1304 The American Journal of Medicine, Vol 118, No 11, November 2005

Internal Medicine survey findings highlight that the over- Bedside teaching of medical students
whelming majority of respondents believed that physicians
are critical to the success of any introduction to clinical To the Editor:
medicine program. Nevertheless, the realities of recent
Omori et al have elegantly covered the issue of clinical
years, with fewer patients in the hospital and fewer faculty
medicine and how to improve the current curriculum.1 They
available for teaching due to service demands, have neces-
have cited how medical students feel that it is important for
sitated changes in the way introduction to clinical medicine
physicians to teach medical interviewing skills and physical
is taught. Standardized patients provide an important
examination. As someone who is working in an institution
method by which students can learn fundamental skills in a
involved with the training of medical students, I am person-
setting that may help alleviate some of their anxieties. How-
ally disappointed by the deviation of clinical medicine from
ever, it is important to highlight that we are not advocating
bedside teaching to the conference rooms. Not infrequently,
that standardized patients are the sole source of patient
I come across patients who are puzzled when I examine
interactions during introduction to clinical medicine. Stan-
their peripheral pulses or look at the fundus. Increasing
dardized patients provide an important supplemental
reliance on conference rooms, instead of the bedside teach-
method for students to learn clinical skills and also for
ing of the medical students, may have resulted in poor
evaluating these skills; however, they do not replace the
cardiac aucultatory skills of the trainees.2 The reason for
need for students to interact with and evaluate patients
such a deviation and decline in bedside teaching is multi-
during their preclinical years under the direct supervision of
factorial, some of which may not be in our control. How-
a physician. Similarly, although our survey findings re-
ever, in an era of technological advances we should re-
ported that fourth year medical students and housestaff are
emphasize the importance of clinical examination and
participating in teaching introduction to clinical medicine
auscultation. For example, it is known that the presence of
courses, we failed to clarify whether they were teaching in
a third heart sound is associated with worse outcome in
a supervised setting, ie, that fourth year students and/or
patients with heart failure.3 It also indicates severe hemo-
housestaff were learning to teach these skills under the
dynamic dysfunction4 and is the most important predictor of
guidance of an experienced teacher. Our anecdotal experi-
postoperative complications.5 The advancement in technol-
ence in speaking with introduction to clinical medicine
ogy has helped medical science tremendously but has un-
directors is that such is the case, and thus experienced
fortunately relegated the stethoscope to be the “forgotten
clinicians are helping to train not only the next generation of
instrument in cardiology.” The use of standard methods of
physicians, but the next generation of teachers as well. In an
assessment, such as objective structured clinical examina-
ideal world, patients and experienced physicians will have
tions, to evaluate students’ clinical performance is highly
adequate time and talents to spend at the bedside teaching
variable among medical schools in the United States.6
students these important bedside skills. In the meantime,
Prompt diagnosis and treatment of heart failure is essential
alternative strategies such as careful planning and selection
for good clinical results. In patients with symptoms of heart
of educators in teaching roles could be successfully in-
failure, there is a good correlation between clinical assess-
cluded in the curricula of many medical schools. However,
ment and objective evidence of left ventricular function.7 In
we too hope that our “seasoned” physicians continue to
a survey of 3 countries, it was noted that the cardiac aus-
actively educate our future physicians in introduction to
cultatory skills of internal medicine residents is universally
clinical medicine courses.
poor.2 However, both British and Canadian trainees wished
Deborah M. Omori, MD, MPH for more auscultatory teaching during their training than
Paul A. Hemmer, MD, MPH their American counterparts.2 British trainees who are ex-
Department of Medicine pected to undergo an objective assessment of physical ex-
Uniformed Services amination skills at the time of internal medicine board
University of Health Sciences certification improved the most over 3 years of training.
F. Edward Hebert School of Medicine Canadian residents, who are trained and tested similarly in
USUHS-EDP examination, had the greatest accuracy.2 Is it time to intro-
Bethesda, Md duce a structured bedside clinical examination in the inter-
nal medicine and other board certification examinations in
Raymond Y. Wong, MD America as well? It may motivate medical students and
Loma Linda University doctors to learn and perform good clinical examinations.
Medical Center
Loma Linda, Calif S. Wamique Yusuf, MD, MRCPI
Department of Cardiology
Mary Ann S. Antonelli, MD MD Anderson Cancer Center
John Burns School of Medicine University of Texas
Honolulu, Hawaii Houston
doi:10.1016/j.amjmed.2005.04.036 doi:10.1016/j.amjmed.2005.02.037
Letters
References
1. Omori DM, Wong RY, Antonelli MA, Hemmer PA. Introduction to
clinical medicine: a time for consensus and integration. Am J Med.
2005;118:189-194.
2. Mangione S. Cardiac auscultatory skills of physicians in training: a
comparison of three English speaking countries. Am J Med. 2001;110:
210-216.
3. Dranzer MH, Rame JE, Stevenson LW, Dries DL. Prognostic impor-
tance of elevated jugular venous pressure and a third heart sound in
patients with heart failure. N Engl J Med. 2001;345:574-581.
4. Tribouilloy CH, Enriquez-Sarano M, Mohty D, et al. Pathological
determinants of third heart sounds; a prospective clinical and Doppler
echocardiograph study. Am J Med. 2001;111:96-102.
5. Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index
of cardiac risk in non cardiac surgery. N Engl J Med. 1977;297:845-
850.
6. Baransky B, Jonas HS, Etzel SI. Educational programs in US Medical
Schools, 1999 –2000. JAMA. 2000;284:1114-1120.
7. Gillespie ND, McNeill GM, Pringle T, et al. Cross sectional study of
contribution of clinical assessment and simple cardiac investigations to
diagnosis of left ventricular systolic dysfunction in patients admitted
with acute dyspnea. BMJ. 1997;314:936-942.
The Reply:
Dr. Yusuf’s reflection on our essay points out a few of
the conventions that may interfere with both student learn-
ing and with evaluating the data obtained from their clinical
data gathering skills.
● “Bedside” rounds are too frequently moved to a didac-
tic conference session for reasons of convenience, ac-
commodation, and efficiency, but lose the essence of
bedside learning. This applies across the clinical skills
learning of students, residents, fellows, and in continu-
ing medical education after training. To quote McGee,1
“One can hardly fault a student who . . . does not talk
seriously about crackles and diminished breath sounds
when all of the teachers are focused on the subtleties of
the patient’s chest radiograph.”
● Faculty who trained in the early technologic era, where
bedside clinical skills may have been overlooked in
favor of technology, may have little knowledge of the
substantial literature1,2 on evidence-based physical di-
agnosis that helps establish which aspect of physical
diagnosis is a “reliable diagnostic tool that can still
help clinicians with many but not all clinical prob-
lems.”1
● Evaluation of performance of skills technique may not
identify the appropriate clinical use of these same
skills.3
We believe that expertise in bedside clinical diagnosis skills
can only be achieved with reinforcement in medical school,
practice, and improvement in postgraduate training, and
careful attention to the art and science for the rest of one’s
medical career.
1305
We agree with Dr. Yusuf that attention to skill standards
in residency and beyond is essential and would suggest
further that adhering to excellence in clinical diagnosis
skills is basic to the ethical and conscientious practice of
medicine.
Deborah M. Omori, MD, MPH
Paul A. Hemmer, MD, MPH
Department of Medicine
Uniformed Services
University of Health Sciences
F. Edward Hebert School of Medicine
USUHS-EDP
Bethesda, Md
Raymond Y. Wong, MD
Loma Linda University
Medical Center
Loma Linda, Calif
Mary Ann S. Antonelli, MD
John Burns School of Medicine
Honolulu, Hawaii
doi:10.1016/j.amjmed.2005.07.032
References
1. McGee, SR. Evidence-Based Physical Diagnosis. Philadelphia, Penn-
sylvania: WB Saunders Company; 2001.
2. JAMA’s “Rational Clinical Exam” series. Various authors, JAMA, 1992
through 2004. Available at: http://www.emory.edu/WHSCL/grady/
inetgrp/ratclin.html.
3. Wilkerson, L, Lee M. Assessing physical examination skills of senior
medical students: knowing how versus knowing when. Acad Med.
2003;78(10 Suppl):S30-S32.
Non-invasive carbon dioxide pressure measurement
To the Editor:
The study by Sin et al1 shows well that arterial carbon
dioxide tension (PaCO2) measured at the time of initial
presentation helps determine prognosis among patients hos-
pitalized for community-acquired pneumonia. Mortality
was higher among those patients with either low (⬍32 mm
Hg) or elevated (ⱖ45 mm Hg) PaCO2. They present several
possible mechanisms for how hypercapnia and hypocapnia
could be “involved in the downward spiral of patients with
pulmonary infections.” If this is the case, then following
PaCO2 during the hospitalization should be more helpful
than a one-time measurement. Their findings do not directly
address but suggest that PaCO2 should be one of the factors
used to help determine whether to hospitalize a patient with
community-acquired pneumonia.
However, it is not practical to repeatedly measure
PaCO2, and it is difficult enough to obtain an arterial blood
gas in the emergency room, as evidenced by more than a