The Road Back to the Bedside

Abstract

According to that old story, a local giving directions to a lost traveler says, "If I wanted to get there, I wouldn't start from here." Medicine finds itself far from the bedside, 1,2 seeking a way back, unsure where to begin.That we have wandered far afield is plain to see. Core bedside skills of history taking and physical examinationstill vital to comprehensive assessment, diagnostic accuracy, 3 and truly patient-focused care-are taught and assessed in the first two years of medical school but largely ignored once the student reaches the clinical years. 4 During residency, development of these skills is assumed when in fact they wither further. 5 The physical examination of newly admitted patients is often cursory and, what is worse, perverted by drop-down boxes into an exaggerated and invented form that reads better than the truth.Technology drives diagnosis, but it often merely substitutes our fears of uncertainty with delusions of certainty. We seem increasingly chained to the computer, providing perfect care to our virtual patient, the iPatient. 2 More has seemed better than less for so long that we now need a national campaign 6 to alert our patients to "Just Say No" and save themselves from the hazards and costs of diagnostic misadventure. While we all agonize over the spiraling costs of a "Hi-Tech, Lo-Think" approach, many stand to gain from its persistence.But we have to start somewhere. The way physicians are taught is fundamental to the type of health care they deliver. The road back to the bedside will, we believe, start at the bedside, in the way that clinical skills are taught and assessed.We in the United States stand out among other major Western health care professionals in having a summative postgraduate medical certification process that is entirely dependent on the assessment of knowledge. Elsewhere, for example, the United Kingdom, internal medicine trainees must additionally pass a clinical skills assessment in which independent faculty-level examiners directly observe resident-level trainees assessing real patients. 7 In the States, no high-stakes clinical skills assessment for the purpose of certification in internal medicine has survived. The USMLE Step 2 CS is for many trainees the last time that their clinical skills are objectively assessed, and it ensures that a basic level of competence is attained. But given its current content and standard, it cannot equip internal medicine trainees for future practice and appears to mark an end, not a beginning. Meanwhile, high scores on tests of knowledge directly translate into better career prospects. If "assessment does indeed drive learning," 8 we should not be surprised if our trainees prefer books to the bedside.

Technology Complements Physical Examination and Facilitates Skills Development among Health Sciences Clerkship Students: <em>An Integrative Literature Review</em>

“…Studies focused on a variety of health disciplines, including medicine (21), nursing (10), pharmacy (1), midwifery (1), and interprofessional (1), and were undertaken in the United States (12), Australia (4), Germany (3), Hong Kong (3), Canada (2), Ireland (2), Brazil (1), Bahrain (1), Colombia (1), Denmark (1), India (1), Japan (1), Taiwan(1), and the United Kingdom (1), The studies used different methods and methodologies, including ethnography, participant observation, qualitative surveys, quasi-experimental designs, and randomised control studies.…”

“…Our findings suggest that uptake of technologies such as POCUS is slow, and a gap exists between current clinical practice and what is included in the bedside curriculum [ 8 ]. Conceivably, a cultural preferencing of touch-based physical examination remains [ 1 3 12 14 ].…”

“…The dominant discourse presents technology, particularly as it relates to ‘cutting edge’ technology, with a techno-utopian lens [ 10 ], and even suggests that emerging artificial intelligence (AI) technologies may replace skills formerly performed by health practitioners [ 11 ]. In contrast, the call to find a “road back to the bedside” (p 1672) [ 12 ] or to “preserve the human touch in medicine in a digital age” (p E622) [ 13 ] preferences touch over technology. The literature suggests that teaching practices may be influenced with reduced frequency of physical examination learning opportunities for students [ 14 15 16 17 ], and there is concern regarding reduced competence and confidence [ 1 ].…”

Creating a Medical School Curriculum to Teach Empathy

“…In addition to observation, there must be direct assessment by these role models. 21 As with physical examination where high-level assessments requires real patients, 21 so too is the case with skills involving emotional intelligence such as empathy. As students advance over the course of their training, they must be encouraged to move from passive observation to active participation with patients.…”