The Stanford 25

An Initiative to Revive the Culture of Bedside Medicine

Diagnosis on a Bicycle?

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These days, all practice-changing research must involve expensive and complex technology, no?

No.

In January’s edition of The Lancet, three Dutch neurologists have published a study that demonstrates how making the difficult distinction between parkinsonism and atypical parkinsonism can be greatly assisted by asking a simple question: Can you still ride a bicycle?

In their paper, The “bicycle sign” for atypical parkinsonism, Drs. Aerts, Abdo, and Bloem conducted a prospective observational study and found a strong correlation between an inability to ride a bicycle and the gold standard of diagnosis for atypical parkinsonism.

Admittedly, the “bicycle sign” is most significant within populations that often bicycle. One study found that the average Dutch citizen bikes nearly 1.5 miles a day; the average American, only 110 yards per day. Even so, the work of Aerts et al is a heartening sign that research focusing on the history and physical examination of patients can yet bear fruit.

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Written by blakecharlton

February 2, 2011 at 10:35 am

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“Inspection…Palpation”

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We are grateful to Dr. Arnold Lieber for the following narrative.

Paul is an old friend of mine, a 78 year old artist. When my wife and I saw him in the fall of last year we were shocked at the change that had come over him in a few months. He had a right facial, the eye lids drooping, mouth sagged open, saliva dripping. He also had more or less continuous severe pain in the area of the angle of the right jaw. He had seen a neurologist who diagnosed Bell’s palsy and reassured him that recovery was likely. My wife (an internist) and I (a psychiatrist) exchanged looks and cautiously observed that it would be a good idea to work this problem up further, see another consultant, but we were not emphatic since we were reluctant to abruptly puncture the optimism of Paul and his wife Mary. “If it doesn’t start getting better in the next week or two, you should see somebody”.

Two cranial nerves involved. What could it be? It seemed ominous to us. I took out my old Grant’s anatomy atlas and studied the brain stem and basal skull. In the weeks that followed, everything got worse, the right facial deepened and pain extended up to the forehead. I found a neurologist who specialized in cranial nerve disorders and neuro-opthalmology. Paul was disconcerted when he went to see him by his freely ventilated hostility directed at his medical assistant. He recommended a CT scan of the head and an LP. Both were unrevealing. Paul, put off by his bedside manner, didn’t want to see him again. The radiologist who interpreted the CT scan was somehow in direct contact with the patient and recommended an exploratory operation to pursue the diagnosis and deaden the trigeminal nerve. Another consultant, Dr. G., a prominent ENT specialist, held out for making a diagnosis before intervening and recommended repeat studies. Time elapsed. Pain, poorly relieved by analgesics, continued. Paul had an episode of weakness and delirium, with hyponatremia, requiring hospitalization.  Uncertainty and anxiety mounted. I noted that Paul had an abducens palsy as well. Finally Dr. G. scheduled an exploratory facial nerve operation.

A lawyer friend strongly urged Paul to see his friend, Dr. P, a head and neck surgeon at a New York medical center. I looked him up online and saw his impressive list of clinical papers. Maybe he could clarify the problem and how to deal with it. I went to the appointment with Paul and Mary.

In the examining room, a nurse took a rather cursory and inadequate history. “This visit isn’t looking good,” I thought. Dr. P. entered the room, a tall handsome gray-haired figure, with a calm, unhurried demeanor. His magisterial air reminded me of Arnold Steinhardt of the Guarneri Quartet. He sat close to Paul, took a meticulous detailed history. Some twenty years ago Paul was treated with a Mohs procedure for skin cancer on his face. Two years ago he had a similar lesion, which was excised without apparent recurrence.

Then he studied Paul’s head and neck carefully, followed by a palpation of the afflicted area. He became interested in the right side of the neck and eventually demonstrated an induration of the greater auricular nerve. He left the room and returned in a few minutes with a cytologist who drew a tiny sample from the indurated nerve.  Another pause. Dr. P. returned to the room and announced that the biopsy revealed squamous cell carcinoma, the clinical picture was one of retrograde infiltration of multiple cranial nerves, and that a course of treatment (radiation) would follow. (Dr. P. drew me aside for a moment and told me, “He’s not going to make it.”)

For me it was breathtaking. In the age of crowded waiting rooms, super-specialists, high tech procedures—in a single visit, a definitive diagnosis was made, mainly by physical examination—inspection…palpation.

What was the reaction of the patient and his wife to the experience, the diagnosis of invasive cancer? Relief and gratitude! “He touched me, he put his finger right on the problem,” Paul declared.

Months later, Paul, an inveterate postcard-sender, sent us a postcard which read in part “Rob is the one who turned us on to Dr. P. who put his finger on my jaw where I’d been pointing to for three months and had been ignored by ten doctors who were competing to see who was the smartest doctor on the block. All duffed [sic] up. This doctor put his finger on the spot and pronounced it cancer, then had an associate come in and perform a needle biopsy which confirmed his prediction, So Rob saved my life as did you earlier (by suggesting further investigation).”

In the year that followed hope passed into resignation as the disease progressed. Paul died last month. He never revised his high opinion of his medical care.

Written by blakecharlton

January 15, 2011 at 12:26 pm

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Obesity and the Physical Exam

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In America, physicians often cite the increasing prevalence of obesity as a barrier to physical examination—the implication being that medical professionals are powerless unless faced with the idealized 70 kilogram patient. However, in this month’s issue of the Journal of the American Medical Association, Drs. Ann Willman Silk and Kathleen M. McTigue address how doctors might update bedside skills to best serve today’s patients. In their article “Reexamining the physical examination for obese patients,” Silk and McTigue write

Physical diagnosis in obese patients is challenging but important in a population in which more than a third of adults manifest obesity. To ensure adequate care of the rapidly increasing obese population, medical education programs should place more emphasis on how to adapt the physical examination for obese patients. Such adaptations are teachable skills like other classically taught examination maneuvers and should not be marginalized. Obese standardized patients should be included in medical training so that students have the opportunity to practice these skills. In addition, physical diagnosis textbooks should include illustrations of obese patients, address aspects of the physical examination expected to be different in an obese patient, and provide suggestions for adapting the physical examination accordingly.

Written by blakecharlton

January 15, 2011 at 12:11 pm

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The Stanford 25 & Simulation Technology

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Dr. Verghese (far right) examines Harvey. On looking are (from right to left) Blake Charlton, Dr. Jeff Chi, & Dr. Errol Ozdalga.

Get into a cocktail party conversation about medical errors and likely someone will bring up air travel. Before you assume the speaker has knocked back one martini too many, consider the analogy between physicians and pilots first drawn by Robert Helmreich in his BMJ article On Error Management: Lessons from Aviation [1]. If you’re guessing that the comparison doesn’t reflect well on doctors, then you’re not too far into your cups either. One advantage pilots have had over physicians is the ability to create highly detailed flight simulators. Unfortunately for medicine, simulating a cockpit is far more feasible than simulating a patient; however, recent advances have made considerable efforts to close the gap.

The Stanford 25 Initiative seeks to train physicians to glean diagnostic information without technology to augment the information gathered by technology. For this reason, we believe we are tied to technical innovation, not opposed to it. In this spirit, we were especially gratified to install and receive training in a “Harvey” cardiology patient simulator, developed at the University of Miami [2].

On first blush, Harvey seems nearly identical to the mannequins that suffer the thousand natural shocks of medical students practicing chest compressions and mouth-to-mouth breathing during basic life support training. But standing beside Harvey, one cannot help but notice that the mannequin is…in a disturbingly life-like way…breathing.

The University of Miami engineer (far right) positions the stethoscope while (from right to left) Drs. Ozdalga, Chi, and Verghese listen in via a transmitted audio signal.

On a bright, late September morning four members of the Stanford 25 team forsook the Northern California sunshine to spend some basement time with Harvey. The uncanny breathing turned out to be only the first of his uncanny features. As an engineer from the University of Miami demonstrated, artificial veins visibly pulse on Harvey’s neck, palpable artificial arteries lie deeper in his throat as well as down his right arm and both legs. On his chest one can feel a steady apical impulse. (Coincidentally, the term “apical impulse” has never been mistaken by anyone at Stanford, most especially not the author of this post, as being synonymous with the term “point of maximal impact.”) Most importantly, all of these features can be altered to mimic a wide range of cardiovascular conditions, from an atrial septal defect to coarctation of the aorta.

After learning how to program Harvey, the author of this post punched in a random condition to give Dr. Verghese a chance to play ‘stump the professor.’ In hindsight, the author realizes that he should have punched in ‘normal’ to truly agitate the team leader. Instead, Dr. Verghese carefully examined Harvey for five minutes and made the correct diagnosis of mitral regurgitation.


Dr. Verghese uses a cotton swab to exaggerate the motion of the apical impulse.

Now that the team knows how to operate Harvey, we face the challenge of making the technology beneficial for trainees. Harvey allows trainees to appreciate an approximation of rare CV findings. Likewise the ability to hide the programmed condition allows a trainee to repeatedly approach an undiagnosed CV patient. This ability to consistently recreate identical challenging tasks—known to golfers as ‘the repeatable stroke’ phenomenon—is difficult to recreate in the wards and yet essential for the improvement of specific skills. We are in the process of determining the best way to bring these advantages to residents and students.

Importantly, we acknowledge that no simulation is exactly representative of a patient. After all, we have chosen the motto “The map is not the territory’ for this website. We do not believe that Harvey, or any other patient simulator, can substitute for time spent at the bedside, just as we do not believe that physical examination can substitute for certain technological examinations. However, we do believe that Harvey and other simulation technology can accelerate bedside learning, help improve diagnostic skill, and…equip physicians to better respond to comparisons to pilots at cocktail parties.

-Blake Charlton, MS4/6


[1] Helmreich R.L., “On Error Management: Lessons from Aviation” BMJ 2000 Mar 18; 320(7237)

[2] Gordon M.S., Ewy G.A., et al. “‘Harvey,’ the cardiology patient simulator: pilot studies on teaching effectiveness.” Am J Cardiol. 1980 Apr;45(4)

Written by blakecharlton

October 4, 2010 at 7:36 pm

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Recent Study Analyzes Give-and-Take of Bedside Teaching

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As a medical student at Stanford, Dr. James Priest was surprised by the different teaching styles he encountered during his internal medicine and pediatric clerkships. Surprised by the minimal amount of hard data on rounds, Dr. Priest decided to explore this difference before starting his pediatrics residency at the University of Washington. He collaborated with residency programs at Stanford and the University of Washington to observe rounds on pediatrics and internal medicine over a 10 month period in 2007-2008. The results of this study were recently published and illustrate the complex, and often unacknowledged, educational consequences unique to the inpatient culture of each specialty.

Dr. Priest and his collaborators found that pediatricians spent less time with patients than internal medicine physicians, and that less teaching on rounds is being conducted than in previous studies of internal medicine. Specifically, the percentage of rounds spent at the bedside on internal medicine was 37% in 2008 compared to 9-11% in the 1990’s, while educational activities dropped from 22-29% in the 1990’s to 9% in 2008. Perhaps most pertinently, the decrease in educational activities was accompanied by an increase in patient interactions; 8-12% in the 1990’s to 25% in 2008.

As Dr. Priest remarked, “One might infer from these data that, on rounds at least, more time is now spent at the bedside interacting with patients instead of upon educational topics. The anti-correlation between education and time at the bedside could mean that, education on rounds occurred away from the bedside, and consequently may not be focused on physical diagnosis or inclusive of patient participation. As a pediatrician in training, our followup work aims better understand the attitudes that shape the inpatient trainee experience on rounds.”

Written by blakecharlton

July 23, 2010 at 6:30 am

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Champions of Bedside Medicine: Barbara Bates, MD

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The following is an excerpt from the National Library of Medicine’s exhibit “Changing the Face of Medicine,” the full text can be found here. A brief video version of the below can be found here.

[Barbara Bates MD] wrote a guide to patient history-taking that has become the standard text for health practitioners and medical students. Her book, Guide to Physical Examination and History Taking, first published in 1974, has been published in several revised editions and includes a twelve-part video supplement, A Visual Guide to Physical Examination.

Bates grew up in Auburn, New York, where her father was a general surgeon, and her mother a registered nurse. She decided to pursue a medical career while in her junior year at Smith College. She attended Cornell University Weill Medical College and got her M.D. degree in 1953. Dr. Bates stayed on at New York Hospital and Cornell Medical College until 1958, when she joined an internal medicine practice in Greenwich, Connecticut.

In 1961 she was recruited to join the faculty at the new University of Kentucky College of Medicine, a school intended to provide physicians and better medical care to the underserved Appalachian region… Dr. Bates moved to the University of Rochester School of Medicine, to oversee the training of medical residents and to participate in the Rochester Regional Medical Care Program in western New York.

In Rochester, she became an activist in interdisciplinary practice, further developing the then new role of nurse-practitioner… She became well known as an outstanding professor of medicine, especially for her expertise in diagnosis and her ability to teach student doctors and nurses the skills of examination and clinical thinking. In 1970, realizing that the standard text used to teach physical examination was not user-friendly, she developed a guide to physical exam and history-taking for use by her nurse-practitioner students. Ten nurses and five physicians who met during the spring of 1970, and called themselves “The Clandestine Group,” helped her with the project. The first guide was hand-drawn, and its organization was based on ornithologist Roger Tory Peterson’s popular guides to American birds. Introductory chapters in Bates’s book discuss interviewing techniques, the health history, common and important symptoms, and assessing the mental status of the patient. Specific chapters review anatomy and physiology, physical examination techniques, and selected abnormalities. Illustrated summary tables for each chapter are marked with red tabs for easy access.

Written by blakecharlton

June 7, 2010 at 10:09 pm