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The Rational Clinical Examination: David L. Simel, MD, explains the origin and development of The Rational Clinical Examination series and the value of this resource to learners and instructors.
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The Rational Clinical Examination: David L. Simel, MD, explains the origin and development of The Rational Clinical Examination series and the value of this resource to learners and instructors.
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Segment:0 .
>> My name is Joan Stephenson. I'm the Director of Medical News for JAMA. And I will be talking with Dr. David Simel today. He will introduce himself. Dr. Simel. >> Hi, I'm Dave Simel. I'm the Chief of the Medicine Service at the Durham Veteran Affairs Medical Center and Vice Chairman of the Department of Medicine at Duke University. I'm talking to you today as the Co-Editor of the Rational Clinical Examination Series.
>> What is the aim of the Rational Clinical Examination Series? Since the teaching and practice of clinical examinations have a long history, why did those who developed the series perceive a need for a new approach? >> Well, the teaching of the clinical exam, which I define as both the taking the patient's history and performing the physical exam, does have a long-storied history. In the past, learners and physicians have basically performed the physical exam based on the way they were taught without any quantitative basis or scientific basis.
So, in other words, we were taught to do a particular thing to try to detect fluid in the lung. And we were simply told that if it was abnormal or positive, there might be fluid on the lung. What we've tried to do is add a quantitative basis and figure out what works and what really works from that quantitative understanding of our history in physical examination. >> How did you become involved in the JAMA Rational Clinical Examination Series? >> Well, this goes way back to the time before there was a Rational Clinical Exam Examination Series when I started to develop an interest as a medical student in the physical examination.
And for me, the first time that I was really a doctor is when I got the tools that we use during the physical examination. And I was fascinated by those tools. The stethoscope, the reflex hammer, the ophthalmoscope. And I really wanted to learn how to use them. But immediately, I began to question how well I used them and what the meaning of the findings were. As time evolved, I embarked on a research career of trying to figure out what works and what doesn't work in the physical examination.
And I was concentrating my studies, initially, my first study was on the physical examination for ascites. It was at that time that Dr. David Sackett from Canada and Dr. Drummond Rennie had the idea of starting the Rational Clinical Examination Series in JAMA. Specifically, to see if they could bring some science to the clinical examination. Well, as luck would have it, that's exactly what I was trying to do with the physical examination for ascites. And I offered Dave Sackett the opportunity to allow me to write the first article in the series, a rather aggressive approach on my part.
But it worked. And I became involved early on as a writer. When Dave Sackett left the series, he left me to work with Dr. Drummond Rennie in the journal on developing more articles for the Rational Clinical Examination Series. The series started in 1992. And I became the Co-Editor about two years after that. >> There are a number of physical examination and diagnosis textbooks. How is the Rational Clinical Examination book different from other physical exam and diagnosis textbooks?
Could you explain how the book is organized? >> So, we perceive ourselves as not being a replacement for the standard physical examination textbook, but we see ourselves as being a supplement to every physical examination book that's out there. Most physicians may not remember many of their books from medical school, but almost every one of them can tell you which physical exam book that they used. And those books are basically organized on a head-to-toe basis.
So, they teach the performance of the complete history in physical examination, starting with the head, working through the eyes, ears, nose, and throat, going to the neck, going to the chest and listening to the lungs, going to the heart, and getting all the way down to the toes, usually ending up with a neurological exam. And in discussing the complete exam, it really is focused on how to do the things that we do. How to perform the certain maneuvers to detect whether or not the patient has a torn meniscus in the knee.
Or certain maneuvers to detect whether or not the patient has an acute abdominal finding. What we do is go a step further. We assume that the person knows how to do the particular findings, but we attach meaning to them. So, in other words, if you're instructed to put the arm through certain motions to determine if there is a rotator cuff tear, we tell you actually how good those findings are at detecting a rotator cuff tear. So, in that way, we're a perfect complement to all of the physical exam textbooks.
Whether you're a physician in training, physician in practice, a physician assistant, or a nurse who's learning advanced physical examination skills, we're there to attach meaning to the individual findings. >> Your reference to meaning leads to my next question which is in the preface of the Rational Clinical Examination, you wrote that quote, ''There is a science behind the art of clinical examination.'' Could you elaborate? >> Well, there are a couple of words in that. The first one that you might focus on is art, and the second one you may focus on is science.
We know that many of our teachers or we think that many of our teachers really were good at the physical examination. And in part, because that was all they had for some of the things that we diagnose these days. On the other hand, in thinking that they were really good, they really didn't know. Because they didn't have reference standards to determine whether or not the patient had the things they thought they had. So, the art is, in part, acknowledging of the role of experience.
The role of experience is very important, not just in the physical exam, but perhaps even more so in eliciting the patient's history. We learn very early on how to begin to classify patients, to recognize them as sick or not sick. The science part attaches the quantitative things that I alluded to. So, if, for example, a patient tells me that their headache is pounding, you might infer that that's a tension headache. But someone else might infer that that represents a migraine or vascular headache.
The science tells you how good the symptom is of pounding for identifying either a tension headache or a migraine headache. And it actually turns out that a pounding headache in combination with several other findings is very good for diagnosing a migraine headache. And so, the Rational Clinical Exam Series actually quantifies the accuracy. >> So, that's what you mean by rational, is the quantification of these various aspects of things. >> Well, the rational part acknowledges that some of the things we do aren't very accurate, and some of the things we do are highly accurate.
So, what we've done, both for learners and for teachers is try to identify the useful from the useless. It turns out that some of the things we do really are kind of useless. They are poor accuracy and shouldn't affect clinical decision-making. To quote my former chairman, ''We're trying to identify pearls from pellets.'' So, there's some things that we find when we do our articles in the Rational Clinical Examination Series that tell us we should stop doing them. An example of that might be the puddle sign for detecting ascites.
It's a fun sign to talk about it, a fun sign to contemplate. But crawling under a patient's belly and tapping the belly in the hopes of detecting fluid is not a very useful thing to do. So, we suggest that learners stop learning how to do the puddle sign. In contradistinction, we can quantify that shifting dullness of flank dullness can be very useful signs. And so, the Rational Clinical examiner would concentrate on learning how to elicit those signs, perfecting their technique and perfecting their interpretation of that technique.
>> Is most of the evidence used in the series based on signs and symptoms or what about basic and more sophisticated lab tests and radiologic studies? >> Well, those of us in the, who do research on the clinical exam would take umbrage with the word ''more sophisticated test''. You know you should never order a laboratory test or a radiologic test or some other test without having a firm understanding about the patient that you're ordering it in.
So, yes, we do concentrate very much on the history or symptoms if given to you by the patient, and the signs, the physical examination signs. That's our major focus. We recognize though that in many, if not most cases, the results from laboratory tests or radiologic images must be interpreted within the context of the patient. So, yes, we do use some laboratory tests. So, for example, the erythrocyte sedimentation rate for temporal arteritis is an extremely important finding.
However, it would be meaningless as a finding for temporal arteritis unless you were applying the results to the right patient. So, when we do use these other tests in the Rational Clinical Examination Series, we have to make sure that the examiner understands which patients they should be ordering it in. And that leads us back to the signs and symptoms that the patient presents with. >> What does the JAMAevidence website offer that's not in the Rational Clinical Examination book?
>> Well, when we first started writing our book and taking our articles that we had published into book form, we knew that we needed to update everything. So, the articles have been going back since 1992. And we began by repeating our literature search and finding what new things have been published since the original article first appeared. One of the goals of the Rational Clinical Examination was to stimulate people to do original research. Once we found that newer literature, we began to abstract it in a format that would be familiar to most readers who are evidence-based medicine practitioners.
So, we did critical appraisal of all the newer articles we found. As we accumulated these new updates and began to put them together with the older information, we created structured literature reviews. Once we were ready to write our book, we realized we had too much information. And so, on the website, we have all the structured critical appraisal that we've done for the new literature. And many readers, as they go through the book, are going to be interested in going to look at the actual data that we used to make our recommendations.
And we provide that on the website, not available in the book form. The second thing that's really exciting about the website is that Dr. Sheri Keitz, working closely with many Duke University junior faculty and house officers, with a few people from around the country and Canada, created a set of education guides for each chapter in the book. What we've done is we've created a series of standardized presentations that begin with a case scenario, present the background for the chapter, review the evidence.
And come up with recommendations in a PowerPoint formatted slide set. These slide sets are only available online. Learners may prefer the slide sets as a way of quickly accessing the information. Teachers have a ready set place to go if they would like to use the information in a lecture format or in a small group discussion to actually teach from the book. All of the education guides have been developed with a learner in mind.
And we've piloted all of them with a group of learners, so we know they work. And we're excited about making them available to everyone. >> That sounds great. What are the plans for the future of the Rational Clinical Examination Series? >> Well, we've now published over 70 articles. At the time we started writing the book, we only included the first 50 articles that appear. So, we have a lot more information that we're going to be adding to future editions of the book and to the website. We will continue to update what we've already done.
We will bring the articles that didn't make it to the book this time into future publications. And we have an active group of authors literally from around the world working on newer topics that will appear in the Journal of American Medicine Association as part of the Rational Clinical Exam Series. In addition to the Rational Clinical Exam Series, we've also begun to focus on another part of the clinical examination, and that is rational clinical procedures. We've been very interested in reviewing the literature for the procedures that the generalist physician would do at the bedside to determine what's the best way, what does the evidence show is the best way to perform those procedures.
This is a natural fit for the Rational Clinical Exam Series because one of the outcomes, not surprisingly from an article on the Rational Clinical Examination to detect meningitis, is going to be a lumbar puncture. And that lumbar puncture is typically performed by the same person who did the history and physical examination. So, working with Dr. Sharon Straus, who's leading this effort for us, we take the same approach to systematically finding the literature that evaluates, for example, the technique for performing a lumbar puncture.
And we're bringing this into a, a series of articles as part of the Rational Clinical Exam Series that we call Rational Clinical Procedures. >> Is there anything else you would like JAMAevidence users to know about the Rational Clinical Examination? >> Well, we write these articles with the user in mind. And we're very, very interested in having a dynamic approach that changes with the time, that takes feedback from our readers so that we can get the information they want.
And so, I would welcome all readers of the Rational Clinical Examination and users of JAMAevidence to be aggressive at contacting us and giving us recommendations for topics they would like to have, to see reviewed. And if there are things that they would like to change on JAMAevidence, we'd like their advice. We are very interested in pilot testing and evaluating newer ways of presenting this information. >> Well, that sounds very exciting, and it would be interesting to see how the website evolves.
>> Well, we're looking forward to it and it's a very exciting endeavor on our part. We certainly hope that those who haven't picked up their physical examination book in many years will be stimulated to look at our book and perhaps review their techniques, be critical about their own performance, and have fun while relearning to do the history and physical examination in a more quantitative way. >> Well, thank you, Dr. Simel. >> Thank you.
Segment:0 .
>> My name is Joan Stephenson. I'm the Director of Medical News for JAMA. And I will be talking with Dr. David Simel today. He will introduce himself. Dr. Simel. >> Hi, I'm Dave Simel. I'm the Chief of the Medicine Service at the Durham Veteran Affairs Medical Center and Vice Chairman of the Department of Medicine at Duke University. I'm talking to you today as the Co-Editor of the Rational Clinical Examination Series.
>> What is the aim of the Rational Clinical Examination Series? Since the teaching and practice of clinical examinations have a long history, why did those who developed the series perceive a need for a new approach? >> Well, the teaching of the clinical exam, which I define as both the taking the patient's history and performing the physical exam, does have a long-storied history. In the past, learners and physicians have basically performed the physical exam based on the way they were taught without any quantitative basis or scientific basis.
So, in other words, we were taught to do a particular thing to try to detect fluid in the lung. And we were simply told that if it was abnormal or positive, there might be fluid on the lung. What we've tried to do is add a quantitative basis and figure out what works and what really works from that quantitative understanding of our history in physical examination. >> How did you become involved in the JAMA Rational Clinical Examination Series? >> Well, this goes way back to the time before there was a Rational Clinical Exam Examination Series when I started to develop an interest as a medical student in the physical examination.
And for me, the first time that I was really a doctor is when I got the tools that we use during the physical examination. And I was fascinated by those tools. The stethoscope, the reflex hammer, the ophthalmoscope. And I really wanted to learn how to use them. But immediately, I began to question how well I used them and what the meaning of the findings were. As time evolved, I embarked on a research career of trying to figure out what works and what doesn't work in the physical examination.
And I was concentrating my studies, initially, my first study was on the physical examination for ascites. It was at that time that Dr. David Sackett from Canada and Dr. Drummond Rennie had the idea of starting the Rational Clinical Examination Series in JAMA. Specifically, to see if they could bring some science to the clinical examination. Well, as luck would have it, that's exactly what I was trying to do with the physical examination for ascites. And I offered Dave Sackett the opportunity to allow me to write the first article in the series, a rather aggressive approach on my part.
But it worked. And I became involved early on as a writer. When Dave Sackett left the series, he left me to work with Dr. Drummond Rennie in the journal on developing more articles for the Rational Clinical Examination Series. The series started in 1992. And I became the Co-Editor about two years after that. >> There are a number of physical examination and diagnosis textbooks. How is the Rational Clinical Examination book different from other physical exam and diagnosis textbooks?
Could you explain how the book is organized? >> So, we perceive ourselves as not being a replacement for the standard physical examination textbook, but we see ourselves as being a supplement to every physical examination book that's out there. Most physicians may not remember many of their books from medical school, but almost every one of them can tell you which physical exam book that they used. And those books are basically organized on a head-to-toe basis.
So, they teach the performance of the complete history in physical examination, starting with the head, working through the eyes, ears, nose, and throat, going to the neck, going to the chest and listening to the lungs, going to the heart, and getting all the way down to the toes, usually ending up with a neurological exam. And in discussing the complete exam, it really is focused on how to do the things that we do. How to perform the certain maneuvers to detect whether or not the patient has a torn meniscus in the knee.
Or certain maneuvers to detect whether or not the patient has an acute abdominal finding. What we do is go a step further. We assume that the person knows how to do the particular findings, but we attach meaning to them. So, in other words, if you're instructed to put the arm through certain motions to determine if there is a rotator cuff tear, we tell you actually how good those findings are at detecting a rotator cuff tear. So, in that way, we're a perfect complement to all of the physical exam textbooks.
Whether you're a physician in training, physician in practice, a physician assistant, or a nurse who's learning advanced physical examination skills, we're there to attach meaning to the individual findings. >> Your reference to meaning leads to my next question which is in the preface of the Rational Clinical Examination, you wrote that quote, ''There is a science behind the art of clinical examination.'' Could you elaborate? >> Well, there are a couple of words in that. The first one that you might focus on is art, and the second one you may focus on is science.
We know that many of our teachers or we think that many of our teachers really were good at the physical examination. And in part, because that was all they had for some of the things that we diagnose these days. On the other hand, in thinking that they were really good, they really didn't know. Because they didn't have reference standards to determine whether or not the patient had the things they thought they had. So, the art is, in part, acknowledging of the role of experience.
The role of experience is very important, not just in the physical exam, but perhaps even more so in eliciting the patient's history. We learn very early on how to begin to classify patients, to recognize them as sick or not sick. The science part attaches the quantitative things that I alluded to. So, if, for example, a patient tells me that their headache is pounding, you might infer that that's a tension headache. But someone else might infer that that represents a migraine or vascular headache.
The science tells you how good the symptom is of pounding for identifying either a tension headache or a migraine headache. And it actually turns out that a pounding headache in combination with several other findings is very good for diagnosing a migraine headache. And so, the Rational Clinical Exam Series actually quantifies the accuracy. >> So, that's what you mean by rational, is the quantification of these various aspects of things. >> Well, the rational part acknowledges that some of the things we do aren't very accurate, and some of the things we do are highly accurate.
So, what we've done, both for learners and for teachers is try to identify the useful from the useless. It turns out that some of the things we do really are kind of useless. They are poor accuracy and shouldn't affect clinical decision-making. To quote my former chairman, ''We're trying to identify pearls from pellets.'' So, there's some things that we find when we do our articles in the Rational Clinical Examination Series that tell us we should stop doing them. An example of that might be the puddle sign for detecting ascites.
It's a fun sign to talk about it, a fun sign to contemplate. But crawling under a patient's belly and tapping the belly in the hopes of detecting fluid is not a very useful thing to do. So, we suggest that learners stop learning how to do the puddle sign. In contradistinction, we can quantify that shifting dullness of flank dullness can be very useful signs. And so, the Rational Clinical examiner would concentrate on learning how to elicit those signs, perfecting their technique and perfecting their interpretation of that technique.
>> Is most of the evidence used in the series based on signs and symptoms or what about basic and more sophisticated lab tests and radiologic studies? >> Well, those of us in the, who do research on the clinical exam would take umbrage with the word ''more sophisticated test''. You know you should never order a laboratory test or a radiologic test or some other test without having a firm understanding about the patient that you're ordering it in.
So, yes, we do concentrate very much on the history or symptoms if given to you by the patient, and the signs, the physical examination signs. That's our major focus. We recognize though that in many, if not most cases, the results from laboratory tests or radiologic images must be interpreted within the context of the patient. So, yes, we do use some laboratory tests. So, for example, the erythrocyte sedimentation rate for temporal arteritis is an extremely important finding.
However, it would be meaningless as a finding for temporal arteritis unless you were applying the results to the right patient. So, when we do use these other tests in the Rational Clinical Examination Series, we have to make sure that the examiner understands which patients they should be ordering it in. And that leads us back to the signs and symptoms that the patient presents with. >> What does the JAMAevidence website offer that's not in the Rational Clinical Examination book?
>> Well, when we first started writing our book and taking our articles that we had published into book form, we knew that we needed to update everything. So, the articles have been going back since 1992. And we began by repeating our literature search and finding what new things have been published since the original article first appeared. One of the goals of the Rational Clinical Examination was to stimulate people to do original research. Once we found that newer literature, we began to abstract it in a format that would be familiar to most readers who are evidence-based medicine practitioners.
So, we did critical appraisal of all the newer articles we found. As we accumulated these new updates and began to put them together with the older information, we created structured literature reviews. Once we were ready to write our book, we realized we had too much information. And so, on the website, we have all the structured critical appraisal that we've done for the new literature. And many readers, as they go through the book, are going to be interested in going to look at the actual data that we used to make our recommendations.
And we provide that on the website, not available in the book form. The second thing that's really exciting about the website is that Dr. Sheri Keitz, working closely with many Duke University junior faculty and house officers, with a few people from around the country and Canada, created a set of education guides for each chapter in the book. What we've done is we've created a series of standardized presentations that begin with a case scenario, present the background for the chapter, review the evidence.
And come up with recommendations in a PowerPoint formatted slide set. These slide sets are only available online. Learners may prefer the slide sets as a way of quickly accessing the information. Teachers have a ready set place to go if they would like to use the information in a lecture format or in a small group discussion to actually teach from the book. All of the education guides have been developed with a learner in mind.
And we've piloted all of them with a group of learners, so we know they work. And we're excited about making them available to everyone. >> That sounds great. What are the plans for the future of the Rational Clinical Examination Series? >> Well, we've now published over 70 articles. At the time we started writing the book, we only included the first 50 articles that appear. So, we have a lot more information that we're going to be adding to future editions of the book and to the website. We will continue to update what we've already done.
We will bring the articles that didn't make it to the book this time into future publications. And we have an active group of authors literally from around the world working on newer topics that will appear in the Journal of American Medicine Association as part of the Rational Clinical Exam Series. In addition to the Rational Clinical Exam Series, we've also begun to focus on another part of the clinical examination, and that is rational clinical procedures. We've been very interested in reviewing the literature for the procedures that the generalist physician would do at the bedside to determine what's the best way, what does the evidence show is the best way to perform those procedures.
This is a natural fit for the Rational Clinical Exam Series because one of the outcomes, not surprisingly from an article on the Rational Clinical Examination to detect meningitis, is going to be a lumbar puncture. And that lumbar puncture is typically performed by the same person who did the history and physical examination. So, working with Dr. Sharon Straus, who's leading this effort for us, we take the same approach to systematically finding the literature that evaluates, for example, the technique for performing a lumbar puncture.
And we're bringing this into a, a series of articles as part of the Rational Clinical Exam Series that we call Rational Clinical Procedures. >> Is there anything else you would like JAMAevidence users to know about the Rational Clinical Examination? >> Well, we write these articles with the user in mind. And we're very, very interested in having a dynamic approach that changes with the time, that takes feedback from our readers so that we can get the information they want.
And so, I would welcome all readers of the Rational Clinical Examination and users of JAMAevidence to be aggressive at contacting us and giving us recommendations for topics they would like to have, to see reviewed. And if there are things that they would like to change on JAMAevidence, we'd like their advice. We are very interested in pilot testing and evaluating newer ways of presenting this information. >> Well, that sounds very exciting, and it would be interesting to see how the website evolves.
>> Well, we're looking forward to it and it's a very exciting endeavor on our part. We certainly hope that those who haven't picked up their physical examination book in many years will be stimulated to look at our book and perhaps review their techniques, be critical about their own performance, and have fun while relearning to do the history and physical examination in a more quantitative way. >> Well, thank you, Dr. Simel. >> Thank you.
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