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The Art of Healing

Retired Faculty Members Draw on Decades of Experience to Teach the Principles of Practice

By Thomas Kohout

Sesum Moosavi, a third-year medical student in the George Washington University School of Medicine and Health Sciences (SMHS), enters the dimly lit hospital room. He introduces himself and briefly explains what he is there to do.

The patient is a heavy-set, African American male in his mid-40s complaining of dizziness, slight abdominal discomfort, and dark urine.

Moosavi begins the examination by taking the patient’s medical history, as Robert Wilkinson, M.D., M.A.C.P., professor emeritus of Clinical Medicine, a Board Certified Internist with nearly 50 years of experience under his belt, sits quietly observing Moosavi’s interaction, his forward-leaning posture, eye contact, and his relaxed but methodical line of questions. Wilkinson takes notes as the student asks a series of questions aimed at developing a differential diagnosis. When Moosavi indicates he has completed the history, Wilkinson asks a few additional questions for clarification before the student moves on. Wilkinson makes notes on a 40-point checklist as Moosavi continues on to the physical exam, checking the patient’s pulse, inspecting his eyes for jaundice and observing their pupillary reflex, and then continues through the steps to an efficient physical exam.

Gently tapping on the upper body, Moosavi listens carefully to the quality of the sound his fingers make. The difference in tone — resonant or hyper-resonant, flat or dull — tells a physician a great deal about the underlying structure. Dullness could indicate an underlying collection of fluid or possibly a mass.

Moosavi next guides firm but careful fingers over the patient’s abdomen, probing the stomach and tracing the outline of the liver to get a sense of his condition. At the end, Moosavi glances over at Wilkinson as if to ask, “Well, how did I do? Did I leave out anything?”

The two chat briefly with the patient, each thanking him for his time, and then retire to debrief in an empty lounge, where the real learning begins.

For nearly 20 years, a small band of retired SMHS clinicians like Wilkinson have been working to hold the line on hands-on care, ensuring that the doctors trained at GW know as much about the art of healing as they do about the science of medicine.

Since the early 1990s, every third-year medical student has taken Observed History and Physical Examination, a two-hour assessment of what Sir William Osler, the Canadian physician credited with first leading medical students out of the lecture hall and into the exam rooms, once called the “principles of practice.”

The course was developed by Stanley J. Talpers, M.D., a long-time clinician with the George Washington Medical Faculty Associates and former SMHS faculty member. After teaching in the Practice of Medicine (POM) program for about 15 years, former chair of the Department of Medicine George Rios, M.D., urged Talpers to launch a different type of program. Together they developed a course to offer third-year medical students an individualized critique of their examination and patient history skills.

Today, Talpers and eight fellow physicians — mostly former internists and all with some current or former GW affiliation — offer up decades of bedside exam experience during extensive evaluation sessions.

Following Moosavi’s examination, he and Wilkinson sit down to discuss how things went. After reviewing the proper use of the ophthalmoscope and the appearance of the fundus, Wilkinson suggests Moosavi and a classmate visit the exam rooms at the Clinical Learning and Simulation Skills Center — GW’s hands-on clinical educational environment. Then they discuss the patient, whom Wilkinson had handpicked earlier that day, asking the patient if he would be willing to participate in the teaching exercise and determining whether his case would be suitable for Moosavi’s history and examination.

“I thought Moosavi did quite well,” says Wilkinson. “When the patient didn’t want to go into details about his mental health history, the student didn’t press him or get confrontational. Ultimately he developed such a good rapport that the patient disclosed his mental health status anyway.”

Each year, some 180 third-year medical students take this rite of passage as they move through the Department of Medicine during their clinical rotations. They have already covered the skills required to take a patient history and give a physical exam during their first two years of POM. But often by the time students advance to their rotations something has gotten lost.

What Talpers calls the “skill of touch” is the point where medicine leaves the scientific arena and moves into the world of art. “That art is fading,” he says. Those skills have diminished in value as access to high-tech testing equipment becomes more commonplace. When students begin their rotations, they’re often left dazzled by that technology, and it’s hard for them to recall those basic skills they’ve learned as well as their value.

“We are giving them something invaluable, that one-on-one time and immediate feedback. That’s precious.”
Stanley J. Talpers, M.D.

“The generation I came out of had little technology,” recalls Talpers. “When I was a young doctor we relied heavily on physical diagnosis; that was an important part of a careful examination.”

Ironically, through the SMHS POM program and the Observed History and Physical Examination course, Talpers believes that today GW might actually be doing a better job of teaching these skills than ever before. When he was a young medical student, Talpers’ examination training came mostly through observing residents and doctors performing exams. “We’re teaching that now over the first two years,” he says. “We teach it very well and make it stick. That’s what this course is about — making those skills stick.”

An important part of this program, says Wilkinson, is that it’s not graded. “I explain that this is purely for their benefit. The students genuinely like the program, not just because they aren’t graded, but also because they are getting feedback from us. If they do something wrong in the physical examination we say, ‘wait, why don’t you try doing that this way.’ ”

Following the exam, physicians and students sit down to go over the procedure. They discuss how things went and explore ways to move beyond any tricky parts. Students, says Talpers, listen carefully when they’re critiqued. “We are giving them something invaluable, that one-on-one time and immediate feedback. That’s precious.”

Many students ask if they can do it over, say Talpers and Wilkinson, and some have suggested each student get a chance to take the course at the start of third-year rotations and again at the end. Unfortunately, there aren’t enough physicians to critique all of the students twice. In fact, time is a large part of why the course is led by retired or semi-retired physicians. Between the exam and the critique, physicians spend at least two hours with each student.

Wilkinson and Talpers agree that the goal of this program is not to move clinical practice back to a 19th century mindset. Modern diagnostics are crucial in the treatment of serious illnesses. But, they add, a physician armed with good examination skills can pinpoint most illnesses just as effectively, possibly faster, and certainly more efficiently than blindly ordering a battery of tests.

“If we could influence our students in these two hours, instilling these good habits and developing the skills that have become part of doctoring for a very long time,” says Talpers, “they could do a better job diagnosing their patients and getting the right answer the first time.”