Bridging
the Gap
Integrating Hypothesis-Driven Physical
Exam and Clinical Reasoning to Mold the
21st Century Physician
Sirisha Narayana, Joshua Stein*, Anita
Richards, Allison Ishizaki, Heather Nye,
Susannah Cornes and Anna Chang
University of California, San Francisco School of Medicine
WGEA Conference, Salt Lake City, UT
February 26, 2017
*presenting
Roadmap
1. Describe current state of physical exam (PE)
teaching and identify gaps in this model
2. Define purpose of our new curriculum
3. Elaborate key steps in building this curriculum
4. Highlight evaluation strategy
5. Share general conclusions and lessons learned
Context
• Physical exam (PE) has traditionally been
taught in a head-to-toe manner
• Experts advocate for a hypothesis-driven
approach
• Variations have arisen to adapt the approach
to best serve early medical students
• PE curriculum is an ideal location to
incorporate instruction in clinical reasoning
Objective
Design and implement case-based standardized
patient (SP) sessions in which first year medical
students apply history-taking and hypothesisdriven PE skills, while integrating the clinical
reasoning principles of data acquisition,
problem representation, and building illness
scripts.
Identified key chief complaints
Fatigue/Weight loss (“Undifferentiated” patient) x 2
Shortness of breath (CV/Pulm)
Vision Loss (HEENT/Ophtho)
Loss of consciousness (Neuro)
Shoulder pain (MSK)
Abdominal Pain (Abd)
Falls and functional/cognitive decline (Geriatric Assessment)
Breakdown for each 4 hour session
Session-oriented didactic (30-60 min)
History and Physical (SP) + Skills Feedback (2-2.5 hrs)
• Student A: Performs clinical skills
• Student B: Keeps time, prompts Student A
• Student C: Fills out clinical reasoning worksheet
Clinical Reasoning Exercise and Debrief (30 min)
Simulation
Clinical Reasoning
Student and Faculty Preparation
• Students:
– Watched skills-based videos or read contentrelevant material
– Completed online pre-session self-assessment
• Faculty:
– Facilitator guide
– In-person faculty development session with
module lead faculty week prior to SP session
– Access to all student preparation materials
Evaluation:
Kirkpatrick’s Four Levels of Outcomes
Results
Transfer
Learning
Reactions
• Evaluation of preceptor perception of
student readiness for clinical preceptorships
• Mid year MS1s > 80% accuracy in
clinical checklists developed by
faculty clinicians in the medical
history, PE, and communication.
• Random sample of students
(46/152) rated sessions at 4.54
(SD 0.75) after the first four
months of the curriculum.
Conclusions
• A clinical skills curriculum incorporating
focused history-taking, hypothesis-driven
physical exam, and clinical reasoning
principles, is feasible and may address the gap
of integration of previously isolated clinical
skill techniques.
Acknowledgements
Anna Meyer, MD
Jacque Duncan, MD
Nikki Schroeder, MD
Derek Harmon, MD
Kim Topp, PhD, PT
Emma Webb, MD
Jacklyn Lee, MD
Sneha Daya, MD
Kanade Shinkai, MD
Wes Cayabyab
Marika Smally
Denise Connor, MD
Catherine Lucey, MD
UCSF Class of 2020
Students and Faculty