Teaching the physical examination: a longitudinal strategy for tomorrow's physicians

Core and cluster or head to toe?: a comparison of two types of curricula for teaching physical examination skills to preclinical medical students

BACKGROUND

Despite the central importance of physical examination (PE) skills to patient evaluation, early trainees struggle with its correct application and interpretation. This struggle may reflect the instructional strategies of PE courses which have largely ignored the clinical reasoning necessary to accurately apply these skills. The "core + cluster" (C + C) is a recent approach to teaching PE to clerkship-level medical students that combines a basic 'core' exam with 'cluster' based on the student's hypothesis about their patient's clinical presentation. Our institution developed a novel C + C curriculum to teach PE to preclinical students. We aimed to assess the impact of this new curriculum on students' clinical skills and course evaluations in comparison to the traditional "head-to-toe" approach we'd used previously.

METHODS

This was a retrospective study comparing two consecutive medical school cohorts exposed to the new (C + C) and prior (HTT) curricula respectively. We studied two complete cohorts of first-year medical students at our institution who matriculated in 2014 and 2015. The 2014 cohort received PE training via an HTT approach. The 2015 cohort received PE training via a C + C approach. Outcomes included performance scores on a statewide clinical performance exam (CPX) and student course evaluations.

RESULTS

We found no statistically significant difference in mean CPX scores between the two cohorts. However, student course ratings were significantly higher in the C + C cohort and students rated the C + C format as highly useful in clinical encounters.

CONCLUSIONS

The C + C curriculum appears to be as effective a method of teaching PE to preclinical students as the HTT approach and is better received by students. We believe that this approach more appropriately reflects the way PE is used in clinical encounters and may help students with diagnostic hypothesis generation.

Education Research: Qualitative Assessment of Virtual Teaching of the Neurological Examination to Students Reveals Importance of Technique, Process, and Documentation

Introduction

Virtual teaching sessions during the coronavirus disease 2019 pandemic were challenging for students and teachers but were also an opportunity to find creative ways to teach physical examination skills, including the neurologic examination. We examined expert opinions of the pros and cons that arise using a virtual platform to teach the neurologic examination and strategies to best address these challenges.

Methods

This was a qualitative study incorporating a focus group of faculty and resident neurologists. Data were coded using conventional content analysis. An interpretivist, social constructionist approach was used to look for interesting or novel ideas, rather than testing a specific hypothesis. Three independent auditors performed a dependability and confirmability audit to confirm that the themes accurately reflected the data.

Results

A single focus group was used. Four of the 6 participants were faculty neurologists and 2 were neurology residents. Five themes were identified: (1) learning the neurologic examination is complex, (2) lack of physical contact is the most important drawback of virtual teaching, (3) virtual teaching can effectively emphasize the organization of the examination, (4) virtual sessions can facilitate combined teaching of technique and demonstration of abnormalities, and (5) virtual platforms do not necessarily imply reduced participation.

Conclusion

Teaching the neurologic examination is a multifaceted process that should emphasize not only technique but also an overall approach to performing and documenting the examination. Many aspects of the neurologic examination can be appropriately taught virtually using various strategies, although there may always be some limitations. Virtual education can play a useful role for future curriculum design and global education.

A structured multimodal teaching approach enhancing musculoskeletal physical examination skills among undergraduate medical students

Current evidence indicates that undergraduate medical students display deficits in musculoskeletal physical examination skills (MPES). While various instructional methods are recommended for teaching clinical skills, effective methods for teaching MPES have not been established. This study compared the effectiveness of a multimodal teaching approach incorporating video-based learning, interactive small-group teaching, hands-on practicing, peer-assisted learning, formative assessment, and constructive feedback with traditional bedside teaching in developing undergraduate orthopedic MPES. Participants were 151 fifth-year medical students divided into two groups. One group received multimodal teaching, and the other received traditional bedside teaching. In both groups, the participants learned how to physically examine the knee and shoulder. The primary outcome was objective structured clinical examination (OSCE) scores, while the secondary outcomes included teaching sessions' total durations, facilitator's demonstration time, participants' practice time, and proportion of students with passing checklist scores and global ratings-based assessments for the two teaching approaches. The multimodal teaching group had significantly higher OSCE scores (checklist scores, global ratings, and passing rates; p = 0.02, 0.02, 0.01, respectively) than the comparison group. Individual OSCE component assessments showed significant improvements in the special musculoskeletal physical examination test. The overall duration and amount of participants' hands-on time were significantly longer for the multimodal than for the traditional bedside teaching group (p = 0.01 and 0.01, respectively), and the facilitator's demonstration time was significantly shorter (p = 0.01). The multimodal learner-centered teaching approach evaluated in this study was effective for teaching MPES. It appeared to maximize learner engagement through enhancing interactions and providing increased time to engage in hands-on practice. This teaching approach improved MPES levels, maximized teaching efficiency for scenarios with limited instruction time and resources, and enhanced competency of undergraduate medical students in performing special musculoskeletal physical examinations compared to traditional bedside teaching.

A clinical reasoning curriculum for medical students: an interim analysis

OBJECTIVES

Diagnostic error is a critical patient safety issue that can be addressed in part through teaching clinical reasoning. Medical schools with clinical reasoning curricula tend to emphasize general reasoning concepts (e.g., differential diagnosis generation). Few published curricula go beyond teaching the steps in the diagnostic process to address how students should structure their knowledge to optimize diagnostic performance in future clinical encounters or to discuss elements outside of individual cognition that are essential to diagnosis.

METHODS

In 2016, the University of California, San Francisco School of Medicine launched a clinical reasoning curriculum that simultaneously emphasizes reasoning concepts and intentional knowledge construction; the roles of patients, families, interprofessional colleagues; and communication in diagnosis. The curriculum features a longitudinal thread beginning in first year, with an immersive three week diagnostic reasoning (DR) course in the second year. Students evaluated the DR course. Additionally, we conducted an audit of the multiyear clinical reasoning curriculum using the Society to Improve Diagnosis in Medicine-Macy Foundation interprofessional diagnostic education competencies.

RESULTS

Students rated DR highly (range 4.13-4.18/5 between 2018 and 2020) and reported high self-efficacy with applying clinical reasoning concepts and communicating reasoning to supervisors. A course audit demonstrated a disproportionate emphasis on individual (cognitive) competencies with inadequate attention to systems and team factors in diagnosis.

CONCLUSIONS

Our clinical reasoning curriculum led to high student self-efficacy. However, we stressed cognitive aspects of reasoning with limited instruction on teams and systems. Diagnosis education should expand beyond the cognitive- and physician-centric focus of most published reasoning courses.

The Cardiovascular Physical Examination - Is It Still Relevant?

Advances in technology have reshaped the practice of medicine. These changes have greatly benefited our patients. However, in the setting of these advances, the importance of basic clinical tools is more pertinent than ever. Despite the growing reliance on technology, the physical exam remains valuable and cost effective, often enabling the well-trained clinician to arrive at the diagnosis, rapidly and accurately. The physical exam must not become a relic of a distant past. We aim to investigate current competency and proficiency, proposals for change in teaching curriculums, and the relationship with technology such as hand-held echocardiography. A skillful exam provides both emotional and intellectual satisfaction. It may be a lost art but it is well worth the effort to restore.

Implementation of a Hypothesis-Driven Physical Exam Session in a Transition to Clerkship Program

INTRODUCTION

The head-to-toe approach to teaching the physical examination (PE) focuses on technique and performing a comprehensive PE whereas core + clusters and hypothesis-driven PE (HDPE) approaches integrate clinical reasoning into performing a focused PE. These approaches can be implemented in a developmental sequence. We report the implementation and evaluation of an HDPE educational session.

METHODS

We designed a 3-hour HDPE session as part of a transition to clerkship program. For each of five clinical vignettes, rising third-year students worked in pairs and then in small groups to generate a differential diagnosis and determine relevant PE maneuvers. Students next performed these maneuvers on peers with facilitator observation and feedback. Students completed postsession surveys on their retrospective pre- and postsession knowledge and confidence, as well as their satisfaction with the session. We completed quantitative and qualitative analyses on survey data.

RESULTS

One hundred ninety-two students participated, and 140 (73%) completed the survey. Students were significantly more likely to report feeling confident generating a differential diagnosis and using it to select PE maneuvers for common complaints postsession. Over 80% of respondents felt the session improved critical thinking about patient presentations and would help them in clerkships.

DISCUSSION

Our session increased student confidence in the progression to performing an HDPE just prior to the start of clerkships. The session is feasible and straightforward to implement. It requires a large number of faculty to facilitate, but the breadth of cases used allows inclusion of faculty from all fields.

How do novices learn physical examination skills? A systematic review of the literature

BACKGROUND

Physical Examination (PE) skills are vital for patient care, and many medical students receive their first introduction to them in their pre-clinical years. A substantial amount of curriculum time is devoted to teaching these skills in most schools. Little is known about the best way to introduce PE skills to novice learners.

OBJECTIVE

Our objective was to conduct a systematic review of how medical students are first taught PE skills and the evidence supporting these strategies.

DESIGN

We searched ERIC, SCOPUS, MEDLINE, PubMed and EMBASE for descriptions of complete PE curricula for novice learners. Inclusion criteria were: (1) English language; (2) subjects were enrolled in medical school and were in the preclinical portion of their training; (3) description of a method to teach physical examination skills for the first time; (4) description of the study population; (5) Description of a complete PE curriculum. We used the Medical Education Research Study Quality Instrument (MERSQI) score to evaluate the quality of evidence provided.

RESULTS

Our search returned 5,418 articles; 32 articles met our inclusion criteria. Two main types of curricula were reported: comprehensive 'head-to-toe' PE curricula (18%) and organ system-based curricula (41%). No studies compared these directly, and only two evaluated trainees' clinical performance. The rest of the articles described interventions used across curricula (41%). Median MERSQI score was 10.1 Interquartile range 8.1-12.4. We found evidence for the use of non-faculty teaching associates, technology-enhanced PE education, and the addition of clinical exposure to formal PE teaching.

CONCLUSIONS

The current literature on teaching PE is focused on describing innovations to head-to-toe and organ system-based curricula rather than their relative effectiveness, and is further limited by its reliance on short-term outcomes. The optimal strategy for novice PE instruction remains unknown.

A novel longitudinal framework aimed at improving the teaching of the neurologic examination

Objective

To develop an educational framework basis for improving the teaching of the neurologic examination (NE) by asking German neurologists to (1) identify the basic elements of the screening NE and (2) nominate the steps they would deem mandatory for medical students to master.

Methods

We conducted a questionnaire-based survey among neurologists working in a hospital or ambulatory setting in southwest Germany. To define the screening NE, neurologists were asked to list the NE components they normally use in clinical encounters with patients in whom neurologic findings are unlikely. Furthermore, they were asked to identify additional elements of the NE which they would consider mandatory for students to master.

Results

Our neurologists nominated a set of 23 elements as being essential for a screening NE. There was high consensus among the 2 groups, and the results were concordant with international data. Furthermore, nearly 60 additional maneuvers of the NE were deemed obligatory for students to master.

Conclusion

Our results reinforce the international consensus for screening NE components and confirm a large set of additional examination steps that medical students should master, thereby indicating the need for an educational NE teaching concept. To solve this educational challenge, we propose a longitudinal curriculum that incorporates the “core + clusters” framework, thus combining the screening NE (core) with hypothesis-driven sets of maneuvers (clusters). Based on our data, we provide an initial proposal for the core and neurologic diagnostic clusters which is applicable to both novice and advanced learners across the continuum of training.

Physical examination competence as a predictor of diagnostic reasoning among new advanced practice nurse students: a cross-sectional study

Aim: To investigate levels of diagnostic reasoning among new APN students as well as students' characteristic affecting such reasoning levels.Design: a descriptive correlational design.Methods: One hundred fourteen APN students in an advanced health assessment course self-assessed their competene in performing examination. The students' self-reported Diagnostic Reasoning Assessment scores were used to categorize them into pre-novice, novice, advanced beginner, and competent levels. Ordinal logistic regression analysis was used.Results: Only physical examination competence significantly predicted the students' diagnostic reasoning levels. Being in a higher diagnostic reasoning level relative to being in a pre-novice, novice, or advanced beginner level was 16.1, 2.6, and 1.9 times greater in the physical examination competence, respectively.Conclusions: Promoting physical examination competence can be an effective teaching strategy for enhancing the diagnostic reasoning of newly enrolled APN students, especially for students who have poor diagnostic reasoning performance.

Advanced physical examination training course improves medical students' confidence in physical examination

BACKGROUND

Physical examination (PE) is a basic diagnostic tool in clinical settings. It is important to enhance medical students' skills and confidence in PE.

SUBJECTS AND METHODS

Our medical students begin learning PE in the fourth medical year (M4). They undergo hands-on clinical training in the fifth medical year (M5). To improve the teaching of PE, we implemented an advanced PE training course (APETC) for M5 students. In APETC, PE skills for chest (CH), cardiovascular system (CV), and abdomen (GI) domains were demonstrated by senior specialists. Under tutors' supervision, students performed PE on selected patients with positive signs. To evaluate the effect of this training course, we designed a checklist to evaluate students' confidence level in PE before and after APETC. Average confidence scores of PE in CH, CV, and GI domains among different years and genders were compared using ANOVA tests.

RESULTS

M5 students' confidence in PE for individual items on the CH, CV, and GI checklists increased significantly after the APETC, in both 2014 and 2015 (all p < 0.0001).The average post-course confidence scores of all items in CH, CV, and GI domains increased significantly over average pre-course confidence scores. The average post-course confidence score in PE was higher in the year 2015 than that in the year 2014. Male students tended to have higher confidence scores in PE than female students.

CONCLUSION

APETC enhanced medical students' confidence in PE. Long-term effects of the training course and the impact of students' gender on learning outcomes remain to be investigated.

Evaluation of simulation methods for teaching peripheral arterial examination to medical students

Physical examination is a critical component of medical practice yet the focus on efficient patient turnover has impacted the availability of patients with clinical findings willing to be examined by students and skills' teaching is not consistent across clinical rotations. This work evaluates simulation methodologies for teaching of the peripheral arterial examination and evaluates whether skills learnt are transferable to clinical practice.

Second-year medical students were taught peripheral arterial examination on a SimMan 3G or with simulated patients (SPs). Both groups were assessed by Objective Structured Clinical Examination (OSCE) with outpatients who have been diagnosed with peripheral arterial disease.

There was no difference in the pass rate at OSCE between the two groups. SimMan better facilitated repeated practice, group learning, peer teaching and discussion, which were highly valued by the students. Students felt that the SImMan tutorial did not facilitate development of spatial cognition or pattern recognition. They also felt less well prepared to deal with real patients in terms of having practised appropriate language, issuing instructions and attempting to reassure patients.

Both methods of simulation teaching have distinct merits and the ideal approach maybe to use the SimMan in combination with SPs.

Teaching Physical Examination to Medical Students on Inpatient Medicine Teams: A Prospective, Mixed-Methods Descriptive Study

Physical examination (PE) is a core clinical competency, and the internal medicine clerkship is a premiere venue for students to develop PE skills. However, clinical rotations often lack opportunities for real-time instruction. We sought to measure the frequency, content, and factors affecting PE instruction during the internal medicine clerkship. We conducted a prospective mixed-methods study at a single academic center. Data were gathered by a student researcher who directly observed inpatient teams over 3 months. We quantified the frequency of PE teaching activities and analyzed daily written observations using qualitative content analysis. PE was most frequently discussed during bedside rounds and least often during workroom rounds. Direct observation of students' examinations rarely occurred. Multiple factors in the learning environment were posited to affect PE instruction. In brief, we found that residents and attending physicians who are part of internal medicine teaching services do not routinely emphasize PE instruction.

Sustained impact of a short small group course with systematic feedback in addition to regular clinical clerkship activities on musculoskeletal examination skills--a controlled study

BACKGROUND

The discrepancy between the extensive impact of musculoskeletal complaints and the common deficiencies in musculoskeletal examination skills lead to increased emphasis on structured teaching and assessment. However, studies of single interventions are scarce and little is known about the time-dependent effect of assisted learning in addition to a standard curriculum. We therefore evaluated the immediate and long-term impact of a small group course on musculoskeletal examination skills.

METHODS

All 48 Year 4 medical students of a 6 year curriculum, attending their 8 week clerkship of internal medicine at one University department in Berne, participated in this controlled study. Twenty-seven students were assigned to the intervention of a 6×1 h practical course (4-7 students, interactive hands-on examination of real patients; systematic, detailed feedback to each student by teacher, peers and patients). Twenty-one students took part in the regular clerkship activities only and served as controls. In all students clinical skills (CS, 9 items) were assessed in an Objective Structured Clinical Examination (OSCE) station, including specific musculoskeletal examination skills (MSES, 7 items) and interpersonal skills (IPS, 2 items). Two raters assessed the skills on a 4-point Likert scale at the beginning (T0), the end (T1) and 4-12 months after (T2) the clerkship. Statistical analyses included Friedman test, Wilcoxon rank sum test and Mann-Whitney U test.

RESULTS

At T0 there were no significant differences between the intervention and control group. At T1 and T2 the control group showed no significant changes of CS, MSES and IPS compared to T0. In contrast, the intervention group significantly improved CS, MSES and IPS at T1 (p < 0.001). This enhancement was sustained for CS and MSES (p < 0.05), but not for IPS at T2.

CONCLUSIONS

Year 4 medical students were incapable of improving their musculoskeletal examination skills during regular clinical clerkship activities. However, an additional small group, interactive clinical skills course with feedback from various sources, improved these essential examination skills immediately after the teaching and several months later. We conclude that supplementary specific teaching activities are needed. Even a single, short-lasting targeted module can have a long lasting effect and is worth the additional effort.

Outcomes of a rotational dissection system in gross anatomy

At the University of Texas Houston Medical School, a rotational dissection system was introduced to improve coordination between the Gross Anatomy and the Introduction to Clinical Medicine (ICM) courses. Six students were assigned to each cadaver and divided into two teams. For each laboratory, one team was assigned to dissect and the other to attend ICM or study independently. For the next laboratory, the assignments were reversed. At the start of the session, the team that had dissected previously spent 30 minutes teaching the other team. In 2012, the students were given three traditional practical examinations with 50 questions drawn equally from each laboratory. Students also completed three mid-course evaluations. There were no significant differences in overall performance between the two teams. Nevertheless, we wanted to determine how well individual students identified structures they had dissected compared with those they had not. For dissected structures, the mean percent correct was 80.0 ± 13.0 (mean ± standard deviation), and for undissected structures, it was 78.3 ± 14.1. The difference was small, but statistically significant (P = 0.0007). Although this result validated the concerns expressed by some students, it did not appear that a change in the system was justified. Students were generally enthusiastic about the opportunity to learn clinical skills in the first semester of medical school, and 91-96% of the students agreed that learning anatomy at the same time helped them understand the physical examination exercises in ICM.

Influences of OSCE design on students' diagnostic reasoning

CONTEXT

Some characteristics of assessments exert a strong influence on how students study. Understanding these pre-assessment learning effects is of key importance to the designing of medical assessments that foster students' reasoning abilities. Perceptions of the task demands of an assessment significantly influence students' cognitive processes. However, why and how certain tasks positively 'drive' learning remain unknown. Medical tasks can be assessed as coherent meaningful whole tasks (e.g. examining a patient based on his complaint to find the diagnosis) or can be divided into simpler part tasks (e.g. demonstrating the physical examination of a pre-specified disease). Comparing the benefits of whole-task and part-task assessments in a randomised controlled experiment could guide the design of 'assessments for learning'.

OBJECTIVES

The purpose of this study was to determine whether the knowledge that an objective structured clinical examination (OSCE) will contain whole tasks, as opposed to part tasks, increases the use of diagnostic reasoning by medical students when they study for this assessment.

METHODS

In this randomised, controlled, mixed-methods experiment, 40 medical students were randomly paired and filmed while studying together for two imminent physical examination OSCE stations. Each 25-minute study period began with video cues and ended with a questionnaire on cognitive loads. Cues disclosed either a part-task OSCE station (examination of a healthy patient) or a whole-task OSCE station (hypothesis-driven physical examination [HDPE]). In a crossover design, sequences were randomised for both task and content (shoulder or spine). Two blinded and independent authors scored all 40 videos in distinct randomised orders, listening to participants studying freely. Mentioning a diagnosis in association with a sign was scored as a backward association, and the opposite was scored as a forward association; both revealed the use of diagnostic reasoning. Qualitative data were obtained through group interviews.

RESULTS

Studying for whole-task OSCE stations resulted in a greater use of diagnostic reasoning. Qualitative data triangulate these findings and show the precedence of cues sourced from the 'student grapevine'.

CONCLUSIONS

In comparison with 'traditional' part-task OSCEs, whole-task OSCEs like the HDPE increase students' use of diagnostic reasoning during study time.

[Assessment of clinical observation skills of last year medical students]

PURPOSE

Clinical examination skills are poorly evaluated by theoretical tests. We observed the clinical examination of real patients by 6th year medical students.

METHODS

Four internists involved in teaching activities defined 11 clinical examination items, with two objective performance criteria each. The students were evaluated in two internal medicine departments during the rotation preceding or following their national graduation test. Scores by item and by criterion and an overall score were calculated and correlated with their rank at the national graduation test.

RESULTS

Thirty-two students were evaluated in one department and 18 in the other; each evaluation lasted approximately 30 minutes. The results were similar in both departments. Only 2 items got a score over 75% in this students' sample (acute respiratory failure, peripheral pulses); 4 items were satisfied at less than 50% (lymph nodes, right heart failure, liver failure, and attention). The mean overall score was 6.5/11 (standard deviation 1.5). National rankings were good (median 1605/8001, interquartile 453-3036) but uncorrelated with the global score (Spearman coefficient -0.13; P=0.39).

CONCLUSION

Bedside evaluation of the students reveals substantial deficiencies, a few months or weeks before taking their position as residents. Several elementary skills are mastered by a minority of them (search for an asterixis, distended jugular veins, deep tendon reflexes), even among those successful at the national graduation test. Bedside evaluation of clinical examination skills should be more systematically performed.