Suck at physical exam, any tips?

[Serous Demilune]

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So during OSCEs with standardized patients, I am pretty decent at running through a full physical exam, although it takes me close to a half hour and I follow the exact steps I memorized from the list we were given. However in our second year we're learning how to do quick, focused physical exams and they're actually letting us do them on real patients on the wards.
I tried it for the first time today and totally fell apart. I tried to cram everything in in under 10 minutes with an attending watching me, and I kept forgetting what came next. The patient looked really weirded out and eventually the attending had to step in and show me exactly how it was done.
How do I learn how to do an actual physical exam that real doctors perform on real patients when they don't have endless time and are looking to flesh out a specific chief complaint?

 

[touchpause13]

Practice?

 

[Serous Demilune]

Practice?

I don't even know how. I don't know what's important and what isn't, I don't know the order that I'm supposed to be doing it in, etc. I need something that walks me through how to evaluate various chief complaints.

 

[ChEMD]

I don't even know how. I don't know what's important and what isn't, I don't know the order that I'm supposed to be doing it in, etc. I need something that walks me through how to evaluate various chief complaints.

You should be learning that throughout the year as you go through different system blocks. It's hard to know exactly what's important until you know what types of diseases manifest with what symptoms. It should get better throughout the year, but the key is to practice and really try to think about some of the things you've learned in class while you're doing your physical. For example, if someone comes in short of breath, you should probably think heart or lungs. So if your goal is to do a focused physical exam, do the things that evaluate the heart and lungs.

I also wouldn't get too obsessed over order either. For the most part, do what feels natural. If you have already moved on to another system and realize you forgot something, just relax and go back to it when you get the chance, it's not a big deal.

 

[TooMuchResearch]

Does the android mobile app frequently crash for anyone else? I wrote a longish response but the thing crashed and did not auto-save.

 

[xffan624]

So during OSCEs with standardized patients, I am pretty decent at running through a full physical exam, although it takes me close to a half hour and I follow the exact steps I memorized from the list we were given. However in our second year we're learning how to do quick, focused physical exams and they're actually letting us do them on real patients on the wards.
I tried it for the first time today and totally fell apart. I tried to cram everything in in under 10 minutes with an attending watching me, and I kept forgetting what came next. The patient looked really weirded out and eventually the attending had to step in and show me exactly how it was done.
How do I learn how to do an actual physical exam that real doctors perform on real patients when they don't have endless time and are looking to flesh out a specific chief complaint?

Did you not get clinical correlation with the exam processes you were practicing first year? Ask yourself, as you're doing an exam, what are you looking for? If it's nothing to do with the chief complaint, then why are you doing it? Start with this now as it will definitely be something the resident or doc asks you. It should get a little easier second year as you learn more path. If you still feel stupid, you can seek out some additional resources on focused complaint specific physical exam and history.

Also I would recommend observing the docs you are with and ask them about exam portions that you unclear with. Another way to get less pressured practice is in a student run free clinic.

 

[MalibuPreMD]

Instead of focusing 100% on the physical exam like you can in a controlled setting on a standardized patient, your attention was split trying not to make a fool of yourself in front of the attending and patient. Are you really surprised that you "totally fell apart"? I'm confident that the vast majority of medical students (myself included) would have done the same so don't worry and keep doing your best.

 

[Keladry]

In addition to what the others said about thinking about what you're doing/doing relevant stuff, a big non-medical aspect is just demeanor. Act professional, calm, and confident - even when (especially when!) you don't feel that way - and at least your patient will think you know what you're doing (even if your attending doesn't). If you screw something up, don't say "Oops," try not to appear flustered, and not only will your patient think it's all fine, but you'll also feel more confident just by pretending to be confident 🙂
This isn't going to replace the need for practice/critical thinking/all the actual medical stuff, but I do think it's important to remember as well.

 

[animando]

I tried to cram everything in in under 10 minutes

That's your problem: there is no such thing as a complete exam, let alone in 10 minutes. Move from one system to another or from top to bottom while checking only for the most important signs because either 1) they are relevant to the case and/or 2) you don't want to miss them.

How do I learn how to do an actual physical exam that real doctors perform on real patients when they don't have endless time and are looking to flesh out a specific chief complaint?

Differential diagnosis. If a patient complains about vertigo, listening to bowels sound during 5 minutes won't help a lot.

 

[Kahreek]

practice, practice, at first it looks easier than it is, it sure is, but then doing the real thing properly, gathering the data and keeping the doc/pt relation afloat is a harder , then it gets easier again.

 

[Kahreek]

That's your problem: there is no such thing as a complete exam, let alone in 10 minutes. Move from one system to another or from top to bottom while checking only for the most important signs because either 1) they are relevant to the case and/or 2) you don't want to miss them.


Differential diagnosis. If a patient complains about vertigo, listening to bowels sound during 5 minutes won't help a lot.

yeah except patients dont say, hey doctor i am having vertigo because such and such (well std pts might, lol).
Besides imagine
The patient might be feeling lightheaded, refers it as vertigo, turns out it is anemia, because it has a lower gi bleed, bamn you need listen to bowel sounds.

Horses dressed as zebras are much more common.

 

[Serous Demilune]

Thanks guys! Some very helpful stuff here.

 

[Meh.meh]

So during OSCEs with standardized patients, I am pretty decent at running through a full physical exam, although it takes me close to a half hour and I follow the exact steps I memorized from the list we were given. However in our second year we're learning how to do quick, focused physical exams and they're actually letting us do them on real patients on the wards.
I tried it for the first time today and totally fell apart. I tried to cram everything in in under 10 minutes with an attending watching me, and I kept forgetting what came next. The patient looked really weirded out and eventually the attending had to step in and show me exactly how it was done.
How do I learn how to do an actual physical exam that real doctors perform on real patients when they don't have endless time and are looking to flesh out a specific chief complaint?

Keeping it limited to a realistic number of items is important, at least for me. ROS helps me think of the things I wanna look for going in.

Strategies that I haven't seen mentioned yet:

1. Move head to toe, left to right when there is no intrinsic order (e.g. sensory exam)

2. Have a specific order in mind (eg. do cranial nerves in order)

3. I try to consider my ROS before I start the exam, and do things in the order I record ROS.... for me that's (General) skin, HEENT, breast, CV, Respiratory, GI, GU, Neuro, MSK, heme/lymph, endocrine.

This isn't perfect....but if I'm blanking it helps me remember. Also helps you organize it in your head for when you present.

4. I always listen to heart and lungs. I'll probably stop someday, but I think it's helpful. Doesn't take much time either.

That's all I got. I also try to organize the history in my head like a soap note, and repeat it back to the patient before I leave.

I think the most important thing is to be consistent with whatever order you choose. It becomes a memory aid.

 

[OPPforlife]

If all else fails...just order a pan scan. Simple.


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[seminoma]

A full PE in 30 minutes is very impressive... As a fellow MS2 my opinion is that a focused H&P requires good basic science knowledge. You can't do a "focused" anything if you don't know what you're supposed to be focusing on.

 

[LChristmas]

Does the android mobile app frequently crash for anyone else? I wrote a longish response but the thing crashed and did not auto-save.

It happens to me sometimes too. Very frustrating after you've written a long post

 

[dienekes88]

Practice. Do everything the same way. Stand on the patient's right. Do all the maneuvers that require the otoscope on the wall: look in the ears, check pupils, look in the nares and throat. Then go from head to toe. Do all your maneuvers that require the stethoscope at the same time: listen to the carotids, heart, and lungs.

Over time, I've slowly gotten more and more focused. If I have a diagnosis I suspect based on the history, I'll change my approach. It helps that I'm in a subspecialty, though.

Doing a trauma secondary survey or two will improve your speed. A lot.

 

[yankeebeckham]

There is no "order." It's your exam. You need to come up with a system that works for you that

a) is systematic, so you're doing it the same way every time so you don't forget everything
b) is convenient so you don't have the patient jumping up and down off the table and lowering and rising her gown and taking her shoes off and putting her shoes back on.

Honestly, feeling inept when you first start is really normal. I had a bad habit of dropping my stethoscope that was hanging around my neck and hitting my patients with it when I first started seeing actual patients in my second year. So awkward. You will get better with practice. It also helps to know WHY you're doing what you're doing. So when you're done with your history, you should have a certain ddx in mind and you should know what things you're looking for in the PE that are going to help narrow down your ddx. For instance, if it's RLQ pain, looking for rebound tenderness is really important because you need to rule out appendicitis. The farther you get in your training, the more you start thinking like a clinician, the easier it gets, not only in physically performing the maneuvers because you have practice, but knowing which ones to do, because you have clinical reasoning to support them. But right now, when you're just trying to remember to do random stuff that you memorized off a list, that's really, really difficult. Try to think about what each maneuver will tell you if positive or negative--it will make you a better doctor to understand the why behind everything.

But the best thing you can do is to not stress. You will get better with practice. And appear confident. The patient doesn't know the list of memorized maneuvers you're supposed to be doing. So do your best and put her at ease. That is an important skill to learn.