The Art and Science of Bedside Medicine with Brian Garibaldi, MD

Erin Spain, MS: Today we're talking about the art and science of medicine and how Northwestern medicine is leading an effort to reimagine the modern clinical encounter through a new center for bedside medicine. Joining me is Dr. Brian Garibaldi, founding director of the Center the Charles Horace Mayo, professor of Medicine and the Division of Pulmonary and Critical Care, at Northwestern University Feinberg School of Medicine. Dr. Garibaldi, a renowned pulmonologist and accomplished clinical educator, also co-founded and was the inaugural co-president of the Society of Bedside Medicine, which is leading a national movement to bring bedside medicine back to the center of clinical practice and education. Welcome to the show, Dr. Garibaldi. 

Brian Garibaldi, MD: Thanks so much for having me. Really excited to be here. 

Erin Spain, MS: You are still fairly new to the university, but you have spent your career really advancing bedside medicine. For those who may not be familiar, what exactly is bedside medicine and why do you think it's essential to the future of healthcare? 

Brian Garibaldi, MD: So bedside medicine refers to really any interaction that happens. Between a healthcare provider and a patient and I, think sometimes we think about whether or not we should use the term bedside because it's not just the hospital, right? It's also the clinic. During COVID, it became telemedicine, it's home care visits. It's patients who are living in assisted living facilities. Whenever there's an interaction between a patient, their family member, and a healthcare provider, that's what we're thinking of as bedside medicine, and it's become increasingly important. Today because as we continue to incorporate wonderful new technology in healthcare, we need to make sure that we protect the fundamental basics of that healthcare interaction. Getting to know patients as individuals, getting to understand their goals and values and preferences, but then also being able to gather information from talking to them, observing them, examining them, and technology can be a part of that. But so is basic human communication skills, things that have been part of the physical exam for hundreds of years still work. And while there are certain things that technology can replace and augment, we need to think about how to combine them intentionally so that we don't lose sight of those uniquely human skills that are still valuable. 

Erin Spain, MS: I understand you kind of. light bulb moment about this years ago when you were in Malaysia. Tell me about that experience and how it shaped your perspective on bedside medicine and really propelled you into this role that you're at here today at Northwestern. 

Brian Garibaldi, MD: So we had an incredible opportunity when I was on faculty at Johns Hopkins. There was a partnership with a Malaysian medical school. And so we were, we moved over there for about a year where I directed the basic pathophysiology courses for the medical school, but also helped to set up the clerkships in the government hospital and. It became pretty clear to me after just being there for a few weeks in the hospital that the Malaysian physicians were better than I was at gathering information from patients at the bedside. And you know, at first pass you could say maybe it's because they didn't have access to the same technology, so they had to be better at some of these, other and older skills. It turns out they had the same five Tesla magnet, MRI scanner that we had at my hospital in the US. They had the same, 256 slice CT scanner. They just accessed those testing differently. You know, if you wanted to get a CT scan of the chest, you had to go talk to the radiologist, present the case, talk about what you found in physical exam. Look at the regular chest x-ray. And more often than not, you already had the information that you needed to come up with a diagnosis or treatment plan, When, after those additional tests, when it became clear that, hey, maybe the story didn't quite fit or the person's not responding and so they just thought of diagnostic testing, starting with your history and your physical exam, and then augmenting it with technology. The other reason I think that they were better than I was at that point in time is that the Malaysian physicians all participated in the MRCP process in the uk. Whereas part of that. Next level of certification you have to pass a high stakes exam where you examine real patients with real stories to share real findings on physical exam. And you do so in front of faculty members who on that day meet the patient, decide together what they think a trainee should be able to do. And because that assessment exists physicians who go through the Mr. RCP places like in the UK or in Malaysia or in India, Pakistan countries all around the world, they begin to study for bedside assessment the way that we study pharmacology in the US. It may come as a surprise to some people or maybe not, but. After medical school there really are no assessments of actual bedside skill, and even in medical school, most of the assessments of bedside skill come with standardized patients for simulation. There are only a few programs in the country in the US where. You actually get observed examining real patients and get feedback in real time on your skills. We had a program at Hopkins that is still going strong. There's a program at St. Peter's in New Jersey. University of Alabama and Birmingham and Stanford have partnered with us through our Society of Bedside Medicine, to do some of this work. But for the most part, it is possible to go through medical school and residency and internal medicine and never be directly observed doing a bedside assessment. Where the observer had to do the same thing and has adjudicated what the findings are. And I think that sends a very different message about what we value at the bedside. And, we can argue about whether or not assessment drives learning, but it certainly drives attention. And because we don't assess these skills in residency and beyond, our attention is focused elsewhere. 

Erin Spain, MS: And you've actually studied this, you found that residents only spend 13% of their time. In patient care. Can you tell me about that? 

Brian Garibaldi, MD: Yeah, so there've been a number of studies through the years that have looked at how physicians and particularly trainees spend their time. The biggest one was the I Compare study, which was run by Sanjay Desai and. He's now at the American Medical Association where they had medical students follow around internal medicine residents and figure out how do they spend their time. And they found that it was about 12 or 13% of their time at the bedside. And we actually tapped into a really cool technology that existed at our hospital that was designed really to track equipment. There are these sensors throughout the hospital and we gave our trainees infrared tracking badges that send out a ping every three seconds that get picked up by these sensors. And we found exactly the same thing. We found that our trainees spend only about 13% of their time in patient rooms. And it's not surprising that if we spend that little time in direct contact with patients' skills, that can only be practiced and improved in the presence of patients or in decline. We know from many studies, including some of our own, that physical exam skills in particular are definitely not where they used to be 20, 30, 40, 50 years ago. When we looked at it, the individuals who have better physical exam technique are much more likely to identify the findings that are present. And if they identify the findings that are present, they're much more likely to include the correct diagnosis on their differential. So these skills still matter. When people have looked at diagnostic errors, about half of errors are probably made related to the physical exam. And the most common mistake in the physical exam is simply that the physical exam was never performed. So it's not like there are these complex five step really difficult maneuvers to perform. It's simply when evaluating a patient with a specific complaint, the part of the body that was related to that complaint was never examined. And part of that is, is because of workflow and part of it's because of high patient throughput and turnover. But I think part of that is also because we've. Shifted our focus away from these skills. Many people don't believe that they're still valuable and many people aren't confident enough in their own skills to actually use them to make decisions. I tell 'em our trainees, one of the simplest things to do is to check reflexes. But if you don't know how to do it. You don't check them. And if you only ever check them when you're worried there might be a problem, how are you gonna know if you did it the right way and that you're interpreting the finding the right way? So part of what we do at our Society of Bedside Medicine and now at our Center for Bedside Medicine is to kind of redirect curiosity and remind people that what you feel, what you hear, those things are really important and can be as powerful and in some cases more powerful than a technology based test. 

Erin Spain, MS: So you mentioned reflexes. What are some of the other sorts of skills that a physician could enhance and learn and perform at the bedside that could help with some diagnostic results? 

Brian Garibaldi, MD: there are so many areas in medicine where observation skills are incredibly important and valuable. James Parkinson, who, many people are familiar with, wrote a seminal paper describing almost all of the features of what we now come to associate with Parkinson's. And the one feature that he didn't describe was rigidity or cog wheel rigidity, which is a very characteristic neurologic finding. And many people take that to mean that he was so good at observation that he actually may not have touched any of these patients that he saw. He was able to put everything together just from observing them. And so I think COVID was an incredible reminder of the power of observation. We had many ICUs where the exam rooms where we put these large windows. So you could observe patients from the hallway while you're putting your gear on and try to minimize the number of times you had to go into outta rooms. 'Cause for many of us in different health systems, we ran out of personal protective equipment at times during the pandemic. And it's incredible if you watch a patient that you can see different patterns of breathing. You can see asymmetry in the way the chest is moving and know that there's a problem in that side of the chest or in that lung. you know, Simple things like going out into the clinic waiting area and. calling out a patient's name. If you see that they're sound asleep and snoring and having APNIC episodes, you've already made a diagnosis of sleep apnea. You introduce yourself, you watch them stand up from a chair, and then you walk with them. You get a gait assessment, you get a basic neurologic assessment, and then you stress their cardiovascular system and do they get short of breath or does their heart rate go down? So those skills are very simple. But if we don't practice them with intent and we, if we don't make them part of our routine, we start to lose that. Sort of ability to pick up on those subtle findings. And there's ways of doing that that aren't just grounded in the hospital. So, many folks have written and done work on taking medical trainees to the museum, for example, to look at artwork. Learning how to describe what in the context of art actually translates into being better at describing what you see in medicine. And that has been shown to improve your ability to make diagnoses like, different dermatologic diseases that are pattern recognition or just describing what you see. and I think observation skill is probably one of the most important things. And, technology can help us with that. If I always use the example of, I'll show a picture of a herpes zoster rash and everyone knows immediately this is zoster. And there are AI tools now that can recognize zoster with sensitivity, specificity in the 90% range. Very powerful tools and we absolutely should be taking advantage of these tools when we can. And there are even video analysis software now that can do gait assessment, right? And predict whether or not someone has neurologic disease or cardiovascular disease. Just from a short video clip of someone walking across the hallway, we should absolutely be taking advantage of these technologies. But our ability to acquire that information and to use multi-dimensional sensing is better than any AI tech that's out there right now and will continue to be. So, you know, during COVID I was part of a research group that was looking at pulse oximetry. And we found, as some other groups had found, that pulse oximeters underestimated hypoxemia, particularly in patients who had darker skin and. The way we did this was by comparing thousands of patients who had a pulse oximeter reading within about 10 minutes of them having a true blood gas analysis, you know, directly measured blood oxygen level from your radial artery. And what was really interesting is that if you looked in the four hours before someone was diagnosed with low oxygen levels, that was missed by a pulse oximeter, nurses were 50% more likely to text the physician about something, even when you controlled for other vital signs and lab abnormalities. So even though the, the subjective a technological device, the pulse oximeter didn't show a problem. Nurses picked up on the problem and they did so because, you know, they have their gut sixth sense that's developed by spending time with patients and correlating all of these different sensory inputs into your clinical impression of what's happening. And that's gonna be tough to replace and tough to beat. We can augment it with technology, but I think if we don't spend time with patients, we're gonna be in danger of losing our ability to pick up on these things. 

Erin Spain, MS: You're trying to shift the mindset a little bit here too, like layering on these technologies along with building these skills, right? That's the approach that you're hoping to take. To train medical students. 

Brian Garibaldi, MD: Absolutely. So I'm, my doctor bag is next to me, right? And, And in that bag is a digital stethoscope that has an AI algorithm that helps you recognize atrial fibrillation or knowing if someone's not in a normal sinus rhythm. It has a detection algorithm for heart murmurs, and when we teach at the bedside, I can project what that digital stethoscope is recording to an iPad so everyone can see a spectro phonograph and a three lead, EKG. And then I can also project that to a speaker so we can all listen at the same time and say, Hey, this person has. A systolic murmur. I know it's systolic because I can see where the QRS complex is on the EKG and I can correlate it to what we're seeing at the bedside. I have a handheld ultrasound that I use almost on every patient that I evaluate now, and it's really become part of the physical exam. And I have to be careful to remind everyone when I talk about the physical exam, I'm including things like point of care ultrasound and point of care technology because it's an incredible extension of what we do at the bedside. And it can, in many cases, answer questions that I can't answer with my eyes, my ears, and my hands. But I will say it more often than not. It usually confirms that, which we already suspect based on talking to the patient and doing some of these basic physical exam maneuvers that have been around for hundreds of years and still work 

Erin Spain, MS: You've also. About this patient physician relationship doing the physical exam, creating some meaning there between the patient and the physician can actually help with burnout in medicine. Tell me about that. 

Brian Garibaldi, MD: At a fundamental level, we are very social creatures, right? And there is power in, engaging in, discussions about difficult issues and in, and being vulnerable, as either a patient or as a physician. And the trust that you can develop very quickly with a patient through. Intentional listening but also touch is really powerful. And we know that it's powerful for patients. We know that there are certain situations in which a physical exam done well can have a placebo effect, particularly in abdominal complaints and maybe some chronic pain issues. It's probably also true that a physical exam done poorly or not done at all, probably damages that relationship with patients. If someone comes into your office in the middle of winter with respiratory complaints and you examine them through their sweater, they know that you're not gonna be able to determine what's going on effectively. But I think it's also important for physicians. You know, there is a meaning that we get in our jobs from spending time with people. And as we spend more time taking care of the digital representation of a patient or what Abraham ese coined at the eye patient about a decade ago, as we spend more time taking care of those digital representations of people, we're not getting the same fulfillment and joy in our jobs as we used to. Like in internal medicine in particular, but in most areas of medicine, we want to understand people as individuals and help them navigate their healthcare journey, hopefully to get better, you know, in some cases to just, navigate difficult situations and help them achieve what their goals are, even if they can't, cure their disease. I think that the fundamental part of being human and wanting to help others and be with others is really affirming and really has value not just to patients, but also to us as providers. 

Erin Spain, MS: Northwestern is known for its medical education as well as its innovation and cutting edge research. Can you talk about why Northwestern is actually an ideal place to have a center? Like this, the Center for Bedside Medicine. This is a pretty unique initiative. So why did you come here to establish this? 

Brian Garibaldi, MD: I can't tell you how happy and grateful that I am to Dean Nielsen and Dr. Green, our vice of education for recognizing. The opportunity that we have to really be a leader in this space. I came out here to do a couple days of faculty development and some workshops with our medicine residents and med students and faculty. And it was after that experience that we started having these discussions about what a center in bedside medicine could look like and how we could leverage the existing research capabilities and outstanding clinical care that's already happening in Northwestern? How could we leverage that to take our bedside medicine ideas to the next level. And so I think what we're uniquely positioned to do is, number one, we have resources to support faculty time in the center to work on different educational initiatives, but also research initiatives. We have a really good data infrastructure here at Northwestern, so the ability to query the electronic health record, not just for patient data, but also to understand how physicians and trainees are interacting with that system. There's an incredible amount of information you can learn about the way that physicians think, the way that they approach problems from looking at how they click through the electronic health record and how they document their ideas. We also have great AI technology capabilities here. So the ability to use that technology both to analyze data about physician behavior and training, but also to create tools that can help both assess clinical skills, but also help people get better at their clinical skills, I think we have just such an incredible wealth of talent and such a deep bench here. I've been here for a little over a year. Every day I'm still meeting people who I'm like, oh my gosh, how did I not meet you on day one? Let's go have coffee and let's talk about how we can partner together. And every meeting that I have, I ask people to tell me two people that I should call immediately after we finish our meeting so that I can continue to learn about all the incredible opportunities that are here at Northwestern and all the incredible work that's being done. 

Erin Spain, MS: Tell me about the students and trainees. What's their reaction when you bring up some of these concepts that maybe they haven't been introduced to before throughout their training? 

Brian Garibaldi, MD: I think what we're trying to do is remind people of what's possible, right? And so we do these sessions two or three times a week with our internal medicine residents, where one of our center faculty. Will lead a bedside session where the center faculty doesn't know what the patient has. We set up a little bit of context. This patient presented with difficulty walking, or this patient presented with breathlessness and then the faculty member leads the trainees through observation skills, physical exam, using technology if it's appropriate. And it's an unbelievable reminder of how powerful these skills are because almost every time the faculty member is able to figure out what the patient has just from their observation skills and directed, focused, intentional, what we call a hypothesis driven physical exam. And so I think it's an incredible reminder, oh my gosh, these skills actually do work. And if I practice these skills the same way that I'm practicing my documentation skills and my ability to gather information from the electronic health record, I can do both of those at the same time. And get to the answer faster, more efficiently, with fewer testing, reduce cost, and have better outcomes for my patients. And that's really part of what we need to prove and study. I think we already know that if you're better at taking history and doing a physical exam, you'll make fewer errors. I think we need to show that this approach of a hypothesis driven physical exam, a hypothesis driven interrogation of the electronic health record, layering on certain technology, both for decision support but also for gathering information. We need to show that this improves outcomes for our patients, improves efficiency, improves cost, improves the way we feel about our jobs, and I think we're uniquely positioned to be able to do that in a rigorous way. The other thing that we're building here, which is similar to what I talked about at Hopkins and St. Peter's we're partnering with patients to build a volunteer patient program where we can do these rigorous assessments of clinical skill for learners at all levels. Medical students, residents, practicing attendings, graduate trainees then we can begin to correlate, what are those bedside clinical skills? How can we look for signatures of good skill or signatures of, maybe providers who need a little bit of support in some of their clinical skills. And how can we create data sets that allow us to do that without necessarily having to build a whole volunteer patient program because. Most places won't be able to do that. They won't have the resources to be able to do that. And I think we're really uniquely poised to combine our partnerships with patients, our supportive faculty, our ability to leverage technology and data analysis to really understand what are the drivers of clinical skill and professional fulfillment and burnout, and how can we design better systems to ensure that our patients are getting what they need and our physicians are happy and good at their jobs. 

Erin Spain, MS: So this really is building time right now. Like you said, you're getting to know everyone. You have your members and faculty coming into the center, you're going to hopefully be designing some studies and interventions to be published. What do you hope will happen 10 years from now? What are your goals? What does success look like for you? 

Brian Garibaldi, MD: you know, I think right now you're absolutely right. It's about building community and so we're really excited. On November 14th to the 15th, we're having our first ever annual conference in bedside medicine. We have over 170 participants from around the world who are coming, including leaders in bedside medicine like Abraham ese, like Andy Elder from the Royal College of Physicians of Edburg, like Kerry Baker, who's the dean of training for the Royal College Andre Mansour, who's an incredibly talented hospitalist who's known on social media as someone who can use social media to teach bedside clinical skills. And so I think part of this is to build community and to make sure that there's a group of educators who recognize the value of these skills, but also recognize the importance of incorporating emerging technology into the way that we think about the bedside encounter and the way that we teach it. So I think in 10 years, I would love for us to be number one, still be here and still be a sort of a convening body for folks from around the world to come to Chicago and share best practices and thoughts in bedside medicine. I'd love to see us continue to partner with our Society of Bedside Medicine, which is a nonprofit that I'm a part of to really build an international community around bedside skills. And I would love us to really have created an evidence base for that. You know when someone raises their hand at a conference and says, why do I need to get good at these skills? I'm just gonna order a CAT scan, or I'm gonna order an echocardiogram. We can have real data to show them. This is why you should care about these skills because if you get better at these skills, your patients will get better care. You'll make fewer diagnostic errors, you'll be happier at your job. I believe these things to be true but I think it's our responsibility and our opportunity to gather a rich data set that can prove definitively that these skills still matter. 

Erin Spain, MS: Your career has really centered on the art and science of medicine. You were also a musician and you actually studied guitar, right? Classical guitar. Tell me a little bit about your background as a musician and, how does that sort of, the art and science of medicine, having that background make you a better physician, do you think? 

Brian Garibaldi, MD: I've been playing guitar since I was, gosh, probably 11 or 12. I was looking for my dad's bowling ball in his bedroom closet, and I heard a weird sound. I was like, what is that? And I found my dad's old classical guitar. I never knew that he had played for just a couple of years and never, never kind of stuck with it. And so we took it to a local music shop. We had the guitar Strong and I started taking lessons. My journey through music has been lots of different pathways. I started out doing classical, then I switched in high school. I was in a rock band and a blues band. In college I found my way back to classical. And then my guitar teacher in Boston at the time had studied in Spain and was a wonderful flamenco guitarist. And so I started. Learning about flamenco and decided that I wanted to spend some time in Spain to really understand that music and to get better technically. And I had this incredible opportunity in college. I had a fellowship from Harvard called the John Finley Fellowship, where the year after senior year I lived in Spain and traveled through Europe. Playing guitar. I studied at a flamenco Tableau in Madrid for about five months, and then just traveled around Spain, but also the rest of Europe, like playing music and meeting musicians. And part of that year was to try to figure out did I want to actually pursue music professionally? And I think I realized that I always wanted to be part of my life, but it was not gonna be my path. But I think in medicine. Music, particularly classical and flamenco guitar really, I think demonstrated to me the value of practice and practice with intention. Which you can apply to any skill that you wanna get better at. So I've tried to use that focus to continue every day to try to get better at my bedside observation skills, my physical exam skills. I didn't start using ultrasound routinely until COVID when, There were times I ran an infectious disease unit and for the first few weeks of COVID we couldn't get CAT scans or MRIs very easily. And so we needed to use bedside technology to augment what we were learning, and particularly when we were wearing these full face respirators and double gloves really impaired some of our ability to do traditional physical exam skills. I've also looked to make music a part of what we do. If we produce a video related to one of our bedside programs, like our Bedside Scholars program, the music that you hear on the video is music that I've recorded and composed, or, during COVID I partnered with a nurse who. She was a first year nurse when I was an intern, and, 20 years later we were taking care of patients on a COVID floor. And she wrote a poem about the experience that she had. She asked if I would set it to some music and that became something that we used. And then whenever I can, I try, I just try to play in public. So at Hopkins, I routinely play at different events throughout the hospital. We partner with the conservatory to partner healthcare providers who are musicians with professional musicians to do sets in the hospital for patients and their families. And I'm hoping to get to do some of that here at Northwestern too. 

Erin Spain, MS: If you could leave us today with some final thoughts, especially for the trainees and medical students who are listening, what message would you like to leave us with about the importance of bedside care? 

Brian Garibaldi, MD: So what I would say and, and what I continue to learn every day is that the answers for the questions that you're seeking are almost always in the room with the patient and the stories that they have to share. The signs that their bodies can show us and guide us. Learning about who they are as individuals, learning about their loved ones and their families and friends. More often than not, the information that you need is gonna be in that room. And that's where we should be spending our time to try to gather that information. And tech can be a part of it, but it all starts with being in the room with the patient and being present with them. 

Erin Spain, MS: Thank you so much for joining us today, and welcome to Northwestern Medicine. 

Brian Garibaldi, MD: Thank you so much. I'm so excited to be here and so privileged. 

Erin Spain, MS: Thanks for listening. Please click the bell to receive notifications about our latest episodes and follow us on social media @NUFeinbergMed to stay up to date with our latest research findings. 

Physicians who listen to this podcast may claim continuing medical education credit after listening to an episode of this program.

Target Audience

Academic/Research, Multiple specialties

Learning Objectives

At the conclusion of this activity, participants will be able to:

1. Identify the research interests and initiatives of Feinberg faculty.
2. Discuss new updates in clinical and translational research.

Accreditation Statement

The Northwestern University Feinberg School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation Statement

The Northwestern University Feinberg School of Medicine designates this Enduring Material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

American Board of Surgery Continuous Certification Program

Successful completion of this CME activity enables the learner to earn credit toward the CME requirement(s) of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

Disclosure Statement

Brian Garibaldi has disclosed financial relationships with include board membership of the Society of Bedside Medicine, paid consultancy with Johnson & Johnson and Gilead, advisor to AriSciences, membership on advisory committees and review panels at the Food and Drug Administration. He has received consulting fees from Clario and National Board of Medical Examiners.

Course director, Robert Rosa, MD, has nothing to disclose. Planning committee member, Erin Spain, has nothing to disclose. FSM’s CME Leadership, Review Committee, and Staff have no relevant financial relationships with ineligible companies to disclose.

All the relevant financial relationships for these individuals have been mitigated.