Spring Quarter - 2009

A.        Course Requirements

The requirements for ICM I are as follows:

• complete a total of 7 medical interviews and write-ups (1 or 2 in spring quarter)
• 7 total interviews, including 1 observed interview and 1 standardized patient interview
• complete at least one videotaped patient interview during the year and have it reviewed by small group leaders
• attend and participate in small group sessions, including completing any assigned readings and preparation for small group activities
• attend and participate in all physical examination teaching sessions and required workshops
• demonstrate satisfactory performance of the basic physical examination before a faculty examiner
• submit a satisfactory write-up of the final basic physical exam
• participate in the Otolaryngology (ENT) Tutorial

Small group leaders, in consultation with the course chairperson, may make additional requirements, either of all students in their groups or of individual students who they believe will profit from additional experience or practice (see below).

B.        Overview of Spring Quarter

During HuBio 535 you will continue to work on the skills you began to learn and practice in the first two quarters of the course.  In addition, during this quarter you will begin the process of learning to perform the physical examination.  This activity is central to the skill of a physician.  Competence and confidence in the performance of the physical exam are the foundation upon which the other aspects of clinical medicine are based.  This quarter you will learn the basic physical examination.  Next year in ICM II you will build on this basic exam as you learn the various advanced physical exams.

Learning to perform a physical examination causes some anxiety for almost all students.  In the same way that the medical interview involves a change from the usual rules of conversation, the physical examination involves dramatic changes from the usual rules of physical interaction.  Some anxiety is inevitable and it is important for you to recognize this fact and to acknowledge and respect these feelings.  Discussing concerns with one another, with your small group leaders, and with course faculty is important and beneficial.  An important part of this process, and of becoming competent and responsible physicians, is learning sensitivity and respect for patients’ modesty and concerns.  This is an extension of the same issues you are dealing with in learning good interviewing skills and in developing your professional identity and sense of professional ethics.

Finally, the work you are doing this year in learning all of these skills is just the beginning of a process of life-long self-instruction and self-examination.  In the same way that you will need to continue to study whatever medical literature is appropriate to your chosen field, you will have to continue to work at maintaining and enhancing the non-cognitive skills of medical practice.  Approaching these activities with dedication and seriousness is the beginning of that life-long process.

Your feedback on any and all aspects of the course – organization, syllabus, labs, lectures, small groups – is very valuable and much appreciated.  Please contact Dr. Goldstein, Dr. Maestas, or Dr. Isaac any time during the course to discuss any of these matters.

C.        Objectives

This quarter you will continue to work on the objectives of the first two quarters of ICM I:

• develop interpersonal communication skills and effective interview methods involving questioning, listening, and observational skills
• develop and practice standards of professional conduct in medicine including:
  • demonstration of sensitivity and caring towards patients
  • appropriate appearance and demeanor in clinical settings
  • responsible performance in commitments, appointments and record keeping
  • conscientious self-directed learning
  • ethical conduct, especially regarding confidentiality and personal integrity
• develop a systematic approach to gathering and organizing a complete medical history
• develop a systematic approach to recording the medical history using the POMR format

In addition to continuing work on these objectives, this quarter will include the following objectives:

• learn to perform a standardized basic physical examination and to appreciate the rationale for that examination
• learn the correct use of the medical instruments in the performance of the physical examination
• develop a systematic approach to recording the basic physical examination
• develop a systematic approach to the verbal presentation of the medical history
• begin to gain an understanding of the clinical reasoning process

D.        Instructional Methods

The course objective will be addressed in several different ways, some are continuations from the first two quarters, some are new this quarter:

• Whole class lectures
• Interview and write-ups
  • As in the previous quarters, write up and critique forms must be uploaded to the portfolio within 48 hours for review.  Failure to meet the deadline requires that a make-up interview be scheduled and completed.  As previously, the interviews this quarter will be conducted at one of the teaching hospitals.
• Small group sessions
  • Regular participation in small groups is required, as are completion of assigned readings and preparation for small group activities.  If you are unable to attend a Friday session, please let either your small group leaders or someone in the ICM office know prior to the session.
• Physical exam labs
  • Attendance and participation in all lab sessions is required.  If you are unable to attend a lab session please let your senior student tutor and/or the course chair know prior to the session.  If you are unable to reach the tutor, call the staff in the ICM office prior to the session and we will make sure the tutor gets the message.
  • At the end of the year, each student performs the basic physical examination on a partner of his or her choice before a faculty observer.
• Otolaryngology (ENT) Tutorial
  • This is the first of the “advanced physical exam tutorials” which continue throughout second year of ICM linked to the organ system courses
  • Lecture followed by tutorial session in the Otolaryngology Clinics at the UWMC
  • Attendance is required

E.         Resources

Textbooks

There is no required text for this quarter.  For resources related to interviewing and professional issues, please see the list of recommended texts for the first two quarters.  These texts contain very little relating to the development of physical examination skills.  Therefore, the resources listed in this section relate to these skills almost exclusively.

The three main recommended texts, all of which are on reserve in the Health Sciences Library, are the following:

Bickley, LS:  Bates’ Guide to Physical Examination and History Taking (9th edition).  Philadelphia: Lippincott, 2006.  This is the required physical exam textbook for ICM II.  This is a detailed text with far more information than you will need this year, but one which many students find useful and which is an excellent reference for future use.  Probably one of the most widely used physical examination textbooks.

Seidel, HM, Ball JW, Dains JE, Benedict GW:  Mosby's guide to physical examination (5th edition).  St. Louis, Missouri, 2003.  This is another basic textbook for physical examination used at some medical schools.

Swartz, M.  Textbook of Physical Diagnosis: History and Examination. (5th Edition).  Philadelphia, WB Saunders, 2006.  Incorporates a review of specific symptoms and aspects of the history and pathophysiology related to each part of the examination.  Again, a great deal more detail than you will need this year, but also an excellent reference for the future.

All three of these texts have a great deal more information in them than you will need in learning the basic physical examination this year.  They are intended as references.  Please do not be overwhelmed by the level of detail they provide, and be assured that we do not expect you to learn the exam in this kind of detail.  It is our hope that in the course of learning the basic exam you may find it useful and interesting to understand the exam in a broader context.  You will learn this broader context in more detail next year in ICM II.  For now, these references may be helpful in answering your questions or satisfying your curiosity as you go through the basic physical examination.  In addition, given the difficulty of explaining in words how some of the parts of the exam are performed, it may be useful to see it described and illustrated in several different ways.

Other texts also useful for these purposes and on reserve in the library are the following:

DeGowin and DeGowin:  Bedside Diagnostic Examination.  New York, Macmillan, 1976.

Morgan, WL, and Engel, GL:  The Clinical Approach to the Patient.  Philadelphia, WB Saunders, 1969.

Orient J:  Sapira’s Art & Science of Bedside Diagnosis.  Lippincott Williams & Wilkins, 2000.  This is a very detailed text, but it is an excellent reference book with a wonderful philosophical approach to the whole notion of physical examination as a critical skill in clinical medicine.  We highly recommend it to those of you with a particular interest in clinical medicine as a valuable reference which we suspect you may find even more enjoyable and instructive in your later training than at this early stage.

Video-tape

Also on reserve is a videotape of basic adult physical examination techniques made here at the UW.  This 20 minute videotape shows an entire exam, as you will be asked to demonstrate on a fellow student at the end of the quarter.  The tape will be used to introduce each exam section in class before the lab sessions.  It is also available on reserve for study outside of class.  Next year each section of the exam will be discussed and learned in greater detail.

Medical equipment

Before beginning the physical examination portion of ICM I each student will need to purchase examination equipment that will be used throughout medical school, residency, and even into practice.  We discussed this in class earlier this year.

You will need the following equipment:

• Blood Pressure Cuff (sphygmomanometer)
• Stethoscope
• Diagnostic Kit (Ophthalmoscope/Otoscope)
• Reflex Hammer
• Tuning Fork (128 Hz and 512 Hz)
  (Protective eye-wear such as goggles or attachments to one’s own glasses will probably be purchased later but are not necessary for the level of patient contact in ICM I)

F.         Evaluations

Because the material to be mastered in fulfilling the course of ICM I is primarily non-cognitive and involves the performance of particular skills, it can not be conveniently tested by written examination.  Evaluation is thus based on performance of these skills.  Students will be evaluated in relation to the achievement of course objectives in the following fashion:

• Interpersonal communication skills and effective interviewing skills will be assessed by small group leaders in small group sessions, in videotaped interviews, and in standardized patient interviews.
• Gathering and organizing the medical data base will be assessed by small group leaders through review of write-ups and student self-critiques, review of standardized patient evaluations, and interactions with students.
• Developing and practicing standards of professional conduct will be assessed by small group leaders and faculty in interactions with students.
• Understanding and performing the basic physical examination and using medical instruments will be assessed by physical exam lab instructors and by performance of the complete exam before a faculty examiner at the end of the quarter.
• Systematic and complete written presentation of the basic physical examination will be assessed by small group leaders.
• Initial progress in verbal presentation skills and appreciation of clinical reasoning skills will be assessed by small group leaders.

Additional observations of student performance may be made by others associated with the course.  Any observation of potential performance difficulties may be relayed to the student’s small group leaders who will work with the student to either dispel or correct concerns.  Small group leaders may request that additional observations or experiences be arranged to assure that students are meeting course expectations.  This will be discussed with the course chairperson and with the student, and if additional work is required, this will be communicated with the student in writing.  A final evaluation for the year will be submitted to the Dean’s office.  A sample of the final evaluation form is on page 289.

G.        Preview for Physical Exam Labs

Most of the teaching of the basic physical examination is done in small groups.  There are a total of six labs which take place on successive Thursday afternoons in April and May.  Prior to each lab session, the entire class will meet as a group in the large lecture hall.  We will review the section of the physical exam to be worked on that day in lab.  We will view the appropriate section of the video and discuss any key points and helpful hints.  We will also review how that portion of the physical exam is written up in the medical data base.  You will then go to your labs in groups of six with a senior medical student and will review the exam, discuss any questions and practice that part of the exam on each other in pairs.  Models will be provided for the female breast and the male genital and rectal exams.  Senior faculty members will circulate through two groups of six to help answer questions and assist in teaching you the exam.

You will be provided with gowns and drapes, tongue blades, pocket visual screener, a mydriatic agent for pupil dilation, and examining gloves and lubricant for the rectal exam.  These supplies should be picked up by one member of each group of six right before the first lab session.  Each student should keep their own gown for the duration of the quarter, and every pair of students should take care of one drape.  The drapes and gowns need to be returned at the end of the quarter or you will be charged.  The other supplies do not need to be returned (although we would appreciate getting the mydriatic back), but one student should take responsibility for keeping them through the quarter.

When you have completed the six lab sessions and have learned and practiced the complete physical exam, you will perform the exam on a partner of your choice before a faculty examiner.  You will be expected to complete the basic examination in a standard sequence in less than twenty five minutes, and to demonstrate an appreciation for the “patient’s” modesty, and an understanding of the rationale for and the significance of the various aspects of the exam.  Satisfactory performance in this evaluation is necessary for completion of the course.  The final evaluation occurs during the eighth and ninth weeks of the quarter at which time the class will be split in half.  Half of you will have your final evaluation and the other half will have a half-day core session in otolaryngology (ENT tutorial), during which you will learn aspects of the advanced ENT exam.  Attendance at this tutorial is required.  The following week each half will do the other activity.

In the lecture hall prior to the lab sessions we will be reviewing and discussing the appropriate format for writing up the various sections of the physical examination.  Following your final evaluation when you perform the physical exam before a faculty examiner, you will submit a complete write-up of the basic physical examination you performed noting any abnormal findings in appropriate detail and in the appropriate fashion.  Please upload your write-up to your portfolio by midnight on Monday.  There is no opportunity to repeat this exercise and there is no provision for a “make-up”, so this deadline must be met in order to fulfill the requirements of the course.  These write-ups are not graded.  Your Friday small group leaders (not the faculty for your lab sessions) will review and return the write-ups to you with comments.  The purpose of this exercise is to prepare you for the complete history and physical exam write-ups you will be doing in ICM II.