We Teach The Physical Exam Wrong

An academic hospitalist talks about 3 big problems with teaching the physical exam to medical, nursing, and PA students:
1. We don't teach how to properly tailor the exam to the patient and situation.
2. We don't include sufficient use of bedside ultrasound.
3. We focus teaching what's included in the classic physical exam textbooks rather than focusing on what exam components and maneuvers are supported by the evidence and which are used in real-life practice by outstanding clinicians (when they are not being observed by students!)

[@StrongMed]

Obligatory disclaimer: This video is not referring specifically to my own institution, but rather to all medical training sites in the US. Also, I'm sorry about the suboptimal lighting and audio. It was such a nice day (and I had been watching some Tom Scott videos) that I felt like recording outside for once, and I didn't have the best setup for it. EDIT: Since many people have been asking about and discussing good physical exam resources, these are the 6 exam textbooks I have on my bookshelf: JAMA's The Rational Clinical Examination (is available from JAMA as individual papers, but can also be purchased as a bound version of all of them): The overall best reference for learning a patient-centered, evidence-based physical exam. Evidence-Based Physical Diagnosis by Steve McGee - Has a ton of data (+LR & -LRs) on physical exam findings with modest-moderate amount of pathophysiology discussion. I think its primary weakness is that it gets lost in the data and doesn't always distinguish findings that have small one-off studies showing benefit from classic findings that have a robust volume of evidence and which are used in common practice. Bedside Cardiology by Jules Constant (out of print) - Goes into ridiculous amount of detail about the pathophysiology of individual findings (e.g. S1, S2, S3, S4, and the opening snap of MS all get their own dedicated chapters!). The book was written pre-echocardiography, so it has limited relevance for contemporary practice, but for physiology-nerds, it's incredibly interesting! Mechanisms of Clinical Signs by Dennis, Bowen and Cho - Great diagrams and figures regarding pathophysiology of findings. Whereas JAMA is a great reference for looking up a patient-specific question, this book is a great reference for looking up a finding-specific question. Sapira's Art and Science of Bedside Diagnosis - A Bible of esoteric physical exam findings from "the days of giants", which is more for bedtime or airplane reading rather than a practical textbook that I would apply to my clinical practice. But the most entertaining read of the group. Bates - Because this is the mandatory textbook for our preclerkship students. I otherwise wouldn't defile my bookcase with it. (I suppose it isn't *that* bad, but I do not recommend this as the go-to reference for students) For web-based resources, I recommend: physicaldiagnosispdx.com/ created by Andre Mansoor of Frameworks for Internal Medicine fame (OHSU) stanfordmedicine25.stanford.edu/ created by Abraham Verghese (Stanford) meded.ucsd.edu/clinicalmed/introduction.html created by Charlie Goldberg (UCSD) (Yes, there is a US West Coast bias!)

[@dizzyboy92]

I think the exploration of outdoor videos as setting for "rants" is great. Also, I agree with your assessment and can tell you that doesn't happen only in the US. I think evidence-based, practical interrogation, and later testing also has the same issues but different causes.

[@Hopeswilldie]

As a last year medical student from Europe I can tell you that teaching physical exam is not a problem just in the states. I absolutely stand behind your opinion that physical exam should be taught alongside pathophysiology. In fact, many preclinical and clinical subjects should be taught more connected to each other. I still don't understand for example why I spent two semesters learning pharmacology and then having to basically re-learn it for my internal medicine exam a year later, when it could've been easily taught alongside each other and it would stick better when presented with case studies... But that's for broader discussion I guess

[@zuhairyassin505]

i think its all about profit medschool can be way shorter in duration and of good quality but it means less money for them if you are paying your fees or like in the US student loans

[@Hopeswilldie]

@@zuhairyassin505 i agree that might be partially the case, however I think the bigger reason is that medical education and field in general is very rigid and traditional and people in charge usually don't want too much changes in how things go. In my country there's a classical system of education, consisting of 6 years in total, loosely divided into preclinical part, and clinical part. Exams are strictly oral and sadly are not usually solving-a-problem oriented, but theory heavy and best students are the ones who can memorize more facts. Which is a system that probably worked well a hundred years ago, when there was a quarter amount of knowledge than today and doctors were supposed to know everything about everything. Today it's just not possible and education needs to be more problem solving based. This system only leads to that if everyone is supposed understand everything, then no one understands anything. Not properly. Also the practical skills education suffers from it a lot, because there's not enough time for it...

[@StrongMed]

Totally agree! Our school teaches physiology, pathophysiology, pathology, pharmacology, and clinical reasoning all alongside each other. And I think we do a better job than many places with teaching the physical exam. Our model is to teach the head-to-toe exam in 2nd semester (i.e. winter of 1st year), and then starting in 3rd semester (i.e. spring of 1st year), we go through organ blocks, 2 at a time (e.g. cards and pulm together) and spend a few afternoons doing "advanced" physical exam techniques relevant to that organ system. For example, students might learn about valvular heart disease pathology one day, and then the next are listening to heart murmurs on our cardiac simulator mannequin. Logistical limitations prevent perfect synchronization, but we tried to do our best with it.

[@Hopeswilldie]

@@StrongMed that's sounds very good!

[@judypeng4748]

In China, med school is 5 years. The bachelor degree requirements is not necessary. but maybe people have different backgrounds and different knowledge if they come from different major. If I know in the beginning I try to apply med school I will not choose nursing major, I may try computer in bachelors so I know more. Medical jobs also need a lot of experience addition to the knowledge from books, those need time.

[@MedlifeCrisis]

Well said Eric. I’ve got my own thoughts about the physical exam (in fact I’m planning a video of my own hopefully not too far away, I’ll definitely put a reference back to this when I do) and I remain passionate about it and I think your point about a real life and evidence-based examination is key. I like learning all the obscure nonsense as it’s interesting and part of our history but that mustn’t be the focus of what we teach students nor test them on. If I didn’t teach regularly, I’d have genuinely de-skilled. Quite possible to treat a patient without touching them once. Which is a bad outcome for everyone.

[@StrongMed]

Rohin, thanks for stopping by! I agree on the connection between teaching the exam and maintaining those skills. I had a gap of 4-5 years between residency and when I started formally teaching the exam to students, and I felt like I had to relearn a whole set of maneuvers that I never actually did in real-life (and ironically, most of which probably aren't helpful anyway). And among many other awful effects of the "Era of COVID", one of the lesser acknowledged ones is that it's now been normalized to treat patients, even acutely-ill hospitalized patients, without touching them. Zoom meetings via bedside iPads have supplanted physical contact. I also appreciate your point about the "obscure nonsense"! You may already be familiar with these, but 2 books I'd recommend for obscure exam findings are Sapira's Art and Science of Bedside Diagnosis and Jules Constant's Bedside Cardiology. The former is full of these random anecdotes where the author cites a conversation with a physician across the world who swears by some random physical finding that's otherwise undocumented in the literature. Much of it is ridiculous, but it's engaging ridiculousness. The latter was written pre-echocardiography (i.e. it's a bit obsolete), but it goes into incredible detail connecting physiology to physical findings (I think there's whole chapters on S3 and S4). I think one of the unspoken challenges with teaching the physical exam to trainees is that some of the exam's strongest proponents seem to almost fetishize the exam as some singularly unique aspect of being a physician, rather than approaching it as a combination of diagnostic tests and an opportunity to build doctor-patient rapport. I appreciate their passion, but by focusing on the ritual rather than the evidence, it gives the impression to learners that the exam is fundamentally unscientific. Sometimes I observe people teaching "conventional" exam maneuvers which actually have no supportive evidence (or which have evidence of uselessness), and I wonder if there's even a line between the "textbook exam" and techniques that western doctors are quick to disdainfully discount as pseudoscience. #EndRant As always, looking forward to your video!

[@joshyantony1932]

Wait, what?! It's Christmas again!

[@twistedtea7046]

when i hear someone say “we do this because this is how we do it” i usually close my ears lol. great lecture

[@Pakanahymni]

Medical teaching across the globe is really ossified, rigid and based on "this is what we've always done". I've studied other things before medicine and I think medical teaching is a good 150 years behind common best practices in pedagogy from state of the art.

[@johnnyzhang5333]

My man spitting out straight facts.

[@imranabdullahkhan9767]

I am a recent medical graduate and I have had similar thoughts as you. Thank you Professor for sharing our unpopular voice.

[@solomonadelaida]

I am an internal medicine doctor teaching 3rd year medical students (semiotics) and I am an avid user of all Eric Strong material I can find. I totally agree with radically changing the whole way we teach physical examination and reasoning! We need to come out of this inertia and actually teach what we practice and what is evidence based! I am using Rational Clinical Examination: Evidence-based Clinical Diagnosis (JAMA), Evidence-Based Physical Diagnosis along with the classical Bates to sift through all the clutter we teach. Thank you Eric Strong@ Stanford for your excellent work!

[@squirreleyy]

At my medical school in Ireland, we begin learning pathophysiology and core clinical skills side-by-side from Day 1. First and second year were all taught this way. It really helped us understand the mechanism of disease and see how it presents in the real world. However to do this, a lot of the basic medical science content was required to be cut down to make it more managable for students. It's a difficult act to balance the two aspects for starters, and I see why in certain schools theres a greater emphasis on one or the other.

[@valentinemcdermott]

Did you have a PBL based course? I’m a 3rd year GEM student in a PBL course and it sounds similar to what you described.

[@StrongMed]

This is interesting to hear. Is your medical school unique, or is this a common approach in Ireland?

[@valentinemcdermott]

@@StrongMed There are quite a few UK and Irish universities that use the Problem Based Learning (PBL) teaching system. As squirrel says the PBL system has its advantages and disadvantages. The focus is on the clinical sciences from day 1 of first year. This is prioritised over the basic science material which is both a major strength and a weakness, depending on how you look at it.

[@salimyaghi605]

Can't agree more. In fact during my training (outside and inside the US), a lot of physicians argue not to do a lot of physical exam but to rely on more objective data like imaging. So it seems in reality the physical exam is falling behind in real practice. Your proposal of assigning official committees to promote evidence based and practical exams is the right way to go. Thank you for valid and accurate points.

[@ayseakpnar6049]

Throughout med school I observed teachers perform same exam on same patient but interpret differently. That's why i find myself unsure especially on subjective ones like scoring pretibial edema

[@StrongMed]

Pretibial edema is my go-to example of how parts of the exam can be completely devoid of interobserver agreement. At least in US medical schools, if you ask 10 different attending physicians for the criteria of how to grade peripheral edema on the ubiquitous 0-4+ scale, you'll get 11 different answers.

[@gilliang.691]

@@StrongMed 😆

[@ramironin2042]

A lot of the problems you addressed are shared in medical schools across the world (I live in Uruguay). I’m glad you mentioned the issue of not teaching exam findings alongside their pathophysiologic basis, this being especially true for the cardiac and neurological exams. In my experience this creates a steep learning curve in which at first one just memorizes the order of techniques and how to do them, and as you learn pathology what to look for becomes more intuitive as you said; correlating knowledge is the most useful way to learn, and teachers fail to emphasize this. Everything holds true for the patient interview too. Regarding the other problems, as a student I’ve experienced having to auscultate fetal cardiac sounds using a Pinard Stethoscope, despite the fact that no gynecologist who taught us this actually uses it ever, just because it’s a “basic clinical skill” (unreliable and affected by many variables at that) but failed to teach us for example fetal cardiac monitoring, and the pathophysiology of diminished heart rate and heart rate variability as a surrogate of fetal suffering!!!!! And this is just one of many examples. Anyway, rest assured that you are not alone!!!! The medical world suffers a lot from the “we do this because it’s the way it’s been always done” mindset worldwide. Another problem we have here which I don’t know if the US schools share is the lack of teaching skills and overall preparation for teaching that doctors have, here you are not required to have any of that in order to teach, just your medical degree. Thank you for venting about issues that need to be discussed!!! Best wishes from Uruguay

[@alexs1122]

Congratulations for this outstanding critical view! As an Internist who practices also Emergency Medicine (in some countries in Europe we don't have EM as a specialty) I fully agree. In my opinion the clue is to be able to adapt what is generally tought (and what generally is supposed to be done by a doctor) in order to be usefull to find out what actually happens to a pacient and what needs to be done considering the pathophysiology and evidence. POCUS is very important and a big step forward. Regarding the physical exam a very good resource is the book "Evidence-Based Physical Diagnosis" by Steven McGee. And as always experience, continuous education and constant critical thinking is crucial and your channel is an excellent resource! Thank you!

[@dancewithunni]

In South Africa it's taught very differently. From the history we must find the system to examine. IPPA - From history we must already know the diagnosis and the physical is to find the signs we think. Asterixis and JVP are important for everything - Resp, Cardiac, Abdominal exams.

[@ahmedmed4811]

A cardiology fellow here, and I just wanted to say that i havent used a stethoscope since I learned bedside echocardiography! Great video as usual! Keep em coming sir!

[@StrongMed]

My wife is a cards attending and when my digital stethoscope broke a few years ago, I asked if I could borrow hers for a little while. I told her just let me know when she needed it back. 2 years later, she hasn't asked about it once...

[@ahmedmed4811]

@@StrongMed hahaha halarious! Thanks again for the videos. I have been following the channel and watching it grow since I was a medicine intern. I ve always found your videos useful and informative much better than text books. Thank you for educating us!

[@ZZuluZ]

What if the patient has massive wheezing! ;)

[@fatmael-menoufi3540]

Amazing perspective. Thank you for bringing this issue up, Doctor!

[@jeremyrussell282]

This is SPOT ON! It's so odd to be living in 2021 and having to sit in on a lecture about "tactile fremitus." Basically, you do what you're taught to get the grade and then never use it again. I completely agree with everything said in this video. We need a change. "99." 🙄

[@albethcajucom]

Thank you for talking about this! The same thing happens here in the Philippines. Before clerkship, it was sort of implied that we just had to master Bates (pardon the pun hahaha) and that was it, we'd be fine. Then clerkship and internship came, and I learned that the way the physical exam was taught lacked an emphasis on time management, and practicality. There was this futile emphasis instead on formality. Most of it was just a list of things we just HAD to know... I've just started to practice medicine since I just got my license last year and now I'm 100% convinced there's a great incongruity between what I've been taught and what I actually needed to know. And to be honest, it makes this art of medicine less exciting for me to practice when there's like a hypocrisy going on (med student present: percuss; no med student present: why percuss?, etc). And I always hate it when seniors just told me "because...that's what our seniors did" as an answer to my question of "why do we do (insert maneuver)?"😫 I don't like the dissonance... 😫 We really need more dedicated teachers, and we need to step things up when teaching our juniors. *end of rant*

[@andressakuzma8780]

As I medical student from Brazil, I wholeheartedly agree with your perspective. Too much of what we do is just because "we've always done it this way", not necessarily based on evidence on what's best for our patients.

[@mateusfernandes7347]

Nice to see another brazillian here! Hugs from Minas :)

[@camilagda5855]

@@mateusfernandes7347 daqui de minas tb 💕!! eu nunca tive aula de pocus e, de fato, muitas vezes não era acessível para fazer em todos os pacientes (um aparelho que demorava a ligar, que tinha qu pegar no cti, etc)...até rx, por mais que tivesse a máquina eram muitos pacientes pra usar. Mas concordo plenamente com o que ele disse, acho que minha base dessas "novas tecnologias" não é nada boa, mas semiologia das antigas deram até demais (e olha que eu falo da melhor - na minha opinião- federal do país heheh 😛)

[@mateusfernandes7347]

@@camilagda5855 Oii! Você é da UFMG? Concordo demais com ele, tem muita coisa no exame físico que nos é ensinado que não tem aplicabilidade clínica atualmente, com os atuais recursos básicos e dinâmica da medicina moderna. Abração!

[@camilagda5855]

@@mateusfernandes7347 sou sim! na verdade era hahah acabei de formar. Ce é de onde? Concordo plenamente, ainda mais que nem mesmo os profs usam na prática. Eu tinha uma professora que me fazia medir a PA dos pacientes 3 x na consulta!! e ainda ver o outro braço. Hoje eu dou risada dessas coisas, mas vejo o tanto que os outros conhecimentos fazem bem mais falta. As coisas evoluem, ter um conhecimento muito bom de USG é extremamente importante...e eu nunca tive aula nenhuma direcionada pra isso. Abraço!

[@mateusfernandes7347]

@@camilagda5855 sou da UFTM! Parabéns pela graduação, muito sucesso para você!

[@aconcretemoth9382]

I'm a nursing student graduating from Hopkins in Baltimore. I'm planning to work Med-Surg in Seattle. My physical assessment skills are by far the least developed. I want to have a degree of mastery that I can reliably notice abnormal signs and symptoms, and activate the systems to have other practitioners examine the patient. We're still taught skills like percussion and palpation, assessing the pupils, describing murmurs, but not always to the degree that we incorporate full head-to-toes and focused assessments into our practice and grow confident in them, and we also receive mixed-messages about whether these skills are evidence based at all. Part of the problem is that we end up graduating feeling guilty, or like bad students, for not fully incorporating these skills into our practice, but also don't have the reinforcement to really learn it. It isn't enough for me, as I enter practice, to just assume that these are skills that the doctor for instance will have, because that underplays my role and responsibility, because also I worry they will have learned under a similar dynamic. Maybe you have some advice for an earnest nursing graduate looking to develop these skills? Is there a reference that you trust more than most?

[@StrongMed]

I can totally empathize with the sense of guilt for not incorporating exam into assessments. For me, it's a cognitive dissonance in that I feel guilty for not doing the exam I was taught in school despite knowing that the evidence doesn't support the majority of the maneuvers. If you are worried that other medical disciplines learned additional physical exam maneuvers that weren't covered in your nursing school, I will guarantee that the majority of things they learned and you didn't fall into the "textbook exam" only category in the Venn diagram (i.e. stuff that's not useful anyway). The single best reference for a patient-centered, evidence-based exam is JAMA's Rational Clinical Exam series. You can buy a bound copy of the individual papers, but any academic institution (and most hospitals) will have institutional access. In fact, if you commit to studying and practicing a patient-centered, evidence-based exam, you'll soon find your skills well ahead of most clinicians, irrespective of what letters they have after their name. Good luck!

[@helenafilar273]

I could not agree more. I study in Poland and I would say we have the exact same situation. A video about what US-bedside diagnosis we should learn to recognize in our first years as interns would have been highly appreciated. Thanks a lot for your great videos and topics!

[@Dunve]

Couldn’t agree more about the Point of Care Ultrasound, Eric. I was fortunate to have great amounts of US training throughout medical school in Europe which has surely improved my diagnostic sensitivity. Although this was out of necessity (lack of resources of “better” imaging modalities) I still believe it is an overlooked diagnostic tool here in the USA. Great to see a passionate clinician striving to improve medical education and patient outcomes with completely transparent explanations.

[@hadihoseinzadehsalaleh269]

Thank you for the rant! I actually now know what to learn on my own ( right now I'm looking for info on Handheld Ultrasound 😅), really appreciate it. 👍🏼

[@MultiplyByZ3r0]

If I can offer ONE argument, as a Medical Student in Brazil, in favour of some evidence based physical exam findings that aren't used in clinic (such as liver and lung percussion, or thoraco-vocal fremitus), it would be to illustrate the pathophysiology. It is one thing to see liquid in the lungs in a chest x-ray, but to actually percuss a thorax and hear that dullness makes you truly appreciate the finding. Imaging is more impersonal, it is easier to dissociate the patient in front of you, to the disease you read in some dusty old tome (or UpToDate). Ascites was always a weird thing to me, I couldn't quite picture it, even after looking at ultrasounds and CT scans, until I found myself standing in front of a nephrotic 21 year old with a bulging abdomen with clear, moveable dullness. We didn't do an ultrasound, because it wouldn't change our conduct, and the finding *is* arguably useless for the same reason, but it did help me understand. In my own practice, when I get there, I probably won't be percussing all that often, especially if I have an ultrasound handy, but it did illustrate the mechanism nicely. Another beautiful example is Trusseau's and Chvostek's signs. Low sensitivity, pointless tests I have never seen done in practice. But they are amazing to demonstrate to students what happens when you have hypocalcemia. To show that low calcium really does have an effect on muscle contraction. Traditional physical examination, the one that is purely academic, may not be the best diagnostic tool anymore, but it connects you to the very core of medicine and brings textbooks and diseases to life, to the patient in front of you. Steven McGee's Evidence-Based Diagnosis is a great book that addresses many of your concerns. If you haven't read it, I strongly recommend it! I would love for it to be one of the basic textbooks instead of Bates', Porto's or Hutchingson's.

[@StrongMed]

This is a very valid point, and I totally agree with the value in demonstrating physical findings that help make connections to pathophysiology. When it comes to evaluations though, students should only be expected to replicate those maneuvers which are helpful in making diagnoses (which, IMHO, would include signs of ascites).

[@ΆγιοςΧίλαριος]

This video is what every intern really needs to watch

[@abdulazeez.98]

I ,as a 5th year medical student, always wondered why they focus so much on clinical exam instead of more robust and technically advanced alternatives (such as ultrasound). I know clinical exams are essential but we need to move forward and be more familiar with advanced technological methods.

[@heterochromatix8406]

I hear what you are saying Dr Strong, I just finished medical school at a US osteopathic medical school. Many of the physical exam maneuvers taught in class incorporate “osteopathic” findings are completely subjective and thoroughly debunked (ie cranial, Chapman’s points). During wards, everyone got the same exact physical exam, regardless of pathology. In my hospital, I was told many times that the physical exam was an outdated practice that was necessary only for billing. Perhaps a video suggestion for the future would be how to properly perform physics exam maneuvers with associated pathophysiology? Keep up the great work, you’ve been a wonderful teacher to me.

[@StrongMed]

Thanks for the comment and suggestion! I hope to include a whole series on the physical exam, but to do it well, I would prefer to film with standardized patients (rather than my wife, who has been my "patient" on all exam videos to date). And would prefer to film in our simulation center to make it feel as "real" as possible. Unfortunately, because of COVID, that idea is on hold for 2021 - hence the undiagnosed diseases and cardiovascular physiology series. But it's definitely on the list of things I'd ideally like to tackle in 2022...

[@monkiram]

Amazing points! I'm a recently graduated MD (pre-residency) and I feel like graduate medical education is very stagnant overall and resistant to change. I really appreciate attendings like you who care about our learning and about doing the best for our patients rather than just doing the same things over and over. I know that the physical exam is very important, but at times it's hard to be convinced about the utility of what I'm doing when I know that sensitivity/specificity are poor and that inter-rater reliability is even worse. Medical associations do a great job of putting out evidence-based guidelines for practice, I love the idea of having evidence-based guidelines for performing physical exams. Edit: I saw that you are recommending JAMA's series on The Rational Clinical Exam in some comments, I think a lot of us would really appreciate videos of you demonstrating them! P.S. I love your channel, your ECG series is life-saving (potentially literally)

[@StrongMed]

Thanks for the kind words! I once had a plan of tackling a dedicated physical exam series this spring/summer (with emphasis on evidence-based maneuvers including the incorporation of ultrasound). Unfortunately, the pandemic has set those plans back a while (our school's simulation center isn't allowing that kind of activity right now) - hence the cardiovascular physiology series which I recently started instead. Hopefully I can do the exam series in 2022...

[@medicineman786]

Dear Sir! I completely agree with you all the concerns you have made in this video. Besides teaching with the latest technology, we also should teach the future medical doctors with the old convnetional ways to diagnose the patients too. By doing so, students will realize practically that how far we have come and they will appreciate the discoveries, inventions and hard work of our ancestors and gave us the opportunities to make our assessment easier,faster and almost accurate. Nobody knows what the future holds for us and sometimes we need to go abroad in the least developed countries to work in for a peaceful mission. And those countries have limited services and almost no equipments at all. So the students from this great nation should learn every single way possible to treat the patients under limited facilities and poor environment too. Please Sir!, make more vidoes of all medical realted topics. You explain medical topics very easy way and very informative too. It really helps me to teach my students around the world. I teach medical students online the foillowing subjects:Physical Diagnosis ( Lectures & Practical s), ENT, Infectious Diseases, Pediatrics, Science of Operation, Forensic Medicine. Thank you for all your hard work & really appreciate and grateful to you forever.

[@jonty9596]

As a 4th year med student I think you are right on Dr.Strong! Love your channel btw.

[@StrongMed]

Thank you!

[@benmerzouk9737]

You will be happy to know that at my school, in the central east coast, ultrasound is a component in every (except summers) semester of our preclinical years. The first is learning normal and the ultrasound exam by system, the second is gaining experience reading and identifying normal, and the third and fourth is identifying pathological findings.

[@PMoney365]

4th year med student here. I also only percuss when the attending is in the room.

[@Dark_Knight_1097]

Truly spoken Sir... I got the same notion while I was doing my internship and I totally agree with you on this sir...but at the same time physical examination plays a very important role in countries like India where XR or USG aren't available at all places, but when we work in places where USG are available, we find it difficult to manage it... In my opinion,as you said, we should also be taught how to deal with the patients of 21st century. Sir, another thing that I request to you is please try to make any videos helping us to depict basic USG findings of important and emergency cases.🙏🏻🙏🏻 Thank you sir for all of your lectures.. In fact, I was watching your videos on EKG when you posted this video😅

[@StrongMed]

I wish I had time to tackle ultrasound cases! Unfortunately, there are a number of additional barriers to covering it. The channel 123sonography has a decent collection of POCUS videos.

[@Dark_Knight_1097]

@@StrongMed Thank you sir for your suggestions. I will look into the channel sir..

[@Dark_Knight_1097]

Sir, I thank you whole heartedly for your videos sir...Since a year, I am watching your videos, they are very informative and useful during my internship, especially the videos on ABG.....Actually they saved a patient's life who was in Respiratory Acidosis Sir..they are master classes👌👌.... Thanks for teaching us Dr.Eric...Thank you very much sir....

[@joshyantony1932]

You don't know how long I wanted to write or make a video on this!! Thank you for this. Do you recommend any such channel or resource for an "updated" version of physical diagnosis.

[@StrongMed]

JAMA's Rational Clinical Exam series is the best resource for a patient-centered, evidence-based exam. There are no KZbin channels that I know of which have this specific focus. Both Stanford 25 and Geeky Medics have a large number of well-produced videos on specific exam maneuvers or types of exams, but they don't necessarily incorporate a discussion of the evidence, nor prioritize those findings which are most helpful. That's not meant to be shade on those channels - it's just that their philosophical approach to teaching the exam isn't entirely the same as what I mean to convey in this video.

[@joshyantony1932]

@@StrongMed Thanks for the reply doctor. Evidence based physical medicine by Dr Steven McGee also provides likelihood ratios for signs, symptoms and manoeuvres in clinical diagnosis. I thoroughly enjoyed the above channels especially Stanford 25, but what you have pointed out is a real issue

[@monkiram]

@@StrongMed It would be super helpful if you could make KZbin videos based on the series you recommended. It's much easier to learn exam skills by seeing them done than from reading about them.

[@carolannekozik2848]

I've been teaching physical assessment for about 20 years and completely agree that how and what we teach needs to be reorganized and updated. It is difficult to do that on a course by course basis, we do need a consensus from expert clinicians and educators on what assessments and skills will create excellent diagnosticians. Has such a group started? I'm willing to put my time and energy into participating. Thanks for all your excellent education.

[@adamhenrie3879]

Thank you Dr. Strong. As a clinician, I agree, the physical exam traditionally taught is not often useful, especially in inpatient settings. Hopefully POCUS will emerge as standard teaching. I will say that bedside ultrasound for personal use by the physician is not always readily available, but I hope to see it become more accessible to practicing clinicians and trainees alike. Thanks for the discussion.

[@abbeylroberts]

It is extremely difficult as an NP student attempting to learn the provider exam as taught in class (textbook) and relating that to actual practice in the clinical setting. I have found myself calling upon my own novice judgment to mentally distinguish which aspects of the taught physical exam are truly superfluous and which focused exams observed in practice are inadequate (may I even say lazy?). This creates quite the challenge while actively learning new skillsets and wanting to implement them (if truly useful in future practice). I am so thankful for educators like yourself that are willing to give students like me practical knowledge and also the rationale.

[@chernorsierrayjalloh6164]

It's so true Dr Eric, but the problem with that is the fact that it's almost impossible in developing countries such as mine. As a physician assistant, the only you have that opportunity to even see a USS machine is when you accompany patients to the scanning room. However, I have been viewing your videos for a while now, I find them very helpful. But my request is if possible, you can create a video video for your viewers showing the evidence based Clinical examination as opposed to the typical and out dated method... Thank you

[@ilm459661]

Well, the same holds up in Portugal. While it is often assumed that many "textbook" exam findings are actually not very sensitive or specific, we still continue to include them in the official exam, especially when we are presenting it in an evaluation. Actually, we keep saying that ultrasound is "operator-dependent" but isn't that true for any physical exam findings? I wish that a fraction of the lecture hours in medical school could have been used to practice ultrasound - it would have made such an impact on my abilities as a doctor. Personally, I've always tried to make connections between patient history, physical exam, pathophysiology, pharmacology and imaging when studying and during rotations, exactly to avoid being short-sided and boxed-in by how the curriculum was structured. Part of this alternative learning included studying your videos, so thank you for that!! Understanding medicine is demanding, but I would urge any medical student to invest and direct their own learning early on - it does pays off in the end! Thank you for the discussion on an important topic! I hope we can evolve as a medical community and make some changes in the future.

[@StrongMed]

>"Actually, we keep saying that ultrasound is "operator-dependent" but isn't that true for any physical exam findings?" Yes! 100% agree. And if anything, ultrasound is better for ensuring interobserver reliability because images can be stored and reviewed by others later. Digital stethoscopes can record sounds for the same purpose, but this cumbersome in practice and virtually never done.

[@anara5570]

It's not a rant, it actually makes SENSE!😊

[@petersutherland3739]

I agree 100%. Evidence based medicine is the way. We need to embrace the technology that makes us better diagnosticians of today’s time not the time back in the Early 1900s or earlier.

[@BelalAlDroubi]

"The Ultrasound is the stethoscope of the 21st century" I LOVE THIS ! Pure wisdom,

[@cathyo1089]

Thanks for this. Very insightful! And I totally agree with your views on the inadequacy of current POCUS training. Hope more residency programs can incorporate this.

[@erikspletter182]

You briefly mentioned EHR's so I want to dive into something that bugs me in this age of computers and EHR's... From the point of view of a surgical service, I don't understand why, today, we still use words to describe wound issues when "a picture is worth a thousand words." Why is there not more widespread use of cameras, with images loaded into the EHR physical exam? It would remove a lot of provider-to-provider ambiguity in exactly how a wound looked yesterday or last week, if the on-service provider could see yesterday's or last week's picture of the wound. And, the same would apply to skin lesions, conjunctiva findings, oral lesions like thrush, even things like clubbing and capillary refill. We type the same descriptive verbage as providers (wrote) in the 1950's. But back then, words were the only way of conveying the information! There's no need to limit ourselves to just words today.

[@darthrevanakc]

Thank you for making this video. I can tell it bothers you and it bothers me as well. Overall I couldn’t agree more! I’ll piggyback on this saying that auscultation is such an insensitive and unspecific exam. Especially in the days of the ultrasound and imaging. One reason is we don’t want to “lose” the knowledge of how to do these previous maneuvers to which I’d say that already happened long ago (no shame, we just have better modalities). Awesome video, keep up the good work. Hopefully this message gains some traction.

[@LECityLECLEC]

I love you sir God bless you keep teaching us our doctors here in cali keep letting us down.

[@laurendahlstedt2723]

NP student here! Just finished my head to toe exam that was 15 pages and 45 minutes long. Very unrealistic and disappointing thinking “I just have to memorize this and get through but won’t use most of it”. I really wish we were learning with modern technology and things that will ACTUALLY be applicable to patients. As an icu nurse, I’ve never seen a physician do a fraction of the assessments we learn. I couldn’t agree more with this video!!!

[@MikeBirkhead]

I ranked my internal medicine residency solely based on their statements, at interview, that there would be a prominent effort to teach POCUS… 2-Years into the program and the only time I’ve used ultrasound is when I track down the one US that is not to ever leave the ICU, and is only used by me and one other resident… without any formal instruction. Maybe ACGME, LCME, and USMLE all need to be replaced. Or have capitalistic competition - based on which body produces clinicians with the best outcomes. It would take a long time, but leaders would emerge.

[@StrongMed]

I'm very sorry to hear about your experience. I've heard similar things from other housestaff (and students). My impression is that many programs and schools honestly want to be teaching more POCUS but unfortunately are limited by insufficient number of machines and insufficient number of faculty with sufficient expertise. Personally, I wish I had a lot more comfort with POCUS. A while back, I made a modest effort to improve my skills (attended several POCUS-specific conferences with workshops), but the actual hands-on "probe time" was very insufficient. And I have not bought my own machine because the risk of it getting lost/stolen currently outweighs how much I can rely on my skills to make clinical judgments. Yet I can't improve my skills without more facilitated practice. It feels like a Catch 22, and it's all very frustrating.

[@hiteshrathore4064]

Thanks sir for sharing wide range of insight of clinical medicine, i have learnt a lot from you. Sir please make a video about how to approach "outdoor patient" in terms of history physical exam clinical diagnosis and management and deciding whether they require symptomatic treatment and whether or not they needed to admit in ward.

[@andresdelavega]

Thank you for sharing your thoughts and experience Strong! Keep your ideas coming.

[@BelalAlDroubi]

Completely agree I always wondered about signs I was taught, I went back home and did a literature review on them, only to burst-out laughing at how unreliable they are, I've seen signs with 5-20% Sensitivity 😂 (kernig & Brudzinski) and instructors still refuse to speak this out loud (most, not all).. And when I taught my students I tried to be the change I wanted to see, so I mentioned these issues. Change is always slow, but I hope instructors like yourself lead this change

[@MrWakka123]

Im hopefully graduating soon, and i teach the junior years frequently regarding the clinical exam. In every session i take part in theres always a point where i say, i seldomly do this in real life because of the reasons you said in this video, but we have to teach you this for your OSCEs. US is definitely the future.

[@ZZuluZ]

As a physician that works remotely (only recently acquired ultrasoud) I can confirm I never percuss anythjing nor do other useless examinations. I’ve had to learn useful evidence based physical exam maneuvers outside of school like the HINTs test for vertigo etc

[@StrongMed]

The HINTS exam is a great example of something our that schools should be teaching but don't! (We're too busy teaching egophony and splenic percussion I suppose.)

[@ToastFairyfloyd69]

Greetings from a tiny European country! First of all i love your video series, i managed to impress a few collegue's with my newly gained abg analysis skills so thanks once again. Im still a lowly med student but lately i fell in love with the physical exam and all it's mysteries, one small suggestion would be a lecture on the JVP, i heard from a lot of docs that it's fairly important but there are so many confilcting sources about the intricacies of the JVP, i.e. internal vs external jugular vein, what is the exact distance to the atrium, do you use the distance to the point of Louis etc. everyone seems to have his own opinion, a comprehensive video would be really nice! Keep up sir you are doing an amazing job! Much love!

[@StrongMed]

Thanks for the suggestion! I had hoped to do a series on the physical exam this year (with demonstrations), but unfortunately COVID has more-or-less closed down our simulation center and standardized patient program for anything not essential. (Thus, the CV physiology series instead!). Hopefully I'll be able to do some of them next academic year. In the meantime, Andre Mansoor (a hospitalist at Oregon Health and Science and University and author of Frameworks for Internal Medicine) has recently posted some videos on the JVP: kzbin.info/door/x83LAQ-Fh7wOUCIqUSSCYA

[@ToastFairyfloyd69]

@@StrongMed Thank you for the thorough answer and the link sir! Once again greetings from a huge fan! :)

[@robertisherwood9261]

I think this is so true, thank you for raising this issue

[@mihailkirtsopoulos183]

''I don't just want them to look like competent clinicians, I want them actually to be competent clinicians'' This sentence sums up, what's wrong with the way many medical schools teach medicine. Sadly this way of thinking poisons the mind of medical students and most propably affects the way their future patients are treated.

[@pranitingale6347]

Absolutely! Checking whispering pectoriloquy even if CTs/Xrays available in the very next room is utter stupidity.

[@andrefranciscocoutodias3663]

I'm a portuguese medical student and really love your channel and agree with what has been said. I've learned a lot from your many videos and are extremely grateful for your guidance. I would really like to build my bedside ultrasound skills and was considering buying something to that effect. Do you recommend any device for personal use? The only things I have to add are: sometimes, some physical examination maneuvers and findings that aren't highly significant by themselves in terms of their statistical importance, in the broader scheme of things in conjunction with other findings and the history they do contribute to a better understanding of the clinical picture. I do agree that reading a classical textbook isn't enough. Nevertheless, I feel that evidence-based physical diagnosis is still very underapreciated and the practical one is practically tabu to talk about in formal settings. Although I know you're not advocating for less physical examination, I find that now, sometimes, things that would be obvious and accessible by clinical observation are later "discovered" by imaging or labs, or missed just because there was simply no sufficient training to be able to climb the learning curve. Sometimes, we just have to be prepared to observe carefully, integrating the pathophysiology and clinical history. (Today, I saw a woman in the neurology consult and although we couldn't see her lower face during the physical exam, I could clearly see her mask flapping to the frequency of a tremor; and it's much easier now to quantify respiratory rate because of the inspiratory negative pressure pulling on the mask). As you say, we have to tailor the exam to the situation. Unfortunately it isn't really taught, although it is at the heart of effective time-management. (A different aspect of this will be important in the future for, if we are to do ultrasounds as an extension of the physical exam, we will start having more incidentalomas - although we will probably learn a great deal about "in vivo" pathophysiology).

[@Jeff-r1q]

here here i agree,, your ideas should also be adapted to training EMS personnel...i enjoy all your lectures i can learn from them more so than some other physician videos

[@andreeintriago8673]

Its an excellent video. Thank you

[@craig3737]

Agree with you 100% wish things would change !

[@dranubhavgoel491]

Thank u sir , for taking and speaking on this issue

[@debs2026]

IF YOU APPLY I PERSON FIRST ETHOS, AS OPPOSED TO DISEASE FIRST, ALL HEALTH CARE PROVIDERS WILL GO THAT MUCH FURTHER TOWARDS A BETTER/ PERSONALISED OPTIMAL OUTCOME.

[@keddymoise]

Thank you for this talk.

[@ahikam546]

Yes, more of POCUS in the undergrad training...please

[@MrVivekbose]

You are great. You spoke the truth.

[@sunving]

Thank you Dr :) I totally agree with you. I kinda instinctively got this since those day but I got screwed so bad, so bad , may be I am ahead of time. :) Anyhow those time , to find big liver or big spleen or tumor in abdomen is off course valuable finding. Modern technology like handheld ultrasound might replace what you said .

[@Plinktitioner]

“Just send them for a CT” or the equivalent instead of actually looking over the patient remains one of my biggest peeves from other clinicians

[@محمودجمال-ب4ت]

I'm an Egyptian medical Student Once in the hospital while co-profs explainig cardiac examination to us one of them asked the other mocking : who does cardiac Examination anyway, nowdays ?!!!

[@tiberiu_nicolae]

It's like driving a car for the driving test and actually driving a car.

[@andreeaclaudiales]

Dr. Strong, I would be extremely grateful if you saw my comment and enlighten me. In Romania, ever since we begin our training in the physical exam, the most important rule is: you should always examine the patient from their right side. You could fail your exams if you do not respect this. My problem is that we were never given a reason why this is such an important aspect. It is just how we do it for decades. When reading English medical literature, I have not encountered this aspect pointed out. Is this something also taught in the USA? If so, why is this such an important detail of the physical examination? Thank you for the answer and for your work!

[@StrongMed]

I've heard this from American physicians on rare occasions. The most common reason for it that I've heard is that certain parts of the exam are easier from the right side of the patient - specifically assessing JVP, the PMI, liver percussion, and spleen palpation. In my opinion, this explanation doesn't hold up: JVP - I think this is actually easier examined from the patient's left side because you are looking tangentially across the jugular vein rather than directly down on top of it. Liver percussion - Not a diagnostically useful skill PMI - information from this has been rightfully replaced by that gained from ultrasound (Splenic palpation is legitimately easier to examine from the patient's right side) Whenever I hear an attending or faculty talk about the importance of examining from the right, I just shake my head and whisper to the students in the room that it's actually not important.

[@andreeaclaudiales]

​@@StrongMed Thank you very much for your answer! Being at the beginning of my career as a clinician doctor, I find myself very often completely clueless, because I do not understand the purpose and utility of many of the physical exam maneuvers that we are doing. And no one bothers to either explain or confront their present validity. Thank you very much for struggling to make us filter the information we are given and not just take everything as "holy grail truth".

[@MrClubjub]

Schools teach this way because boards don’t adapt to knew technology and therefore keep us learning from old techniques that are one in a million chance we might see that clinical presentation. It irks me when I hear, “ if you hear this buzz word, then the answer is this” when in clinical practice will that ever make sense??? Now with both COMLEX and USMLE dropping the PE portion, how as students are we supposed to be motivated to learn these essential skills?

[@BelalAlDroubi]

There's this british guy, Dr. Des Spence. He hates these things about the physical exam and roast it professionally in multiple papers, they're really amazing. Titled "Bad Medicine.. X Examination" check 'em out, this is one of them: Spence D. Bad medicine: chest examination. Bmj. 2012 Jul 4;345.

[@doctorosullivan]

I'm going to use this speech if I don't know the answer in my next exam :D

[@Headphone-Heroes]

Interesting, i'm from a PBL course, so we would learn every subject - pharm, physio, ddxing etc (everything) while on that specialty, so for cardiology we would learn everything anatomy through to the drugs as well as learning the cardiological examination and then usually within a week or two we would have a placement with a cardiologist to experience pathology. Also our osces are fucking brutual, they're more feared than our written exams.

[@JsForLyf23]

Hello. Dr. Strong. Have you looked into "Mechanisms of Clinical Signs" by Bowen and Cho? It does a good job at explaining certain exam finding and even designating it a "sign value" to provide more clinical relevancy. I'd like to know your opinion on this textbook

[@StrongMed]

It's sitting on my bookshelf in front of me at the moment! It's good, particularly as a reference - if you hear someone mention a specific physical exam finding that you aren't familiar with, or if you see a finding yourself that you haven't seen for a while, and you want to make sure you are correctly identifying it and haven't forgotten about any critical etiologies. It has lots of nice tables and other figures. The book does include "sign value" for each finding, but it's usually just 1-3 sentences that summarizes no more than 1 relevant study - I wish that were a little more in depth, like if one took the figures and non-data content from "Mechanisms of Clinical Signs" and combined it with the data from "Evidence-Based Physical Diagnosis", that would be a synergistic combination. But I do like the book and find it useful.

[@franzliszt3195]

Bravo! Hey, ultrasound units only coste $200 or so, so why does not every GP have one?

[@StrongMed]

$200 - I wish! (I think you left off a zero...) Depending on the features, new handheld ultrasound devices retail for $2000-$5000.

[@franzliszt3195]

@@StrongMed Thank you for the reply. Well, the cost of a high end TV. My GP has a EKG, so for$ 2K they should have a ultrasound, too. I am so shocked there is non-evidence based stuff going on. I had thought the scientific method was the sole basis for Western medicine. Your channel is a gem.

[@andresbluebird]

I’ve spent so much of my time in med school de-learning and relearning concepts and frameworks because a lot of what they teach is simply not useful for clinical practice. On another note, I had a staff surgeon told me very proud of himself that he knew ‘over 100 signs for appendicitis’ and that I should be grateful that now med student are only taught 5-6 signs. 🙄

[@StrongMed]

Anyone who told me that they knew "100" signs for appendicitis, and who was serious, would immediately lose all credibility.

[@stevehawke9819]

Dude, you and Andre Mansoor (Frameworks for Internal Medicine) need to get together! :)

[@StrongMed]

Yes, someday!

[@kamranmahfooz7798]

Have you seen the Stanford Med 25 ? I think the examination shown is relevant. But yes, POCUS needs to be in the curriculum in IM residency .

[@StrongMed]

Yes, I know them well! The Stanford 25 group are all in the same department as me. ;)

[@kamranmahfooz12]

I am a Non US IMG recently got an IM residency position in NYC community hospital with good patient volume and overload. I chose it because it has POCUS. In preparation to intern year I am using your Intern Course and individual lessons as well. What more do you recommend?

[@StrongMed]

First, congratulations! Regarding how to prepare for an IM internship in the US, I think there are 3 specific key skills that can be mastered relatively quickly with dedicated practice: - Interpreting an ECG (focus on the approach and common diagnoses, don't worry about zebras) - Interpreting a chest X-ray (same as above) - Giving a concise and organized oral presentation A few softer skills that are still really important but hard to practice ahead of time include how to call a consult, give signout, responding to cross-cover calls from nurses, and run a family meeting. And of course, much of internship is about figuring out how to get stuff done. That is, who to call to get a specific study ordered or a patient's dispo need met (e.g. home oxygen, wheelchair, PT eval, transportation, etc..). And how to optimize your use of the hospital's EMR to be as efficient as possible without sacrificing patient safety by cutting uncuttable corners (e.g. don't mindlessly copy and paste the plan from one day to the next - unless you are really sure it hasn't changed in any way). All of these are hospital-specific, so it's impossible to prepare for these types of things ahead of time. Last, don't forget to rest, relax, catch any movies or television that you've been wanting to see, eat at your favorite restaurant (if safe to do so given your local COVID situation), scope out the neighborhood that you'll be moving to, etc... Intern year doesn't need to be brutal (and IM internships rarely are), but the year will probably be busy. Good luck!

[@shirkeomkar]

Dr Strong has special access to AREA 51.

[@mikewazowski6469]

Do you have any recommendations for an evidence based physical exam textbook?

[@StrongMed]

Evidence-Based Physical Diagnosis by Steven McGee is the standard among textbooks, though I think the overall best reference is the JAMA's rational clinical exam series.

[@amalvraj5311]

@@StrongMed Sir, will you be starting a course on physical examination soon?

[@StrongMed]

I was hoping to, but to do it right will require hiring actors/actresses to play the patients (rather than using my family members, which has been my strategy for exam videos so far!) and filming in our school's simulation center. Both of those are not going to happen this year due to COVID. Hoping to tackle this in 2022.

[@hyguruprep]

any good KZbin channels for POCUS and bedside exam?

[@StrongMed]

I think 123sonography is probably the single best KZbin channel specifically for POCUS, but if other viewers want to recommend their favorite, please do so! For non-ultrasound, physical exam, Stanford 25 and Geeky Medics both have a ton of well-produced videos, though neither necessarily incorporates much of the evidence behind the maneuvers.

[@AbdelhamidBenSelma]

Great video. Totally agree with you. What resources do you use to teach your med students and residents ?

[@StrongMed]

I'm a huge fan of JAMA's Rational Clinical Exam series. Steve McGee's book Evidence-Based Physical Diagnosis is pretty good too. And the Stanford 25 group has put out some great exam videos that are available on KZbin or their website. Our school has also produced a handful of exam videos for our 1st and 2nd year students that unfortunately sits behind a firewall.

[@vandorenkd]

I 100% agree with you.

[@otralee]

Thanks for the help

[@jakubmach3667]

Well, I guess the question is clear - when is the ultrasound series coming up? ☺️👍

[@StrongMed]

Lol. I wish I had time for this! Too many other competing priorities right now, combined with the fact that to do a series on POCUS well would take a lot more time than other video topics.

[@jakubmach3667]

@@StrongMed I'm sure its time will eventually come ☺️

[@beatrizdesa7601]

Great video!

[@dr.d.arunkumarbsms9232]

Thank you sir

[@manpreetsingh83]

Is there any good resources to learn exams?

[@user-tw2op7km1v]

What sources do you recommend to integrate the EBM and practical medicine exam skills ?

[@StrongMed]

The best resource for this is JAMA's series on The Rational Clinical Exam.

[@sumithreddy8629]

Thank you sir From India

[@goofyglp]

Please create a strong's book or video of physical examination,

[@StrongMed]

If only I could clone myself or survive without sleep, I'd love to do this!

[@glaucomflecken]

I need some subtitles... Who else wants subtitles?

[@StrongMed]

Sorry, I didn't realize they weren't turned on. I can't do it from mobile at the moment, but will when I'm back home later today.

[@doctorvai0]

You are awesome

[@HMS20th]

Exactly the same issue sir in Kuwait University ! Do you what I do ? I skip their classes that don't integrate the pathology with the exam and don't emphasise evidence-based findings, and I depend on myself. Medical Education across the entire globe not just the US is compromised and is retarded and is as you said based on (this is how we're used to do so). Do you believe that this year in KU, third year students are taught Forensinc Medicine Pathology together with cardiology? Disaster !

[@StrongMed]

Forensic medicine is a required subject for medical students? Wow. That's an intense and relatively specific field!

[@DomiPordeus]

I love point-of-care US 😍

[@dailydoseofmedicinee]

👏👏

[@ahealingplace7350]

So what can I do as a medical student to overcome this and increase my efficiency on practical, evidence based techniques that effectively benefit the patient? What can I do???? Genuinely concerned........

[@StrongMed]

It's really just about reading and practicing. I would familiarize yourself with the topics included in JAMA's Rational Clinical Exam series - as in, don't read each paper, but just copy down the list of topics somewhere. And whenever you pick up a patient on the wards or in clinic that has a clinical question that's included in the series (e.g. "Does this patient with chest pain have ACS?", "Does this woman have a UTI?", etc...), use that as an opportunity to read the relevant review paper from the series (before seeing the patient if you have time, but afterwards is great too).

[@ahealingplace7350]

@@StrongMed thank you

[@rajushahi1760]

On target ...