Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Department of Medicine, Pennsylvania Hospital, Philadelphia, Pennsylvania, USA.
Teach Learn Med. 2020 Aug-Sep;32(4):442-448. doi: 10.1080/10401334.2020.1724792. Epub 2020 Feb 24.
The physical examination has been in decline for many years and poorer skills contribute to medical errors and adverse events. Diagnostic error is also increasing with the complexity of medicine. Comparing the physical examination in Ireland and the United States with a focus on education, assessment, culture, and health systems may provide insight into the decline of the physical exam in the United States, uncover possible strategies to improve clinical skills, and limit diagnostic error. The physical exam is a core component of both undergraduate and postgraduate medical education in Ireland. This is reflected by the time and effort invested by medical schools and medical societies in Ireland in teaching and assessing skills. This high standard of skills results in the physical exam being a key component of the diagnostic process and a gatekeeper to expensive investigations essential in a resource-limited health system such as Ireland. Use of the physical exam in the United States is hindered by the high-tech transformation of healthcare and a more litigious society. Known strategies to highlight the role of the physical exam in clinical practice include creating an evidence base to show that better physical exam skills improve outcomes, identifying accurate physical exam maneuvers, stressing the therapeutic alliance the physical exam brings to the patient encounter, and the incorporation of technology into the bedside exam. Contrasting the education and clinical use of the physical examination in the United States with Ireland allowed us to identify a number of strategies which could be used to promote the physical exam among learners in both countries. Highlighting simple and pragmatic physical exam maneuvers combined with evidence-based physical exam diagnostic data may renew confidence in the physical exam as a core diagnostic tool. Use of the hypothesis-driven approach may streamline a clinician's physical exam during a patient encounter, focusing on the key examination components and avoiding unnecessary and low yield maneuvers. The absence of assessment of physical exam skills using real patients in United States licensing exams communicates to learners that these skills are not important. However, steps to introduce a culture of assessment to drive learning are being introduced. One area Ireland could learn from the United States is incorporating more technology into the bedside exam. Enhanced physical examination skills in both countries could reduce reliance on expensive investigations and improve diagnostic accuracy.
多年来，体格检查一直在衰落，技能较差会导致医疗差错和不良事件。随着医学的复杂性增加，诊断错误也在增加。比较爱尔兰和美国的体格检查，重点关注教育、评估、文化和医疗体系，可能有助于深入了解美国体格检查的衰落，发现改善临床技能和限制诊断错误的可能策略。
体格检查是爱尔兰本科和研究生医学教育的核心组成部分。这反映在医学院和医学协会在教学和评估技能方面投入的时间和精力。这种高标准的技能使体格检查成为诊断过程的关键组成部分，也是资源有限的医疗体系（如爱尔兰）中昂贵检查的必要把关。在美国，体格检查的使用受到医疗保健高科技转型和更具争议性的社会的阻碍。突出体格检查在临床实践中作用的已知策略包括：创建一个证据基础，表明更好的体格检查技能可以改善结果；确定准确的体格检查手法；强调体格检查给患者带来的治疗联盟；以及将技术融入床边检查。
将美国和爱尔兰的体格检查教育和临床使用进行对比，使我们能够确定一些策略，可以在这两个国家的学习者中推广体格检查。强调简单实用的体格检查手法，并结合基于证据的体格检查诊断数据，可能会重新建立对体格检查作为核心诊断工具的信心。使用假设驱动的方法可以简化临床医生在患者就诊期间的体格检查，重点关注关键检查组件，并避免不必要和低收益的手法。美国执照考试中不使用真实患者评估体格检查技能的做法向学习者传达了这些技能不重要的信息。但是，正在采取措施引入评估文化以促进学习。爱尔兰可以从美国学习的一个领域是将更多技术融入床边检查。两国的体格检查技能增强都可以减少对昂贵检查的依赖，并提高诊断准确性。
