Emphasizing High Value, Cost-Effective Care in Physical Examination Instruction – A Qualitative Content Analysis of Interviews with Expert Educators

This article was migrated. The article was marked as recommended. Introduction Physical examination and cost consciousness are critical competencies for medical trainees, but the intersection of these two skill domains is not described. We aimed to elucidate the role of physical examination in providing high value, cost conscious care (HVC) and to explore how clinical skills curricula could integrate principles of HVC. Methods We conducted a qualitative study of semi-structured interviews with 20 experts in the instruction and clinical applications of physical examination. We identified experts through purposeful sampling and snowball sampling. Audio-recorded interviews were coded using qualitative content analysis. Coded passages were categorized and reported as key themes and recommendations. Results Experts affirmed physical examination’s indispensable role in clinical reasoning. When integrated with history-taking and additional diagnostic data, physical examination can further the aims of HVC. However, experts noted that the pace and demands of contemporary clinical practice present barriers to the idealized application of physical examination. In turn, participants discussed how to improve clinical skills curricula, both broadly and to promote HVC. Discussion To advance HVC through physical examination curricula, the clinical relevance of bedside skills needs to be emphasized across the training spectrum. Key strategies include revisiting evidence-based medicine principles and integrating physical examination instruction with teaching clinical reasoning.


Introduction
As soaring health care expenditures outpace the growth of the American gross domestic product [Centers for Medicare and Medicaid, 2015], high value care (HVC) has become a curricular priority in medical education [Ryskina et al, 2014;Korenstein et al, 2016, Patel et al, 2015].While many factors contribute to overuse of healthcare resources, the culture in medical education likely has played a prominent role [Emanuel & Fuchs, 2008;Smith & Levinson, 2015].Accordingly, educational campaigns have been launched to effect cultural change; examples include the American Board of Internal Medicine (ABIM) Foundation's Choosing Wisely initiative [ABIM Foundation, 2017] and the American College of Physicians and the Alliance for Academic Internal Medicine curriculum in HVC.[American College of Physicians, 2017] Cost awareness has even become a core competency in systems-based practice in contemporary medical education.
Performing comprehensive and focused physical examinations are also expected competencies of graduating medical students [AAMC, 2014].In the past decade, a task force convened by the AAMC provided a blueprint for today's clinical skills curricula [AAMC, 2008].Since this AAMC report, the concept of teaching and assessing learners on a hypothesisdriven physical examination has emerged as an alternative to the traditional approach of teaching head-to-toe examinations [Yudkowsky et al, 2009].Other educators have subsequently called for a streamlined 'core and clusters' approach in which learners master a foundational basic examination and augment this exam with clusters of maneuvers specific to the clinical context [Gowda et al, 2014a;Gowda et al, 2014b].
The desire to streamline physical examination instruction stems from a perceived need to eliminate maneuvers of "little clinical or educational value" [Gowda et al, 2014b] and to impart learners with more effective clinical reasoning skills [Yudkowsky et al, 2009].While the hypothesis-driven approach and the core and clusters model both hint at the concept of value, they do not explicitly address how a more selective physical examination allows trainees to deliver HVC.Likewise, HVC curricula to date have not emphasized bedside skills [Smith & Levinson, 2015;Stammen et al, 2015].Even the popular Choosing Wisely recommendations for clinical practice rarely mention how physical examination findings can obviate further low-value testing [ABIM Foundation, 2016].This lack of integration between teaching physical examination and HVC is surprising; physical examination represents one of "the most cost-effective of all tests" [Schattner, 2012].When thoughtfully applied in a hypothesis-driven manner, physical examinations should reduce unnecessary follow-up studies, especially when fairly robust evidence for specific examination maneuvers exists [Simmel & Rennie, eds., 2008;McGee 2012].Physical examination still helps to establish most medical diagnoses [Paley et al, 2011, Reilly 2003], and its omission contributes greatly to diagnostic error [Verghese et al, 2015;Schiff et al, 2009], an enormously costly problem itself [Newman-Toker et al, 2013].Conversely, undirected physical examinations may represent low value care themselves [ABIM Foundation, 2016;Mehrotra & Prochazka, 2015] and may uncover false positive findings that in turn can beget cascades of exorbitant testing and even treatment [Rothberg 2014].
We feel that clinical skills curricula are prime venues to enhance trainees' provision of HVC [Bergl et al, 2015], and we sought to understand how clinicians and educators viewed the intersection of HVC and physical examination.Because much of the curricular framework and content for both of these subjects relies on expert consensus [Corbett et al, 2008a;Cassel & Guest, 2012], and not necessarily on empirical evidence, we examined the opinions of educational leaders in physical examination instruction to explore this novel area of inquiry.The primary aim of this study was to elucidate how experts understood the concept of a high value, cost effective physical examination.Additional areas of inquiry included (1.) understanding real-life barriers to using physical examination to help provide HVC and (2.) determining the optimal teaching strategies and content for a curriculum in the high value physical examination.The ultimate goal of this study was to create an idealized curricular model that integrated clinical skills with principles of HVC.

Study Overview
We designed a qualitative study based on interviews with national experts in physical examination.We used semistructured, partially scripted interviews to gather perspectives of those teaching physical examination and to interpret potential meanings of a high value physical examination.Our interview data was analyzed with conventional qualitative content analysis using an inductive approach [Cho JY, 2014;Hsieh & Shannnon 2005;Teherani et al, 2015;Elo & Kyngas, 2008].To direct interviews, we created a scripted interview guide (Appendix A) consisting of open-ended questions that corresponded to themes that we had previously identified in the literature [Bergl et al, 2015].The institutional review board (IRB) at the Medical College of Wisconsin (MCW) deemed this study exempt from IRB oversight -project #24436.

Recruitment
Potential subjects were initially identified through purposeful sampling from the professional networks of the study team and from a review of contemporary literature on teaching physical examination.To account for regional variations in health care expenditures and its impact on trainees [Arora, 2012], we sampled by primarily focusing on geographic diversity of subjects.After generating a list of initial contacts, additional subjects were recruited by snowball sampling.Inclusion criteria required that subjects had at least one of the following qualifications: (1.) authored at least one peerreviewed publication on physical examination instruction or clinical skills education, (2.) authored or contributed to a physical examination textbook, (3.) actively participated in the AAMC's Directors of Clinical Skills (DOCS) group, or (4.) directed a physical diagnosis or clinical skills course at their own institution.For subjects identified by snowball sampling, we searched Medline and reviewed online biographies on public websites to determine eligibility for participation.All subjects were invited to participate by email and were offered a $30 Amazon.comgift card for participation.

Development of Interview Guide
Our interview guide focused on four areas of inquiry: defining physical examination's role in providing HVC, identifying ideal content for a medical school curriculum on high value physical examination, discussing optimal delivery of such a curriculum, and describing barriers to using physical examination in a cost-effective manner in daily practice.The four key questions to our guide were directly informed by our previously published opinions on the interview topics [Bergl et al, 2015] and one of our investigator's (J.F.) involvement in DOCS, a national organization dedicated to enhancing clinical skills curricula.
In developing our guide, we deliberated over whether to provide a definition of high value and to explicitly discuss costeffectiveness.Recognizing that the term high value is variably interpreted and does not always imply cost-effective [Blumenthal-Barby 2013; Porter 2010], we ultimately agreed to begin the interview with an open-ended question including both terms: value and cost (Appendix A).Prior to contacting subjects, this interview script was piloted with two clinician-educators at MCW. (These preliminary interviews were not included in our final analysis.)Piloting the interview did not result in any major revisions.As we interviewed subjects, the interview guide underwent two minor revisions that provided clearer follow-up probe questions; the four key questions used to guide the interview were not altered at any point.

Data Collection
Between August 2015 and January 2016, our primary investigator (P.B.) conducted semi-structured telephone interviews with individual participants.While the interviewer had previously made brief contact with several of the subjects prior to the study period, there were no ongoing, substantive professional relationships between the interviewer and interviewees at the time of the study.All subjects provided verbal consent to participate.Interviews were recorded using a digital device and were subsequently transcribed.Transcripts were stored on a secure internal server at MCW and imported into the qualitative research software package NVivo (Version 10.0, QSR International, Melbourne) for analysis.

Data Analysis
We analyzed our data using conventional qualitative content analysis and inductive open coding [29,31].In our approach, we reviewed subjects' responses to the open-ended interview questions for key statements and experiences, and we used these key passages to formulate an initial set of codes.Our coding was open and grounded in the themes that emerged from the interview transcripts.In other words, even though we anticipated that our four key interview questions might form the four main domains in our coding scheme, we did not define or apply codes a priori.We developed our coding scheme iteratively while interviews were ongoing.After the first ten interviews, two investigators (P.B., E.C.) met to review a sample of 4 de-identified transcripts.Prior to this meeting, both team members had applied open coding to these 4 transcripts using NVivo.We (P.B. and E.C.) then generated a preliminary coding scheme and initial list of clusters and codes to facilitate future analyses.The remaining interviews were coded independently by the same investigators with regular meetings to discuss discrepancies in coding, to describe emerging themes, and to determine the need for codebook revisions.A third investigator (J.F.) periodically reviewed coded interview transcripts, adjudicated disagreements about the coding scheme, and helped formulate the final codebook.
Prior to closing the study, the study team reviewed coded passages from the first 17 interviews to assess for theme saturation.At a team meeting, we explored whether the codebook had evolved substantially during the study period, a finding that would suggest themes were still emerging.We found no evidence of new themes when comparing the codebook to previous iterations and concluded theme saturation had been achieved.

Results
Twenty physicians participated in interviews and represented 19 unique medical schools.Subjects had a mean of 24 years of clinical experience since medical school graduation.Additional demographic information is available in Table 1.
As interviewees discussed the idea of using physical examination to promote HVC, three major themes emerged: (1.) Physical examination has value in contemporary clinical medicine that can in part be captured by economic analysis but that often defies a quantifiable cost benefit.(2.) Various practical factors impede clinician's abilities to use physical examination to provide HVC, and many of these are attributable to the physicians themselves.(3.) Opportunities to improve physical examination instruction abound --both generally and within the framework of HVC -and specific areas would merit more attention in a curriculum seeking to integrate these two subjects.These themes are further explored in the following sub-sections and in Tables 2-5.Direct quotations are in italics.

Physical examination's continued relevance in clinical medicine
Though prompted to define a "cost-effective, high value physical examination", subjects tended to discuss the value of physical examination more broadly.Nonetheless, subjects cited physical examination's critical role in clinical decisionmaking and diagnostic reasoning as having significant economic implications.Interviewees suggested multiple other ways in which physical examination could contribute to HVC as elaborated below and as represented in Table 2.
Enhancing diagnostic reasoning.Participants almost universally noted how physical examination can test hypotheses and refine probabilities of disease.By extension, participants saw indirect economic benefits from skilled history-taking and physical examination.
When I tried to structure our curriculum, I spent a lot of time with the Rational Clinical Examination series in JAMA... thinking about which parts of the physical exam have test characteristics that would make them diagnostically valuable.And if they're diagnostically valuable, then theoretically they should have the ability to lower the number of unnecessary tests we're ordering to ostensibly confirm or rule out a diagnosis.Directly reducing costs.Participants also underscored physical examination's role in limiting testing that is already widely believed to be unnecessary and costly.
An easy [example] that comes to mind on the outpatient side is evaluation of low back pain.. you know, super common complaint.There's a lot of good information about what components of the history and exam are high yield.I think there's a lot of potential savings there...I think maybe we could avoid a lot of unnecessary imaging with all its undesirable downstream effects.
Assessing the impact of disease on the patient.Participants pointed out that physical examination can be used to assess the functional impact of a patient complaint and to monitor trajectory of illness and response to treatment.
One [scenario] is just following somebody's diuresis with heart failure.What things change and what tells you they're actually getting better?You don't really have to 're-x-ray' them or 're-echo' them to make sure they're getting better.
Establishing clinical diagnoses.Though most participants referenced available resources that provide test characteristics for physical findings [Simmel & Rennie, eds., 2008;McGee 2012], several noted that not all value in physical examination can be quantified.These scenarios included diagnoses which are highly based on clinical features (e.g.cellulitis, rheumatoid arthritis, and decompensated heart failure).
I think probably the highest value physical examination is one where the findings are actually superior to other diagnostic tests, or in fact, there is no diagnostic test that even exists for that.A classic example would be Parkinson's disease.That's probably the best example of cost effective physical examination because it's [historically been] the only choice.
Similarly, clinicians had encountered other scenarios in which the evidence is underdeveloped or non-existent, but in which logic suggests unequivocal economic value for physical examination.A pediatrician suggested the newborn examination was the quintessential example in which value had not been explicitly quantified, but she highlighted the critical role of early detection of congenital abnormalities in optimizing newborn health.I'm big into some of the nursing literature around perhaps even a therapeutic value of physical exam and laying on [of] hands.Even if the physical exam's not used diagnostically, there's some evidence that those who had a physical exam felt better.
Factors impairing physical examination's contribution to clinical practice Though participants saw physical examination as a core skill in providing high value clinical care, they identified a range of practical limitations and cultural factors that diminish physical examination's role in providing cost-effective care.As demonstrated in Table 3, barriers were identified in four domains: (1.) the patient-physician interface, (2.) the practice of modern medicine, (3.) the nature of physical examination itself, and (4.) the current state of physical examination instruction.The most frequently discussed factors are further detailed below.
The patient-physician interface.By far, experts cited physicians themselves as the biggest hindrance to using physical examination to provide HVC.Common themes included a lack of confidence around bedside skills, inadequate training, a lack of clinical experience, and a general decline in observational and perceptive skills at the bedside.
The next most commonly referenced barrier were patients.Physicians referenced the difficulties in performing and interpreting physical examination on patients who were obese, frail, or immobilized.Furthermore, many experts perceived that patients often expect advanced diagnostic testing and have their own intolerance to uncertainty that can only be assuaged with further testing.
The practice of modern medicine.Participants pointed out that routines and clinical guidelines often render physical examination unnecessary in diagnostic evaluations.Many participants also stated that the widespread use of imaging and laboratory studies has negatively impacted physical examination's value.In turn, access to technology has fed into a reliance on technological surrogates to diagnose disease.The ubiquity of technology also contributed to a stronger sense of efficiency; simply stated by one expert, 'Sometimes it's just quicker to order the test.' At least one expert felt that this focus on increased clinical efficiency and physician productivity has crowded out the more humanistic elements of care such as physical examination.
The bean counters want to bill more and they want to penalize us if we don't bill more.The doctors are spending more time with a computer, less with the patients.So, tell me, Where you are going to fit the physical exam [in]?
Participants voiced concerns about litigation as well, and specifically feared that physical examination may not provide adequate protection against a lawsuit.There was often the sense that diagnostic tests are seen as a standard of care in court and provide additional objective evidence.
You just order the test because then you'll have something concrete that you can put in the record -[something] defensible so to speak --versus just your physical exam.
Beyond litigation, participants often feared missing diagnoses simply out of concern for the patient's well-being; advanced diagnostic testing provides reassurance for the provider as well.More importantly, for many uncommon yet high stakes diagnoses, physical examination was felt to be too inadequate to forego further testing.
Physical examination itself.While often touted as a strength, the evidence basis for physical examination was also seen as an impediment.For some participants, the evidence is simply not strong enough to alter clinical routines that include a low threshold for testing.Other concerns included the low interobserver reliability of elements of physical examination and the fact that not all examination maneuvers are validated for every patient complaint.Finally, the validity of the evidenceand therefore the impact of the exam -varies across cases, specialties, and practice settings.Culture of academic medical centers is to prioritize additional diagnostic testing.

Availability of technology
Ease of ordering advanced diagnostic tests results in physicians' forgoing examination.
Physicians depend on technological surrogate, rather than clinical impression, to establish diagnoses.

Intolerance to uncertainty
Physicians' innate fear of "missing something" prompts further testing.
Laboratory testing and imaging confer additional layers of reassurance to physicians.

Practice of defensive medicine
Diagnostic testing offers more concrete, objective findings than physical examination and thus better protection against litigation.
Diagnostic testing may be viewed as standard of care by litigators and lay people.

Pace and delivery models in modern medicine
Fragmented care and desire for clinical efficiency prohibit physicians from observing signs and symptoms over time.
Physicians' productivity demands and the burden of electronic health record crowd out hands-on elements of care.

Incomplete evidence basis
Evidence for physical examination is not robust enough i.e.Physical examination instruction.Finally, experts discussed a number of fundamental problems in the existing educational infrastructure that need to be addressed before physical examination can be used to advance HVC (Table 3).
Teaching strategies and content for a high value physical examination curriculum Specific clinical areas to teach.Participants emphasized problem-focused examinations over an organ-based approach, particularly when discussing how to teach HVC.Approaches to teaching problem-based examinations included focused examinations targeted to a chief concern, clinical assessments (such as intravascular volume status, presence or absence of inflammatory arthritis), clinical diagnoses (e.g.heart failure).Experts rarely mentioned specialized or eponymic maneuvers to enhance diagnostic yield.Topics suggested at least twice appear in Table 4. Overall, the musculoskeletal and neurological examinations were the most frequently referenced organ systems.Participants noted that complaints in these organ systems often generate costly imaging studies that infrequently change management.
Teaching strategies.Discussants described how common teaching strategies in physical examination could be adapted to also promote HVC.These included traditional didactic activities like lectures and classroom-based group work, using simulation and standardized patients, and practicing clinical skills on real patients with real pathology.Several participants advised incorporating actual costs of diagnostic testing into didactic and simulation activities.
Our experts also identified how clinical skills curricula could better incorporate HVC principles.First, such curricula should emphasize the clinical relevance of physical examination by highlighting its utility, openly discussing its evidence basis, and acknowledging its limitations.Participants also pointed out that physical examination's role in clinical reasoning needs to be taught across the training continuum i.e. beyond the preclinical medical school curriculum.Ideally, formal assessments would complement efforts to integrate clinical reasoning with high value care, and experts Neck pain and cervical radiculopathy 5 Chest pain 5 Pelvic pain 3

Altered mental status 2
Abdominal pain 2

Specific Clinical Findings
Heart murmur 8

Heart gallops 2
Abnormal gait 2 * Tallies reflect how often chief concerns and clinical findings were explicitly suggested as teaching topics -and not simply mentioned in passing during interviews.
recommended both formative and summative assessments of these clinical skills.Finally, experts suggested developing master teachers adept in bedside diagnostic skills and the tenets of HVC.Details of these proposed improvements are outlined in Table 5.

Discussion
Expert clinicians and educators view clinical and diagnostic reasoning as the key links between teaching HVC and physical examination instruction, and many of our findings reflect this overarching theme.While physical examination adds value to practice in many ways, the predominant message was that physical examination is critical to hypothesis testing and clinical assessments.Educational strategies to integrate HVC with physical examination instruction should include reinforcing trainees' reasoning skills and discussing the evidence basis of physical diagnosis.Our subjects cited numerous factors that impair physical examination's contribution to contemporary medical care, and any curriculum connecting HVC to physical examination would need to acknowledge these limitations.
Interviewees preferred to focus more generally on the value of physical examination and often avoided discussing costs outright.These findings are unsurprising given the ambiguous nature of the term high value care [Blumenthal- Barby, 2013;Porter, 2010;Riggs & Knight, 2017].In agreement with other experts' opinions, our experts saw physical examination enhancing HVC by facilitating patient-physician connections and as a low-cost monitor of treatment responses or disease progression [Zaman et al, 2016].
We did not further define value, and this approach may have neglected the patient's perspective.Patients may find value when being examined leads to a positive subjective state, such as reduced anxiety and reassurance.[Blumenthal-Barby, 2013] On the other hand, some elements of physical examination, such as the rectal examination, are uncomfortable.If these elements provide little objective value, (i.e. they have limited diagnostic yield) and create a negative subjective state (i.e.pain and embarrassment), then patients may find more value in other diagnostic approaches.Clearly understanding value in health care as a relationship between outcomes per unit of cost [Porter, 2010] may trivialize other ways that physical examination adds or subtracts value to the patient encounter, and focusing exclusively on using physical examination to contain costs could send the wrong message about HVC [Riggs et al, 2017].
Viewed through the lens of HVC, historical approaches to teaching physical examination may need modernization.Consistent with the "core and clusters' and hypothesis-driven approaches that have recently appeared in the literature, [Yudkowsky et al, 2009;Gowda et al, 2014b] our experts advocated for more pragmatic curricula that prioritized clinical reasoning and hypothesis testing.They also called for longitudinal development of skills rather than relying on the current Dissecting diagnostic thought-processes of master clinicians model of a defined preclinical curricula followed by inconsistent reinforcement throughout clinical rotations.While discussants were open to incorporating HVC into teaching physical examination, they discussed a number of barriers that already constrain clinical skills curricula, such as faculty availability and the breadth and depth of the curriculum.These larger issues might need to be resolved before fully integrating HVC.On the other hand, our work aligns with recent efforts to streamline clinical skills curricula by establishing a core curriculum [Gowda et al, 2014a] and determining optimal timing for introducing more advanced skills.[Corbett et al, 2008b;Harin et al, 2013] Finally, our work suggests that trainees should learn clinical skills from instructors versed in both bedside diagnostic skills and HVC; as reflected by our experts' perspectives, teachers adept in clinical reasoning would fulfill this role.
Our work highlights specific chief concerns and clinical findings (Table 4) that could be priorities for streamlined curricula, and this study provides a novel framework for teaching physical examination skills.We did not ask subjects to elaborate on why specific chief concerns or findings were mentioned though experts gravitated toward conditions often recognized in other high value educational campaigns.[ABIM Foundation, 2017] Items in Table 4 may simply reflect familiarity with other HVC curriculum.Accordingly, rather than using Table 4 as the sole blueprint for advancing physical diagnosis curricula, we would suggest a more integrated approach based on our findings as shown in Figure 1.
Our findings also add to the literature on how to better teach HVC.Educational strategies suggested by our experts overlap significantly with recent calls to incorporate more experiential learning and foster a culture that supports trainees in providing HVC [Smith & Levinson, 2015].Thus, integrating HVC with physical examination instruction may have a synergistic effect in advancing learning in either domain.Consistent with other studies [Colla et al, 2016;Zikmund-Fisher et al, 2017;Bishop et al, 2017;Kanzaria, 2015], we found that physicians' perceptions of patient expectations and fear of liability diminish physical examination's role in providing cost-conscious care.However, our experts more frequently implicated the physicians themselves and the clinical environments in which they work as drivers of overuse of low value services.Leaders in HVC should address the other barriers noted by our interviewees (Table 3), and educators should strive to impart trainees and clinicians with greater confidence in their bedside skills.We found that many physicians still view trust-building as one of the primary roles of performing a physical examination, a view that may be shared by patients as well [Kadakia et al, 2014].Educators developing HVC curricula may wish to highlight this role in particular.Trainees might even be given specific strategies to capitalize on this valuable aspect of the bedside examination.
There are several key limitations to our study.First, many subjects were identified by their expertise in curriculum development in clinical skills, not by their command of HVC.Because of this academic focus, and perhaps due to the ambiguity of the term high value, subjects gravitated toward discussing how to best teach physical examination.When prompted to recommend content for a high value physical curriculum, subjects often had difficulty generating specific topics extemporaneously.Some clinical areas also engendered controversy; for example, echocardiographic evaluation of systolic heart murmurs was referenced as both a quintessential example of overuse and also as an example of necessary care because of the limitations of the bedside assessment.Additionally, as participants mostly were internists by training, clinical and educational expertise from other specialties were highly under-represented.Thus, suggestions on curricular content (Table 4) should not be interpreted as a definitive guide to a physical diagnosis curriculum for advancing HVC.Furthermore, all subjects held medical school faculty appointments at the time of their interviews, so their opinions may not reflect practice in non-academic settings.Because most of our subjects work directly with trainees, their perceptions of what "other physicians" do are likely skewed.On average, subjects had been in practice for 24 years, and generational differences may also be relevant in this type of study.Further studies including other medical specialties, physicians in non-academic settings, younger physicians, and non-experts would strengthen our conclusions.Given the conversational nature of semi-structured interviews, we also cannot exclude bias introduced by the interviewer during questioning.
Because we began coding prior to conducting all the interviews, it is possible that subsequent interviews and analysis were colored by the investigators' impressions of preliminary data.In other words, we may have introduced ascertainment bias, or finding what is expected to be found.Finally, our sample size may not have allowed for complete thematic saturation.Even during our last few interviews, relatively novel perspectives were shared.However, the research team agreed these emerging ideas still fit within existing codes, and thus we believe our results sufficiently capture major themes that answer our primary research questions.

Conclusion
In summary, our research offers key implications for clinical skills curricula and the HVC movement.It argues for physical examination instruction and assessments to more frequently incorporate elements of clinical reasoning.Even advanced learners may need additional instruction in physical examination as these learners possess the scaffolding onto which advanced diagnostic reasoning and HVC can be added.To substantiate physical examination's role in HVC in clinical practice, learners will need to receive mentorship from master clinicians fluent in both bedside skills and diagnostic reasoning.Educators should underscore all valuable elements of physical examination and should point out that not all of this value is quantifiable.These teachers will also need to acknowledge the myriad limitations of physical examination encountered in daily practice.Finally, clinical skills curricula can borrow approaches from the HVC movement to impart learners with a commitment to HVC as outlined in Figure 1.

Take Home Messages
Physical examination and high value care are two major areas of competency in medical trainees, but these competencies are often taught in siloed curricula.We believe that integrating high value care into teaching physical examination could make clinical skills curricula more practical.However, the available literature provides little guidance on how to achieve that aim.This paper summarizes how expert educators conceive of a "high value physical examination," and it provides a roadmap for marrying clinical skills curricula with efforts to teach high value care.Ultimately, expert clinicians and educators view clinical and diagnostic reasoning as the key links between teaching HVC and physical examination instruction.A very well articulated, well executed and well presented manuscript!The authors have brought forth the need vis-a-vis the present scenario regarding a vital competency for any health professional -the clinical reasoning skills for high value care by physical examination.The qualitative approach is robust and the data analysis is worth to learn not only about the findings but the manner in which it should be analysed and presented.'Framework for an integrated curriculum in teaching high value care and physical examination' within the manuscript is a splendid suggestion that can be adopted in academic hospitals, especially in areas with economic limitations.Highly recommended!

Figure 1 .
Figure 1.Framework for an integrated curriculum in teaching high value care and physical examination

Table 2 .
How physical examination can advance high value care in clinical practice Participants routinely mentioned how they use physical examination to develop connections, to provide reassurance, and to facilitate communication.This is a ritual, and it establishes trust.. hands-on [is] a very important connection with the patient.
complaints Providing fringe benefits Using technology to enhance senses at the bedside e.g.point-of-care ultrasound, pan-optic ophthalmoscopy Maximizing success of blind bedside procedures e.g.arthrocentesis Using validated aspects of the screening exam e.g.blood pressure measurements Fostering connections.

Table 3 .
Factors impairing physical examination's contribution to high value care

Table 4 .
Commonly suggested topics for a high-value physical examination curriculum