Although it feels like a lifetime ago, I remember buying my copy of Bates’ A Guide to Physical Examination and History Taking early in medical school. That purchase was more than the transition from the preclinical years to the juicy part of my education. Even at the time, it felt like I’d bought a book of spells, some kind of arcana that allowed me to use my hands to see inside. I don’t think I’m the only one who feels there is something almost magical about a skillful diagnostic examination. An older physician-mentor’s gift to me when he learned I’d be going to medical school was his even-then-ancient copy of Cope’s Early Diagnosis of the Acute Abdomen. Learning physical diagnosis is the beginning of, no pun, our indoctrination. The problem is, for many conditions, the physical examination just isn’t that great. There are few worse feelings than missing a diagnosis, except, perhaps, making one that isn’t there, which can result in providing treatments the patient doesn’t need. Hip dysplasia in neonates is a diagnostic minefield. The recommended physical examination maneuvers [3]—the Ortolani and Barlow tests—may miss as many as one in four infants with the condition [9]. Widely used clinical and sonographic diagnostic approaches also may result in overdiagnosis and overtreatment, so much so that they don’t meet the World Health Organization’s standards for effective screening regimens [8]. As a measure of how desperate things are on this topic, consider this recent publication: “Improving Resident Education Through Unstable Chicken Hips: A Novel Way to Teach an Infant Hip Examination” [2]. If we’re sending learners to the lab to examine capsulotomized poultry in the hopes they’ll be able then to detect a potentially disabling condition in someone’s newborn baby, we’ve got plenty of room for improvement. The latest American Academy of Orthopaedic Surgeons clinical practice guideline recommends not performing universal ultrasonographic screening of infants for developmental dysplasia of the hip [6]. But, like all recommendations, one can imagine it changing if the test were to become more consistently useful, which, in the case of ultrasound, means first that it must become more consistent. Ultrasound is not an easy tool to use reproducibly. For this reason, as well as another important one that I’ll return to, I was excited to publish this month’s Editor’s Spotlight/Take 5 paper by Dr. Pablo Castañeda’s international team. In the context of a 2-hour course involving some videos, some clinical observation, and a little closely supervised ultrasound practice, the group’s teaching program was able to bring learners of different levels who were new to ultrasound up to a high level of proficiency: A correlation coefficient of 0.97 for the diagnosis of normal versus abnormal hips, when the learner’s findings were compared to the expert’s [4]. If this can be replicated and generalized, it may change the way we diagnose this disabling condition. But for those who don’t diagnose hip dysplasia in our practices—which is to say, most of us—the effectiveness of Dr. Castañeda’s program still should command our attention. Reliability statistics consistently in excess of 0.9, which the program achieved, are numbers I’m not used to associating either with the teaching of complex skills or with ultrasound. Here, they pulled it off in a setting that involved both. I’d like to know how. Wouldn’t you? Join me to go behind these exciting discoveries in the Take 5 interview that follows with Dr. Pablo Castañeda of New York University Hospital, senior author of “What is the Interobserver Reliability of an Ultrasound-enhanced Physical Examination of the Hip in Infants? A Prospective Study on the Ease of Acquiring Skills to Diagnose Hip Dysplasia.” Take 5 Interview with Pablo Castañeda MD, senior author of “What is the Interobserver Reliability of an Ultrasound-enhanced Physical Examination of the Hip in Infants? A Prospective Study on the Ease of Acquiring Skills to Diagnose Hip Dysplasia” Seth S. Leopold MD:Congratulations on this exciting study. Because more readers here are teachers and learners than are pediatric orthopaedic surgeons, let’s focus on their goals first. All of us would like to be able to teach (or learn) a complex task as well and as quickly as your protègès did. Break it down for us: What were the general principles of your program that we can apply to the development (or teaching) of any surgical skill? Pablo Castañeda MD: As doctors, we are involved in three essential domains: the clinical care of patients, research, and education. We try to improve our patients’ outcomes by measuring different variables, but we don’t always have a tangible measure for our abilities in educating other physicians. If you can’t measure it, you can’t improve it.Pablo Castañeda MDOur teaching program works off the “see one, do one, teach one” principle. It became evident that certain learners could spend some time watching an expert perform the technique in clinical practice and easily acquire the skills to accomplish it. Whether it’s a physical exam or a procedure, teaching any technique is fundamentally a process that includes planning, implementation, evaluation, and revision. For this technique, the planning phase began with an appraisal of where each learners’ confidence level was when dealing with infantile hip dysplasia by having the learners complete a five-question survey that provided a scale of self-assessed knowledge. We then formulated a simple curriculum that was understandable. Learners could quickly identify the benefits inherent to the technique. The implementation phase meant going over these principles in real-time; we hammered home the same concepts that the learners heard in the required videos in the same style when they were seeing actual patients. Repetition is the mother of learning, the father of action, and the architect of accomplishment. Our learners did well. The evaluation and revision phases were constant and interactive; we encouraged continual communication to better understand the nuances, including positioning and technical aspects. We then implemented the same five-question survey to evaluate self-assessed competency. I reviewed this with each learner. One of the real advantages we had when teaching ultrasound compared to teaching surgical techniques was that we were using a technology that is noninvasive, carries no risk, and has no side effects. In surgery, at some point, we have to give up the knife to a trainee. That’s a huge responsibility. But we have to trust the people we are educating and allow them to perform procedures under a supervised eye. I found that leaving the learners on their own provided them the time and a stress-free environment to learn how to use a simple device that can cause no harm. I think that the knowledge that the findings of the gold-standard examiner would be used for any treatment decisions took the pressure off the learners to understand the technique and perform it without causing any adverse effects. Dr. Leopold:How are you using those teaching principles to good effect beyond hip dysplasia in other parts of your “didactic life” as a professor of orthopaedic surgery, and how are they working? Dr. Castañeda: The most important thing I have learned from teaching these techniques is simplifying things without making the learner feel things have been “dumbed down.” In my experience, the best teachers can break down complex problems into simple principles that people can understand at different levels of knowledge. We have incorporated video into the entire curriculum for pediatric orthopaedic surgery. To go back to “see one, do one, and teach one,” the smaller surgical volume of each procedure that we perform compared to adult reconstructive or sports surgery means that most residents will not have a chance to see enough repetitions of a procedure to feel confident doing it themselves. However, the ubiquity of high-definition cameras that can record techniques makes this process much more accessible. For example, when residents help me perform a pelvic osteotomy, they must watch a video that I have created and edited so that they are on the same page as me. I learned that the procedure runs much more smoothly and faster when they have watched the video. We also must be aware that the way we learned years ago probably is no longer a valid didactic method. Learners today expect their education to be online, on-demand, video-based, and accessible. There is a wealth of knowledge, some of which is of questionable value, readily available on the web. We have implemented a brief but specific competency evaluation that learners take at the beginning and end of their educational time with us. Dr. Leopold:Any hiccups you’ve noticed as you’ve been implementing these ideas with your learners, and if so, how have you overcome them? Dr. Castañeda: The biggest issue is intrinsic motivation; some learners are intrinsically motivated to learn these techniques; in fact, this is a source of potential bias in this paper as the people involved had been self-selected because they were interested in learning this technique. It becomes much more challenging when the learners are less interested in a specific topic. The second obstacle is intrinsic ability; some people simply have better visual-spatial skills and can learn the technique more quickly and efficiently than others. Frankly, I don’t have a good way of identifying this beforehand. However, having the video-based lectures prepared for the learners is always helpful. They have this resource to go back to time and time again until they feel comfortable performing it independently. Dr. Leopold:Back to hip dysplasia diagnosis with ultrasound: What kinds of studies would it take to show that your approach is generalizable, and when might readers expect to enjoy reading about them? Dr. Castañeda: Ultrasound has been considered the primary imaging modality for the diagnosis of infantile hip dysplasia since the 1980s; however, the techniques that were initially described have not been adopted worldwide, and sadly, the rate of late detected hip dysplasia remains high even in developed countries. Not to take away from the pioneers of the technique, but we need to find ways to make this generalizable, cost-efficient, and effective. One great advantage we have today is the exponential growth and rapidly decreasing cost of portable ultrasound devices. With more and more physicians using these point-of-care ultrasounds as part of their physical exam, it is natural to expect its use in orthopaedics to increase as well. While it is true that not everyone has access to an ultrasound device, in my experience point-of-care ultrasound can increase diagnostic accuracy, help clinicians better engage with their patients, and increase patient satisfaction by decreasing the amount of time spent in the clinic and ultimately being able to provide care for a greater number of patients. I also think that studies showing how healthcare providers on many different levels could be taught to perform this technique would be incredibly useful. This is a noninvasive technique with a minimal downside; in settings where physicians are scarce, we would do well to train other healthcare providers to help unload the burden. Dr. Leopold:The diagnosis of hip dysplasia is even more burdensome in resource-constrained areas than in industrialized nations, and in other cultures, the disability associated with missed hip dysplasia can result in patients being marginalized and experiencing terrible social hardships[5, 7]. Your study group included colleagues from three different continents, which helps to give a broader perspective, I would think. But I understand that in many parts of the world, orthopaedic surgeons do not perform their own ultrasounds, and perhaps are not even permitted to. In light of that, how do you imagine disseminating your discoveries to those parts of the world that may need them the most? Dr. Castañeda: One of the major obstacles is that while the learners involved in this study were from three different continents, they were all able to learn this technique while with me, in a highly developed and urban part of North America. However, the devices we use are so low in cost that they can be acquired and used in their home countries in most instances. We have also been working closely with other groups. For example, under the leadership of Charles T. “Chad” Price MD, one of the leading voices in research into hip dysplasia for the last 30 years, we have been looking at developing ultra-low-cost acoustic devices that could identify hip dysplasia at a tiny fraction of the cost of a missed diagnosis. In many parts of the world, surgeons will have a difficult time obtaining an ultrasound because it can be heavily regulated in certain countries. But I believe that it is on us to change the mindset that this is a complex procedure that requires external personnel. My analogy is that orthopaedic surgeons should carry point-of-care ultrasound devices around with them the way cardiologists sling their stethoscopes around their necks. What we are doing is harnessing technology to enhance our ability to perform a physical exam. I am simply following in the giant footsteps of Sir William Osler, who taught his students in the 19th century: “Listen to your patient; he is telling you the diagnosis.” Only now, we can listen with the aid of these technological wonders.