Dr. Verghese’s Rules for the Bedside Exam
Stanford Medicine 25’s Abraham Verghese says he’s learned key lessons at the patient bedside over the course of his career, all of which can be applied to enhance physical exam skills and foster the physician-patient connection. His insights are pillars of our annual skills symposium and, as noted by Dr. Verghese, serve as a transformative and transcendent component of patient care. Whether you’re improving your own physical exam skills or mentoring others, his list of bedside medicine pointers can help inspire and ground medical providers.
Here is a sampling of his rules for the Bedside Exam, from reminders on being present during clinical interactions to identifying physical exam findings:
1. Physical findings are scientific: “When we shortcut the physical exam, when we lean toward ordering tests instead of talking to and examining the patient, we [overlook] simple diagnoses that can be diagnosed at an early, treatable stage,” Dr. Verghese explains in his widely acclaimed TED Talk.
2. Embrace the RITUAL: “The [physical exam] is a ritual of exceeding importance. If you shortchange that ritual by not undressing the patient, by listening with your stethoscope on top of the nightgown, by not doing a complete exam, you have bypassed the opportunity to seal the physician-patient relationship,” states Dr. Verghese.
3. To grow your bedside skills, start small and build upon them: He advises learners to grow a repertoire of 5-Minute Moments and consider them building blocks. “You add up these blocks and eventually you will have quite a robust set of skills. At any moment and any bedside, no matter what the patient has, you can chart out your favorite thing and get a conversation going.”
4. Prioritize your patient’s comfort: “Please keep in mind the appropriate draping of the patient when you’re examining them,” says Dr. Verghese. “Keep them feeling comfortable, covered and unexposed.”
5. Encourage the patient to share their story and avoid interruption: “We know that the average American physician interrupts their patient in 14 seconds. If I ever get to heaven, it will be because I held my peace for 45-minutes and did not interrupt my patient,” comments Dr. Verghese of a memorable experience in dealing with a medically-complex patient.
6. Carry the right tools and use them wisely: Dr. Verghese says there is good reason he carries the following in his lab coat:
o Magnifying glass to look at nail beds or more closely at a skin lesion
o 128-frequency tuning fork because it’s useful for a quick neuropathy screen
o Drops for dilating the eye
o Ophthalmoscope because many diseases “are related to disease of the [eye] vessels (diabetes, ischemia, etc.)” and “it’s a wonderful gift to be able to look into the eye and see how the patient’s vessels look”
o Pens for marking patients while teaching
7. Technique matters, but so does rote learning. Model both and memorize all the steps for specialized exam when you need them: Dr. Verghese uses the car as a metaphor for the human body: “I think if you drive a stick shift and you know how to change a tire and you know how to change the oil, you have some sense of the machine. It’s not as though you’re driving a sofa down the freeway… without a sense of how much damage you can do or what’s involved. Whereas I think appreciating the technique of this complex machine gives you a sense for it.” He notes this concept inspired Stanford Medicine 25. “We did not want to teach physical diagnosis all over again. But we thought if we can pick 25 technique-dependent maneuvers and make residents appreciate how technique matters—how if you have the wrong technique, you won’t get the result you want—we can elevate technique, in general.”
8. Have fun. Find new things—it’s not over!: “A new infectious disease always provides opportunities for new clinical observations,” he explains, while sharing notes on oral manifestations of COVID-19 during the 2021 Stanford 25 Skills Symposium.
We advise medical providers to adopt these rules into their practice as a means to enhance patient care at the bedside. For further instruction on their application, visit our Stanford Medicine 25 video gallery.