We Teach The Physical Exam Wrong

An academic hospitalist talks about 3 big problems with teaching the physical exam to medical, nursing, and PA students:

1. We don't teach how to properly tailor the exam to the patient and situation.

2. We don't include sufficient use of bedside ultrasound.

3. We focus teaching what's included in the classic physical exam textbooks rather than focusing on what exam components and maneuvers are supported by the evidence and which are used in real-life practice by outstanding clinicians (when they are not being observed by students!)

[StrongMed]

Obligatory disclaimer: This video is not referring specifically to my own institution, but rather to all medical training sites in the US. Also, I'm sorry about the suboptimal lighting and audio. It was such a nice day (and I had been watching some Tom Scott videos) that I felt like recording outside for once, and I didn't have the best setup for it.

EDIT: Since many people have been asking about and discussing good physical exam resources, these are the 6 exam textbooks I have on my bookshelf:

JAMA's The Rational Clinical Examination (is available from JAMA as individual papers, but can also be purchased as a bound version of all of them): The overall best reference for learning a patient-centered, evidence-based physical exam.

Evidence-Based Physical Diagnosis by Steve McGee - Has a ton of data (+LR & -LRs) on physical exam findings with modest-moderate amount of pathophysiology discussion. I think its primary weakness is that it gets lost in the data and doesn't always distinguish findings that have small one-off studies showing benefit from classic findings that have a robust volume of evidence and which are used in common practice.

Bedside Cardiology by Jules Constant (out of print) - Goes into ridiculous amount of detail about the pathophysiology of individual findings (e.g. S1, S2, S3, S4, and the opening snap of MS all get their own dedicated chapters!). The book was written pre-echocardiography, so it has limited relevance for contemporary practice, but for physiology-nerds, it's incredibly interesting!

Mechanisms of Clinical Signs by Dennis, Bowen and Cho - Great diagrams and figures regarding pathophysiology of findings. Whereas JAMA is a great reference for looking up a patient-specific question, this book is a great reference for looking up a finding-specific question.

Sapira's Art and Science of Bedside Diagnosis - A Bible of esoteric physical exam findings from "the days of giants", which is more for bedtime or airplane reading rather than a practical textbook that I would apply to my clinical practice. But the most entertaining read of the group.

Bates - Because this is the mandatory textbook for our preclerkship students. I otherwise wouldn't defile my bookcase with it. (I suppose it isn't *that* bad, but I do not recommend this as the go-to reference for students)

For web-based resources, I recommend:


(Yes, there is a US West Coast bias!)

[Hopeswilldie]

As a last year medical student from Europe I can tell you that teaching physical exam is not a problem just in the states. I absolutely stand behind your opinion that physical exam should be taught alongside pathophysiology. In fact, many preclinical and clinical subjects should be taught more connected to each other. I still don't understand for example why I spent two semesters learning pharmacology and then having to basically re-learn it for my internal medicine exam a year later, when it could've been easily taught alongside each other and it would stick better when presented with case studies... But that's for broader discussion I guess

[MedlifeCrisis]

Well said Eric. I’ve got my own thoughts about the physical exam (in fact I’m planning a video of my own hopefully not too far away, I’ll definitely put a reference back to this when I do) and I remain passionate about it and I think your point about a real life and evidence-based examination is key. I like learning all the obscure nonsense as it’s interesting and part of our history but that mustn’t be the focus of what we teach students nor test them on. If I didn’t teach regularly, I’d have genuinely de-skilled. Quite possible to treat a patient without touching them once. Which is a bad outcome for everyone.

[twistedtea]

when i hear someone say “we do this because this is how we do it” i usually close my ears lol. great lecture

[imranabdullahkhan]

I am a recent medical graduate and I have had similar thoughts as you. Thank you Professor for sharing our unpopular voice.

[salimyaghi]

Can't agree more. In fact during my training (outside and inside the US), a lot of physicians argue not to do a lot of physical exam but to rely on more objective data like imaging. So it seems in reality the physical exam is falling behind in real practice. Your proposal of assigning official committees to promote evidence based and practical exams is the right way to go. Thank you for valid and accurate points.

[squirreleyy]

At my medical school in Ireland, we begin learning pathophysiology and core clinical skills side-by-side from Day 1. First and second year were all taught this way. It really helped us understand the mechanism of disease and see how it presents in the real world. However to do this, a lot of the basic medical science content was required to be cut down to make it more managable for students. It's a difficult act to balance the two aspects for starters, and I see why in certain schools theres a greater emphasis on one or the other.

[ramironin]

A lot of the problems you addressed are shared in medical schools across the world (I live in Uruguay). I’m glad you mentioned the issue of not teaching exam findings alongside their pathophysiologic basis, this being especially true for the cardiac and neurological exams. In my experience this creates a steep learning curve in which at first one just memorizes the order of techniques and how to do them, and as you learn pathology what to look for becomes more intuitive as you said; correlating knowledge is the most useful way to learn, and teachers fail to emphasize this. Everything holds true for the patient interview too.

Regarding the other problems, as a student I’ve experienced having to auscultate fetal cardiac sounds using a Pinard Stethoscope, despite the fact that no gynecologist who taught us this actually uses it ever, just because it’s a “basic clinical skill” (unreliable and affected by many variables at that) but failed to teach us for example fetal cardiac monitoring, and the pathophysiology of diminished heart rate and heart rate variability as a surrogate of fetal And this is just one of many examples.

Anyway, rest assured that you are not alone!!!! The medical world suffers a lot from the “we do this because it’s the way it’s been always done” mindset worldwide. Another problem we have here which I don’t know if the US schools share is the lack of teaching skills and overall preparation for teaching that doctors have, here you are not required to have any of that in order to teach, just your medical degree.

Thank you for venting about issues that need to be discussed!!! Best wishes from Uruguay

[ahmedmed]

A cardiology fellow here, and I just wanted to say that i havent used a stethoscope since I learned bedside echocardiography! Great video as usual! Keep em coming sir!

[ayseakpnar]

Throughout med school I observed teachers perform same exam on same patient but interpret differently. That's why i find myself unsure especially on subjective ones like scoring pretibial edema

[alexs]

Congratulations for this outstanding critical view! As an Internist who practices also Emergency Medicine (in some countries in Europe we don't have EM as a specialty) I fully agree. In my opinion the clue is to be able to adapt what is generally tought (and what generally is supposed to be done by a doctor) in order to be usefull to find out what actually happens to a pacient and what needs to be done considering the pathophysiology and evidence. POCUS is very important and a big step forward. Regarding the physical exam a very good resource is the book "Evidence-Based Physical Diagnosis" by Steven McGee. And as always experience, continuous education and constant critical thinking is crucial and your channel is an excellent resource! Thank you!

[Pakanahymni]

Medical teaching across the globe is really ossified, rigid and based on "this is what we've always done". I've studied other things before medicine and I think medical teaching is a good 150 years behind common best practices in pedagogy from state of the art.

[solomonadelaida]

I am an internal medicine doctor teaching 3rd year medical students (semiotics) and I am an avid user of all Eric Strong material I can find. I totally agree with radically changing the whole way we teach physical examination and reasoning! We need to come out of this inertia and actually teach what we practice and what is evidence based! I am using Rational Clinical Examination: Evidence-based Clinical Diagnosis (JAMA), Evidence-Based Physical Diagnosis along with the classical Bates to sift through all the clutter we teach. Thank you Eric Strong@ Stanford for your excellent work!

[PMoney]

4th year med student here. I also only percuss when the attending is in the room.

[fatmael-menoufi]

Amazing perspective. Thank you for bringing this issue up, Doctor!

[jeremyrussell]

This is SPOT ON! It's so odd to be living in 2021 and having to sit in on a lecture about "tactile fremitus." Basically, you do what you're taught to get the grade and then never use it again. I completely agree with everything said in this video. We need a change.

"99." 🙄

[andressakuzma]

As I medical student from Brazil, I wholeheartedly agree with your perspective. Too much of what we do is just because "we've always done it this way", not necessarily based on evidence on what's best for our patients.

[ΆγιοςΧίλαριος]

This video is what every intern really needs to watch

[helenafilar]

I could not agree more. I study in Poland and I would say we have the exact same situation. A video about what US-bedside diagnosis we should learn to recognize in our first years as interns would have been highly appreciated. Thanks a lot for your great videos and topics!

[abdulazeez.]

I, as a 5th year medical student, always wondered why they focus so much on clinical exam instead of more robust and technically advanced alternatives (such as ultrasound). I know clinical exams are essential but we need to move forward and be more familiar with advanced technological methods.