Systems thinking: How I do the same exam over and over and over

A mentor told me, “Do the same exam, the same way, every time.”

It is something that I took seriously and implemented. I made sheets of the exam, laminated each test, and practiced with every person that came in (I used the International Academy of Orthopedic Medicine initially before morphing it into my own style).

AND I was awkward for the first month.  It embarrassed me that I would forget parts of the exam.  I also hid the sheets from my colleagues because I did not want anyone to know that ‘this idiot’ needs a cheat sheet.

After each visit, I marked on my sheet if I got all the tests in the right order.  After  2 months of doing this with the low back exam, I moved to the hip. After a month, I owned the hip exam.  One month later it was the knee, then the foot then whole spine, then the upper extremity.

Each visit I made a point to do the exam the same. This repetition was a game changer for my hands and skill.  I started to notice capsular patterns and empty end feels and muscle guarding.  I diagnosed an ACL tear then a posterior horn meniscal lesion. It was not that I knew exactly what those were but I knew what normal was across a huge swath of different people and presentations.  When something not normal came up, I knew it instantly and started to dig.

The digging is only possible after I knew what normal was.  I defined the exam and then gave myself the freedom to explore abnormal.

It is common to ignore normal presentations but for me it has been the most valuable of teachers.

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