Physical examination teaching for the 21st century:
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 The International Conference on Residency Education | La conférence internationale sur la formation des résidents 2 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) The International Conference on Residency Education | La conférence internationale sur la formation des résidents 4 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 The International Conference on Residency Education | La conférence internationale sur la formation des résidents 5 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 The International Conference on Residency Education | La conférence internationale sur la formation des résidents 6 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 The International Conference on Residency Education | La conférence internationale sur la formation des résidents 7 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 The International Conference on Residency Education | La conférence internationale sur la formation des résidents 8 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 The International Conference on Residency Education | La conférence internationale sur la formation des résidents 9 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 The International Conference on Residency Education | La conférence internationale sur la formation des résidents 10 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 The International Conference on Residency Education | La conférence internationale sur la formation des résidents 11 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) The International Conference on Residency Education | La conférence internationale sur la formation des résidents 12 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) The International Conference on Residency Education | La conférence internationale sur la formation des résidents 13 Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D “Empathy” Artist: Dr. Ken Robb The International Conference on Residency Education | La conférence internationale sur la formation des résidents 14 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 The International Conference on Residency Education | La conférence internationale sur la formation des résidents 15 Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D The International Conference on Residency Education | La conférence internationale sur la formation des résidents 16 Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D The International Conference on Residency Education | La conférence internationale sur la formation des résidents 17 Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D The International Conference on Residency Education | La conférence internationale sur la formation des résidents 18 Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D The International Conference on Residency Education | La conférence internationale sur la formation des résidents 19 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 The International Conference on Residency Education | La conférence internationale sur la formation des résidents 20 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 The International Conference on Residency Education | La conférence internationale sur la formation des résidents 21 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 The International Conference on Residency Education | La conférence internationale sur la formation des résidents 22 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 The International Conference on Residency Education | La conférence internationale sur la formation des résidents 23 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 The International Conference on Residency Education | La conférence internationale sur la formation des résidents 24 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 The International Conference on Residency Education | La conférence internationale sur la formation des résidents 25 Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D Technology in bedside teaching Current situation? The International Conference on Residency Education | La conférence internationale sur la formation des résidents 26 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 The International Conference on Residency Education | La conférence internationale sur la formation des résidents 27 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 The International Conference on Residency Education | La conférence internationale sur la formation des résidents 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 The International Conference on Residency Education | La conférence internationale sur la formation des résidents 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 The International Conference on Residency Education | La conférence internationale sur la formation des résidents 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 • • • • The International Conference on Residency Education | • • • • • • • Pleural effusions Pneumothorax DVT Pulmonary edema Line placement Lumbar puncture Paracentesis La conférence internationale sur la formation des résidents Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D Ultrasound Basics The International Conference on Residency Education | La conférence internationale sur la formation des résidents Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D Ultrasound Equipment The International Conference on Residency Education | La conférence internationale sur la formation des résidents Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D The ultrasound screen The International Conference on Residency Education | La conférence internationale sur la formation des résidents Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D Adjusting Gain The International Conference on Residency Education | La conférence internationale sur la formation des résidents Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D Adjusting Depth The International Conference on Residency Education | La conférence internationale sur la formation des résidents 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 The International Conference on Residency Education | La conférence internationale sur la formation des résidents 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! The International Conference on Residency Education | La conférence internationale sur la formation des résidents Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D Is There Ascites??? The International Conference on Residency Education | La conférence internationale sur la formation des résidents 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%) The International Conference on Residency Education | La conférence internationale sur la formation des résidents Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D Morison’s Pouch The International Conference on Residency Education | La conférence internationale sur la formation des résidents Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D Morison’s Pouch KIDNEY LIVER The International Conference on Residency Education | La conférence internationale sur la formation des résidents Workshop- Ultrasound in bedside rounds| Nadjafi, M; Chenkin, J; Cavalcanti, R; Frost, D Free Fluid LIVER KIDNEY The International Conference on Residency Education | La conférence internationale sur la formation des résidents 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 The International Conference on Residency Education | La conférence internationale sur la formation des résidents 44 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” The International Conference on Residency Education | La conférence internationale sur la formation des résidents 45 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 The International Conference on Residency Education | La conférence internationale sur la formation des résidents 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) The International Conference on Residency Education | La conférence internationale sur la formation des résidents 47 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 The International Conference on Residency Education | La conférence internationale sur la formation des résidents 48 • PORTAL MED-ED TUTOR’S GUIDE- COMING SOON! The International Conference on Residency Education | La conférence internationale sur la formation des résidents 49 Acknowledgements • The Herbert HoPingKong Centre for Excellence in Education and Practice • Dr. Danny Panisko • Sonosite, Inc. • Our patient models The International Conference on Residency Education | La conférence internationale sur la formation des résidents 50 Help us improve. Your input matters. 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