The physical exam: Upholding a history of front line work

01/04/11  Portland, Ore.

Dr. SullivanQuietly, politely, five medical students enter the hospital room and are introduced to the patient by the supervising physician. For the next few minutes all is silent as fingers probe for pulses and eyes narrow to scan the waves of blood flowing through the veins in the neck. Stethoscopes are applied gently to back and front, tentatively encroaching on the patchwork boundaries of respect suggested by the standard-issue hospital gown.

"So," said Dr. Sullivan. "What have you learned?"

Peter Sullivan, MD, R '98, Assistant Professor, Department of Medicine, is spending this Friday afternoon much as he spends every Friday afternoon during the academic year – leading a group of students in the practical art of the physical exam and diagnosis. There is no grade, no credit. "We do this because this is a unique opportunity to gain additional experience at the bedside," said Crystal Hammer, a third-year medical student. "You can't learn this any other way."

Dr. Sullivan started the group in 2001 at the invitation of Lynn Loriaux, MD, PhD, Professor and Chair, Department of Medicine. "A group of second-year students wanted more experience in bedside examinations, and he asked if I would help," said Dr. Sullivan. "I've been doing it ever since." Each week he emails a select group of hospital colleagues to learn about patients who could offer a valuable learning experience for the students. "I ask the patient's permission first, and then we go and visit them," he said. "The patient and I are in on a secret that the students aren't. I encourage the students to follow the clues."

Back in the hospital room, his question to the students has evoked another thoughtful silence.

"I heard a really loud S2," said Bailey Pope, a second-year student. The first clue.

"There is an increase in jugular venous pressure," said Rebecca Sauerwein, a fellow MS2. A second clue.

The group pieces together a diagnosis of a mechanical aortic valve coupled with a leaking tricuspid valve. "We've encountered each of those individually, but never together," said Elliot Naidus, also in his second year, as the group members each thank the patient and leave the room.
Sullivan VA BridgeDr. Sullivan appreciates the imaging and other technologies that also support diagnoses, but he firmly believes in the primacy of the physical exam. "This is front line work," he said. "Patients come in completely undifferentiated and the physical exam is our first encounter. It sets the tone for almost everything that comes after. Unless you have the history and the exam, then you don't know what tests to run." Only after an hour and fifteen minutes does the group gather around a computer monitor – the only piece of technology they will consult all afternoon.
A history major prior to obtaining his medical degree, Dr. Sullivan brings a historian's perspective to each patient. "Look at the history. There are entire books written on the cardiovascular exam but each patient is different," he said. "The conclusion is never certain."

His historical perspective extends also to the study of his own profession. "There have been so many mistakes made in the past," he said. "History makes us humble about where we are and how we got there."

Pictured: (top) Dr. Sullivan at the “front line” of physical diagnosis; (bottom) Dr. Sullivan (front left) and class participants cross the VA bridge to visit a patient in the Portland Veterans’ Affairs Medical Center.