis and enhanced procedural
safety
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Standard Practice?
• Core requirement for many specialties
• Emergency medicine, obstetrics, anesthesia,
critical care
• Advanced training now common
• Other specialties adopting training
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Common Uses for Bedside Ultrasound
Pericardial effusion
JVP
Cardiac function
IVC for volume
assessment
• Ascites
• Joint effusion
•
•
•
•
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•
•
•
•
•
•
•
Pleural effusions
Pneumothorax
DVT
Pulmonary edema
Line placement
Lumbar puncture
Paracentesis
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Ultrasound Basics
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Ultrasound Equipment
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
The ultrasound screen
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Adjusting Gain
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Adjusting Depth
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Ultrasound Basics
• Fluid is BLACK
• Tissue/organs are GRAY and have TEXTURE
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Probe orientation
Always to the operator’s LEFT or patient’s HEAD!
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Is There Ascites???
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Ultrasound for Ascites
• Free fluid – one of the first applications of
bedside ultrasound
• Type of fluid indistinguishable (blood, ascites)
• High sensitivity (>90% for 250cc)
• High specificity (>95%)
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Morison’s Pouch
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Morison’s Pouch
KIDNEY
LIVER
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Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D
Free Fluid
LIVER
KIDNEY
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The Task
Create a lesson plan to deliver a teaching session to trainees
on examination for ascites that is augmenting by
ultrasound
• 20 minutes, nominate a group member to present
• Use the template as a guide for the lesson plan
• Use JAMA article as the basis for evidence based physical
exam
• Volunteers with “ascites”
• Ultrasound consultant
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Discussion
• Groups report back (5 min each)
– What worked in your group?
– Teaching strategies you chose?
– What did NOT work?
– Challenges in implementing at “home”
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Discussion
• Based on this workshop:
• Think of one thing you would like to
– Implement
– Improve
– Learn
• Write a “letter to yourself” using the
envelope and we will mail it to you
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Gel Rounds
• In our Clinical Teaching Unit, we developed an innovative
teaching session that combines bedside ultrasound with
physical examination teaching.
• We have called this session Gel Rounds.
• In a pilot study, we ran monthly sessions with 3-5 junior
internal medicine residents (Postgraduate year 1 and 2).
• So far, 50 residents have participated.
• See our poster- Abstract # 175 (Saturday 11-12:30)
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A session on Ascites
SCENARIO: Patient presenting with increasing abdominal
girth. Examine this patient to determine if there is ascites
TASK: Learn to examine patient for ascites using evidencebased medicine (JAMA RCE series used as discussion tool)
ULTRASOUND: Instructor to demonstrate how to check for
presence of ascites on ultrasound to confirm or disprove
exam findings
LANDMARKING: If ascites present, then instructor to
demonstrate how to use ultrasound for landmarking for
bedside procedures
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• PORTAL MED-ED TUTOR’S GUIDE- COMING SOON!
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Acknowledgements
• The Herbert HoPingKong Centre for
Excellence in Education and Practice
• Dr. Danny Panisko
• Sonosite, Inc.
• Our patient models
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