Wednesday, June 15, 2016

What does a 'focused' history taking and physical mean?

I received the following email from an OSCE candidate and would like to share it with you:

Dear Dr Al lmari,

I am still confused regarding Focused physical examination.
I need your guidance for 5 min, 8 min stations.

I read it from your notes that it is not a head to toe examination.
But still not getting it, Could you please guide me.

Is it
  1.        .   To focus on Only the system asked to exam as per chief complaint e.g CVS, Respiratory etc.  OR
  2.       .    Do physical as per differential + focused examination of system asked as per Chief complaint.

For example
  1.        .   in case of patient with cough, Face, Neck, LN & Respiratory System + Upper Abd ( GERD) or Only Respiratory ( Chest Only)   or only Chest
  2.       .    In case of Fluid Assessment CHF pt- BP, JVP, Kausalmaul, hepatojuglar reflux, CVS( Ins, Pal, Ausculation) +  Vessels-Radial, + Carotid, Aorta, Renal & Illac for Bruit, + Popletial, Post Tibial and Dorsalis pedis,  Edema over leg, crepts on base of lungs and Abdominat Girth, Ascites

Am I right ? Sir please guide me. Thanks for your time.

With Best Regards


Hello Dr ....,

Sorry for the delay of my reply.

You are right its somehow confusing what a focused approach is.

Basically, the shorter available time is, the more focused you should be.

But focused on what? You should be focused on the differential diagnosis (DDx) of the chief complaint, not the system.

Your focus is on developing a differential diagnosis specific for this patient with your first guess is the best match followed by less matching DDx.

If you noticed, OSCEhome flow charts’ questions box for each system does cover all the required differentials for any chief complaint from other systems.

For example, the first few system specific questions box for chest pain are similar in cardiology and respiratology and even GI.
Meaning after asking these few questions you will know that you are dealing with a cardiac, respiratory, GI, or MSK case and proceed with questions of that system specific questions/examination box.

Similarly, questions for each symptom, e.g cough, are identical in any system specific questions box.

However, if you thoroughly practice our flow charts, you will be fast to ask and do more than needed if you are not sure.
This will assure checking all the required check marks to be on the save side.

The main logic of the OSCEhome Systematic Approach to the OSCE and clinical patient encounters is to eliminate burden of focusing on WHAT to ask or do, HOW to ask or do, and WHEN to ask or do and redirect your attention and thinking to focus on developing a specific DDx for this patient, to build rapport with the patient and a plan to proceed,

In answering your questions:

Is it
  1.         .  To focus on Only the system asked to exam as per chief complaint e.g CVS, Respiratory etc.  OR
  2.         .  Do physical as per differential + focused examination of system asked as per Chief complaint.

By using the OSCEhome flowchart for history taking, you do have now a DDx.
Next, for examination select the system specific box that match your first DDx.
Similar to questions boxes, OSCEhome examination flow charts do cover related symptom/sign DDx.
Meaning your above #2 answer is the way to go.

  1.         .  in case of patient with cough: Face, Neck, LN & Respiratory System + Upper Abd ( GERD) or Only Respiratory ( Chest Only)   or only Chest
  2.        .    In case of Fluid Assessment CHF pt- BP, JVP, Kausalmaul, hepatojuglar reflux, CVS( Ins, Pal, Auscultation) +  Vessels-Radial, + Carotid, Aorta, Renal & Illiac for Bruit, + Popletial, Post Tibial and Dorsalis pedis,  Edema over leg, crepitus on base of lungs and Abdominal Girth, Ascites

1- If you look at the OSCEhome questions set for cough in all system specific questions boxes you will find them identical and by asking them you will know which system specific examination box to follow.
(Note: Face and neck in cough cases are for upper respiratory causes which is already covered in chest examination box).

2- For CHF, the cardiac specific examination box cover all these.

Hope this answers your questions.

All the best for your OSCE preparation.

Have a nice day.

Wednesday, November 21, 2012

Physicians' Top Ethical Dilemmas

Physicians' Top Ethical Dilemmas:

Would you fight with a family that wanted to withdraw care from a viable patient? Would you follow the family's directive to continue treatment if you thought it was futile? Would you date a patient? More than 24,000 physicians told us how they feel about this and other ethical dilemmas.

Check this interesting Medscape survey..

'via Blog this'

Wednesday, June 20, 2012

Are The OSCEhome Systematic Approach Flowcharts The Answer To Today’s Short Patient-Physician Encounters?

Recently, I received an email from one of newsletter subscribers concerning a valuable article in Newsweek Magazine titled “The Doctor Will See You- If You’re Quick”. In that article, the Author, Shannon Brownlee, points out that ‘they are signs that something in the world of medicine is seriously amiss’. She said patients ‘tell tales of being rushed out of the office by harried doctors who miss crucial diagnoses, never look up from their computers during an exam, make errors in prescriptions, and just plain don’t listen to their patients. Studies show a steep decline over the last three decades in patients’ sense of satisfaction and the feeling their doctors are providing high-quality care. And things don’t seem much better from the other side of the stethoscope. In a recent survey by Consumer Reports, 70 percent of doctors reported that since they began practicing medicine, the bond with their patients has eroded’.

The main issue she stated is that ‘Today visits are still short… The number of required tests and conditions primary-care doctors are supposed to screen for has skyrocketed’. One physician in the article said: ‘When you have only 15 minutes per patient, then there are home visits and hospital visits, you feel like you’re on a hamster wheel’.

Then, she reported studies that concluded that ‘This is not a recipe for optimal care. One Canadian and U.S. study found that doctors interrupt their patients on average within 23 seconds from the time the patient begins explaining his symptoms. In 25 percent of visits, the doctor never even asked the patient what was bothering him. In another study that taped 34 physicians during more than 300 visits with patients, the doctors spent on average 1.3 minutes conveying crucial information about the patient’s condition and treatment, and most of the information they provided was far too technical for the average patient to grasp; disconcertingly, those same doctors thought they had spent more than eight minutes’.

On the patient clinical management side, she said ‘At the same time, doctors often prescribe too much of the wrong kind of care. Between 2000 and 2005, the number of CT scans performed annually nearly doubled to more than 75 million a year, many of them given, say experts, out of habit or fear of litigation, not because they were likely to help the doctor make a diagnosis’.

Concerning patient-physician relationship, she emphasized that ‘Numerous studies have found a link between how well the doctor and patient communicate and the patient’s sense of well-being, his number of symptoms, and his overall health.

Bottom line reality is; 1) physicians have limited time allocated to each patient visit. There are more patients than physicians and training more physicians with these economical circumstances is not possible, 2) have a wide list of differentials to cover in order to be a good physician and to protect themselves. Obviously, the focused history and physical approach became so focused that failed frequently, 3) have no time for establishing an effective patient-physician relationship, and 4) have limited time to explore patient management options.

Currently, physicians have to adopt a focused approach. It is kind of the third world out-patient approach for treating patients’ symptoms. In order to protect themselves, they instruct patients to come back if things don’t improve! It is kind of an initial screening process during which physicians omitted several important issues concerning clinical and patient-physician communication. This may work initially. The problem is that when the patient comes back for a second visit, will he be allocated more visit time and addressed differently? What if the patient will see another physician who will re-initiate this focused approach?

So, how to solve this?

Since 2004, introduced the Systematic Approach to focused history taking, physical examination, and counseling in which a set of grouped carefully phrased questions and actions sets are arranged based on patient complaints, not body systems or physician specialty. It has the same rationale of ATLS APLS, ALSO, and ACLS approaches. After memorizing and practicing all the flowcharts, physicians can pick specific sets of history taking questions and physical exam actions to perform during the patient encounter based on the presenting patient complaint.

Verbal and non-verbal communication skills are embedded within this system. By practicing these flowcharts over and over until it become a second habit, physicians can be confident that they accomplished a professional conduct. This focused approach puts the physician on an autopilot mode to cover all relevant differentials without thinking about them as they have no time in today’s short patients’ visit.

This approach ensures that the physician won’t forget to ask or examine crucial things. In stead, they’ll have relatively more time for clinical decision making, establishing rapport, and discussing the patients’ options, attitude, and compliance.

Read more about the OSCEhome Systematic Approach at

Read the full Newsweek article at The Doctor Will See You- If You’re Quick.

Have a nice day.

Dr Al Imari.

Tuesday, November 29, 2011

How would you deal with someone who is insisting to have mammogram without indication?

Sent: Tuesday, November 29, 2011 12:08 PM
Subject: Conflicted roles Dear Doctor Al Imari, Could you please give more idea about dealing with conflicts as there is only one phrase you have mentioned in the remedy part, can you elaborate what to be explained about the conflict in the case and what should we inform as a doctor about what we could do. This is from OSCEhome ebook “How To Unlock Difficult Medical Encounters”. To be more precise how would you deal with someone who is insisting to have mammogram without indication or a mother who is asking why her teenage daughter was in your clinic etc.

Kind regards

Hello Ravi,

For "how would you deal with someone who is insisting to have mammogram without indication ":

1- Address their needs with respectful, empathic, and generous care directed towards physical and emotional comfort. Ask why she is really concerned to have the mammogram now? Hidden issues? Educate the patient about the limited benefits of mammogram, as the fact is that the younger the women is, the more difficult to efficiently read the mammogram films as younger women have more glandular breasts which limits the benefit, and its risk of radiation.

2- Set limits of your “Contract” with the patient:
 1) Provide written instructions: brochures, web sites about the recommended guidelines. Discuss a risk-benefit balance
 2) Set follow-up appointments.
 3) Set limits on phone calls.
 4) Set limits on prescriptions refills.

3- Emphasize the patient responsibilities:
 1) Understanding the nature and characteristics of their health problem.
 2) Behavior change and adherence to therapy. Self examination and periodic physician exam.
 3) Fulfilling his/her part of the “therapeutic contract”. Negotiate a plan TOGETHER. Don't be confrontational. The agreed upon plan is for her best interest and you gain nothing for ordering the mammogram or not.

4- Avoid making promises that you cannot keep (e.g. nursing or insurance problems). Apart from reconsidering the issue on next appointment.

5- Remind the patient that available time is limited. “You certainly have a lot of important problems, but since our time is so short, I’d like to get back to your …cc ”

6- Do not take credit for remissions in the patient’s symptoms, because you will be blamed for a relapse in the future. Note: Sometimes physicians order tests to relief anxious patients, but try to avoid that during OSCEs. ----------------------------------------------------------------------------------

About "a mother who is asking why her teenage daughter was in your clinic":

1- Clearly communicate to the patient, individual, and institution your double role right from the beginning. “Mr./Ms. …, although I am your doctor and I am obliged to do all my best to serve your interests, I also have other obligations and duties by profession or law that might limit my obligation towards you. I’ll do my best to serve both obligations.

2- Clearly explain what the conflict is in this case. "Your daughter is mature enough to take care of herself and, by privacy and professional laws, I cannot give you any relevant information."

3- Clearly inform him/them about what can you do. "I cannot help you here and I recommend discussing this issue directly with your daughter. Please excuse me. I don't want to waste your time as well as other waiting patients' time." and end the encounter. If she continues to ask in different ways, just keep saying “Discussing this issue directly with your daughter.”

Hopefully this answers your questions.
Have a nice day.