Overcoming the barriers of teaching physical examination at the bedside: more than just curriculum design

Entrustable professional activities for bedside clinical teachers

BACKGROUND

Bedside teaching is an important modality for training medical students and postgraduate trainees in clinical settings. Despite its significance, the effective practice of Bedside teaching has been declining over the past few decades. The literature highlighted the need for structured training, assessment, and certification or in other words entrustment of bedside teachers. The current study aims to develop and validate the Entrustable Professional Activities (EPAs) for bedside clinical teachers.

METHODS

A multi-method study with clinical teachers, medical educationists, and postgraduate medical students was conducted from July 2021-22. First, a nominal group using the jigsaw puzzle technique was conducted with 16 participants to identify EPAs. Then these EPAs were mapped and validated by the skills/competencies identified in the literature. Next, the EPAs were evaluated using the EQual rubric by 3 medical educationists. This was followed by two-rounds of modified Delphi to develop consensus among 90 participants in round-one and 69 in round-two. For qualitative data, a thematic analysis was conducted. For quantitative data, means and standard deviations were calculated.

RESULTS

The study identified five EPAs for bedside clinical teachers: developing bedside teaching program, planning bedside teaching session, conducting bedside teaching, conducting bedside assessments and evaluating bedside teaching.

CONCLUSIONS

This study comprehensively developed and validated a full description of EPAs for bedside clinical teachers. The EPAs identified in the study can serve as a guiding framework for bedside clinical teachers' training, assessment, and entrustment.

Structure and quality of bedside teaching: A videographic analysis

Bedside teaching (BST) is a core element of medical education. In light of a reported decrease in BST, evidence on how to use BST time most efficiently should be developed. Given that little research into the tangible quality characteristics of good BST has been reported, we investigated the influence of various teacher and structural characteristics on the perceived quality of BST. We filmed and coded 36 BSTs involving 24 lecturers and 259 students. Structural characteristics of interest were: number of students and patients, overall duration, and the proportion of clinical examination. Lecturer questionnaires provided insight into teaching experience and intrinsic motivation, and student evaluations assessed the quality of BSTs in three dimensions. Correlations are reported using the Pearson r and a linear mixed model (LMM). The intrinsic motivation of lecturers was significantly positively correlated with perceived quality, but their experience was only weakly so correlated. In the LMM, a significant association was observed for the quality dimension of clinical teaching with the number of patients and the proportion of time spent on clinical examination. Based on our findings, we recommend including multiple patients in BSTs, and providing substantial opportunities for clinical examination. Regarding lecturers, motivation matters more than experience.

Lost in translation: Unveiling medical students' untold errors of medical history documentation

OBJECTIVE

The accurate documentation of a medical history interview is an important goal in medical education. As students' documentation of medical history interviews is mostly decentralised on the wards, a systematic assessment of documentation quality is missing. We therefore evaluated the extent of details missed in students' medical history reports in a standardised setting.

METHODS

In this prospective, observational study, 123 of 380 students (32.4%) participated in an Objective Structured Clinical Examination (OSCE) regarding history taking and documentation. Based on the interviews and nine deductively selected main categories, a categorical system was established using a summarising qualitative content analysis. The items in the transcripts (defined as ground truth) and in students' reports were labelled and assigned to the correct subcategory. The ground truth and students' reports were compared to quantify students' documentation completeness.

RESULTS

Next to the nine deductively selected main categories, 61 subcategories were defined. A total of 8943 items were labelled in the 123 interview transcripts (ground truth), compared with 5870 items labelled in students' reports (65.6% completeness of students' reports compared with ground truth). The main category personal details overlapped with 94.2% between students' report and ground truth in contrast to the main category with the highest discrepancy, allergy, with 41.1% overlap. Pertinent negative items and non-numerical quantifications were often missed.

CONCLUSIONS

Medical students show incomplete documentation of medical history interviews. Therefore, accurate documentation should be taught as an important goal in medical education.

Patients' attitudes to bedside teaching after the COVID-19 pandemic

BACKGROUND

Bedside teaching (BST) is a method of structured clinical teaching where the patient is central in education. We had previously explored the patients' perceptions of BST using both a qualitative research study and validation of a questionnaire, both showing strong support by patients for BST once basic rules of respect and confidentiality are followed. With the COVID-19 pandemic, clinical education transitioned to online/virtual learning.

AIM

The aim of this study was to explore patients' attitudes towards reintroduction of BST as the pandemic restrictions have lifted.

METHODS

Patients were invited to complete a validated questionnaire exploring their attitudes towards BST. A descriptive analysis was performed. Results were compared to a previous study performed before the COVID-19 pandemic.

RESULTS

Four hundred patients consented to complete the questionnaires. Participants included women attending for antenatal (40%), postnatal (33%) and gynaecology issues (28%). Most patients (> 94%) reported that they were happy to be involved in BST. Patients believed that they should not be asked to participate in BST should they feel stressed or unwell (69%). These findings were the same as our previous study, performed prior to the pandemic.

CONCLUSION

This study shows extensive and persisting patient support for BST. BST is unique in that it allows students to gain a deeper understanding of the disease which are hard to elicit through online/virtual methods.

Practicing Peer Physical Examination by Medical and Allied Health Professions Students: Why the Hesitation and Where are We Now? A Narrative Literature Review

Objective

This narrative review aimed to examine the common existing factors that can influence medical students' attitudes and acceptability of peer physical examination, the presence of any variations of such attitudes over the time period included in the review, and provide measures to improve the acceptability of this practice, and directs attention to future research.

Methods

This study utilized a systematic and comprehensive search technique to find relevant publications based on pre-defined eligibility criteria. Electronic searches were conducted using two search engines, PubMed and Google Scholar, with an additional manual search on Medical Teacher Journal. In addition, a critical evaluation tool was applied to critically assess each article.

Results

Evidence indicated that gender is consistently reported as the most influential factor affecting the acceptance of peer physical examination among healthcare professionals, independent of the presence of other factors. Essentially, conservative cultures, religion, and particular ethnicities are still exerting their impacts on the participant's willingness to participate in this activity. In addition, the current study found no significant variations in accepting this practice by the students over the reviewed period of time.

Conclusion

According to the evidence provided by this review, a number of possible recommendations should be considered to boost and optimize the applicability of PPE. These include starting with non-sensitive areas, using single-gender pairing, and considering cultural and religious beliefs. Finally, there is a pressing need for future research, including multi-centric studies with larger and more diverse samples.

Cardiac Physical Exam Skills and Auscultation Session for Pediatric Interns

Introduction

Physicians need adequate physical exam skills. Unfortunately, interns have variable physical exam skills, and teaching is often limited to rounds, an inconsistent setting. Physical exam skills, particularly those involving auscultation, require practice. Our goal was to create a cardiac physical exam workshop for pediatric interns that would improve their performance on an interactive assessment of their ability and understanding in physical exam and murmur interpretation.

Methods

We completed a targeted needs assessment and then developed a 2-hour workshop on the pediatric cardiac physical exam targeted to pediatrics residents. The workshop included didactics, group discussion, and practice interpreting common pediatric murmurs. Pediatrics residents completed the assessment as a pretest and then participated in the workshop. At the end of the workshop, the assessment was administered as a posttest, followed by a reassessment 3 months later. Nonparametric statistical analysis was conducted. Pre- and posttest scores were compared using the Wilcoxon signed rank test.

Results

Twenty-five residents completed the workshop, including 22 pediatrics residents, one pediatrics/anesthesia combined resident, one pediatric neurology resident, and one resident completing a preliminary year in pediatrics prior to dermatology residency. There was a significant increase in the mean score on the assessment from pre- to posttest (pretest M = 54%, posttest M = 71%, p < .001). This increase was sustained at the 3-month reassessment (M = 67%).

Discussion

This cardiac physical exam workshop demonstrated improvement in physical exam knowledge and interpretation ability as measured by an online pre-/posttest.

Technology Complements Physical Examination and Facilitates Skills Development among Health Sciences Clerkship Students: An Integrative Literature Review

Background

Technology is increasingly present in the clinical environment. There is a dearth of investigation of the relationship between technology and touch concerning student learning of physical examination practices.

Method

Integrative review methods were used to synthesise empirical literature to provide a comprehensive understanding of the relationship between physical examination, learning and technology in the context of health professional student clerkships.

Results

Three databases including MEDLINE, CINAHL and Eric were searched for all articles published from 2014 to 2021 using terms relating to (i) physical examination, (ii) technology, and (iii) student clerkships. Thirty-three studies met the inclusion criteria. From the analysis, it is evident that technologies that intersect with learning of physical examination may broadly be apportioned into two categories: 1) technologies that mediate physical examination practices; and 2) technologies that mediate the learning of physical examination.

Conclusions

This review indicates that technologies may have multiple roles in the student learning of physical examination, including technology mediating increased diagnostic accuracy and access to supplementary learning material relating to physical examination that is integrated for the clinical clerkship environment. It highlights a need to further understand the touch versus technology relationship and explore the dynamic intersection.

Will clinical signs become myth? Developing structured Signs Circuits to improve medical students' exposure to and confidence examining clinical signs

BACKGROUND

Correctly eliciting and interpreting physical examination (PEx) signs contributes to successful diagnosis and is fundamental to patient care. A significant decline in the time spent acquiring these skills by medical students, and the decreased ability to elicit and recognise signs is widely acknowledged. However, organising teaching to counteract this in the busy clinical environment is challenging. We evaluated the prior exposure to clinical signs, and experience of examination teaching among a cohort of final-year medical students. Following this, we assessed the utility of a structured circuit-based approach (Signs Circuits) using hospital inpatients and junior doctors to provide high-yield PEx teaching and overcome these limitations.

MATERIALS AND METHODS

Qualitative and quantitative survey feedback, including a standardised list of 62 clinical signs, was sought from final-year medical students during their rotations at a teaching hospital in London, UK, before and after the provision of Signs Circuits.

RESULTS

Prior to the course the 63 students reported limited exposure to even the most common clinical signs. For example, the murmurs of mitral and tricuspid regurgitation and the sound of lung crackles eluded 43%, 87%, and 32%, respectively. From qualitative feedback, the reasons for this included that much of their prior PEx experience had focused on the performance of appropriate examination steps and techniques in patients without pathology. During the course, students were exposed to an average of 4.4 new signs, and left with increased confidence examining and eliciting signs, and a firmer belief in their importance to diagnosis.

CONCLUSION

Medical students continue to have limited exposure to clinical signs in medical school. This signs-focused approach to PEx teaching is an effective and reproducible way to counter the deficiencies identified in signsexposure.

How is modern bedside teaching structured? A video analysis of learning content, social and spatial structures

BACKGROUND

Bedside teaching (BST) is an essential and traditional clinical teaching format. It has been subject to various impediments and has transformed over time. Besides a decrease in bedside time, there has also been a didactic diversification. In order to use time at the bedside effectively and understand the current design of BST, we here offer an evidence-based insight into how BST is practiced. This may serve as a basis for a refinement of its didactic design.

METHODS

In the current study, we investigate the interrelationships between learning content and the social as well as spatial structures of BST. To this end, we have empirically analysed almost 80 hours of video material from a total of 36 BST sessions with good interrater reliability.

RESULTS

BST lasted on average 125 min, most of which was spent in plenary and less than a third of the time at the patient's bedside. History taking was primarily practiced at the bedside while case presentations, clinical reasoning and theoretical knowledge were largely taught away from the patient. Clinical examination took place to a similar extent in the patient's room and in the theory room.

CONCLUSIONS

Even though the filmed BSTs are not purely "bedside", the teaching format investigated here is a typical example of undergraduate medical education. In order to maximize the teaching time available, a suitable learning space should be provided in addition to the bedside. Moreover, the clinical examination should be revised in its general sequence prior to the BST, and conscious decisions should be made regarding the social structure so as to optimize the potential of small groups and plenary sessions.

Medical school curriculum in the digital age: perspectives of clinical educators and teachers

BACKGROUND

There is a need to reexamine Singapore's medical school curricula in light of the increasing digitalization of healthcare. Notwithstanding Singapore's digital competitiveness, there is a perceived gap in preparing its medical students for the digital age. Furthermore, limited research has evaluated the extent to which skills in using digital technologies should be taught to medical students in Asian medical schools to prepare them for future clinical practice- a gap that is filled by this study. Using Singapore as a case study, it explores the views of some local clinical educators and teachers towards the need to impart skills in digital technologies to medical students. It also offers recommendations on ways to balance the clinicians' concerns about these technologies with the digital competencies needed for clinical practice.

METHODS

Findings were drawn from individual interviews with 33 clinical educators and teachers from Singapore's public and private healthcare sectors. They were recruited using purposive sampling. Data were interpreted using qualitative thematic analysis.

RESULTS

Participants included vice deans of education from all three local medical schools and senior consultants from a wide variety of disciplines. Overall, they acknowledged two benefits of equipping students with skills in digital technologies including promoting the culture of innovation and improving work efficiency. However, they also highlighted four main concerns of imparting these skills: (i) erosion of basic clinical skills, (ii) neglect of a generalist approach to healthcare characterized by holistic management of patients, inter-professional collaboration, and commitment to breadth of practice within each specialty, (iii) rapid pace of technological advances, and (iv) de-personalisation by technology.

CONCLUSIONS

The findings show that medical students in Singapore would benefit from a curriculum that teaches them to use digital technologies alongside core clinical skills.

Teaching Evidence-Based Physical Diagnosis: A Workshop for Hospitalists

INTRODUCTION

Teaching on physical examination, especially evidence-based physical diagnosis, is at times lacking on general medicine rounds. We created a hospitalist faculty workshop on teaching evidence-based physical diagnosis.

METHODS

The workshop included a systematic approach to teaching evidence-based physical diagnosis, multiple teaching resources, and observed peer teaching. A long-term follow-up session was offered several months after the workshop. Participants completed questionnaires before and after the workshop as well as after the long-term follow-up session.

RESULTS

Four workshops were conducted and attended by 28 unique participants. Five hospitalists attended long-term follow-up sessions. Due to the COVID-19 pandemic, repeat sessions and long-term follow-up were limited. In paired analyses compared to preworkshop, respondents after the workshop reported a higher rate of prioritizing ( p = .008), having a systematic approach to ( p < .001), and confidence in ( p = .001) teaching evidence-based physical diagnosis. Compared to before the workshop, participants after the workshop were able to name more resources to inform teaching of evidence-based physical diagnosis ( p < .001). Informal feedback was positive. Respondents noted that the workshop could be improved by allowing more practice of the actual physical exam maneuvers and more observed teaching.

DISCUSSION

We created and implemented a workshop to train hospitalists in teaching evidence-based physical diagnosis. This workshop led to improvements in faculty attitudes and teaching skills. Long-term outcomes were limited by low participation due in part to the COVID-19 pandemic.

The COVID-19 pandemic as a catalyst for medical education innovation: A learner's perspective

The COVID‐19 pandemic has been transformative for healthcare and medical education. Physician trainees and the education system that serves them adapted quickly so that trainees could finish the academic year on time and advance to the next phase of training without compromising clinical competency or public safety. Systemic changes have had the most significant impact on telemedicine training, virtual learning, secure testing, and the interview process for residency and fellowship training positions. Trainees are now getting regular, supervised practice experience with telemedicine. Some secure testing is being done remotely, without jeopardizing examination test items or trainee assessment. Attending physicians are experimenting with novel ways to engage learners with video for virtual rounds to keep the rounding team safe. Finally, the interview process for medical school, residency, and fellowship programs, which has traditionally been an expensive and travel‐laden process, has been made completely virtual for the first time ever. These changes have disadvantages, including a lack of social connection, potential distraction when learning remotely, and limited contact with a potential training program when interviewing by video. This perspective paper, written by a senior internal medicine resident, details his firsthand experience with these changes during the pandemic. It also looks forward to how the current changes will likely change medical education permanently and for the better.

Outpatient Exam Room Presentations in Resident Continuity Clinics: a Qualitative Report

INTRODUCTION

Outpatient exam room presentations (OERPs) in resident continuity clinics could address several current challenges in graduate medical education including increasing patient satisfaction, enhancing patient-centered care, and operationalizing competency-based education through direct observation. The authors' aim of this study was to explore the positive and negative aspects of OERPs as a precepting model in resident continuity clinics and to develop a list of best practices for medical educators to utilize when conducting OERPs.

MATERIALS AND METHODS

The authors defined an OERP as a case presentation and subsequent discussion taking place inside the exam room with the attending physician, resident physician, and patient present. Following a 1-month pilot period of conducting OERPs in internal medicine resident continuity clinics, the authors conducted individual phone interviews and focus groups with internal medicine attendings and residents, respectively. The authors analyzed transcripts using thematic analysis and the constant comparative method. Sixteen attendings participated in individual phone interviews and four resident focus groups averaged five participants per group.

RESULTS

Four main topics emerged: (1) effect of OERPs on patient care, (2) effect of OERPs on medical education, (3) barriers to OERPs, and (4) OERP best practices.

CONCLUSION

Participants noted both positive and negative effects of OERPs on patient care and medical education. Best practices suggested to maximize these benefits and minimize drawbacks included targeting OERPs to certain types of clinical encounters and employing strategies to preserve the resident physician-patient relationship and resident autonomy.

An exploratory analysis of factors contributing to resident pass rates on a national licensure OSCE in the United Arab Emirates

Purpose

To explore resident perceptions of factors contributing to pass rates on a high-stake licensing objective structured clinical exam (OSCE).

Materials and Methods

A cross-sectional survey was administered to all 51 applicants of the April 2019 internal medicine Arab Board OSCE examination in Abu Dhabi, United Arab Emirates (UAE), and included questions on preparedness, stress level, and prior educational experiences. Exposures were evaluated for correlation against Arab Board pass rates using Pearson correlation and the two-tailed significance was recorded.

Results

All 51 examinees completed the survey (100% response rate). Participants were primarily female n = 35 (67%) and all completed residency training in the UAE. Gender differences were noted, with higher pass rates for the male residents (13/35, 37% females vs. 8/16, 50% males, P < 0.05). Further, 65% (P < 0.001) of female examinees reported higher levels of anxiety than male residents. Examinees reported regular exposure during residency to clinical skills training (74%), standardized patients (71%), simulation (66%), and OSCEs (72%) but none of these educational modalities correlated with higher pass rates. Of multiple exam preparation modalities, only self-directed learning with deliberate practice, the intentional repetition of a task with feedback, was associated with higher pass rates.

Conclusion

Clinical exam skills are vital for trainees to deliver high-quality primary healthcare services. National licensure OSCEs have become the norm in the Arab world for assessing resident clinical exam skills. Our results suggest that residency programs should encourage residents' intentional deliberate practice and mastery learning in the acquisition and retention of physical examination techniques.

The Modern Physical Exam - A Transatlantic Perspective from the Resident Level

Issue: The physical examination has been in decline for many years and poorer skills contribute to medical errors and adverse events. Diagnostic error is also increasing with the complexity of medicine. Comparing the physical examination in Ireland and the United States with a focus on education, assessment, culture, and health systems may provide insight into the decline of the physical exam in the United States, uncover possible strategies to improve clinical skills, and limit diagnostic error. Evidence: The physical exam is a core component of both undergraduate and postgraduate medical education in Ireland. This is reflected by the time and effort invested by medical schools and medical societies in Ireland in teaching and assessing skills. This high standard of skills results in the physical exam being a key component of the diagnostic process and a gatekeeper to expensive investigations essential in a resource-limited health system such as Ireland. Use of the physical exam in the United States is hindered by the high-tech transformation of healthcare and a more litigious society. Known strategies to highlight the role of the physical exam in clinical practice include creating an evidence base to show that better physical exam skills improve outcomes, identifying accurate physical exam maneuvers, stressing the therapeutic alliance the physical exam brings to the patient encounter, and the incorporation of technology into the bedside exam. Implications: Contrasting the education and clinical use of the physical examination in the United States with Ireland allowed us to identify a number of strategies which could be used to promote the physical exam among learners in both countries. Highlighting simple and pragmatic physical exam maneuvers combined with evidence-based physical exam diagnostic data may renew confidence in the physical exam as a core diagnostic tool. Use of the hypothesis-driven approach may streamline a clinician's physical exam during a patient encounter, focusing on the key examination components and avoiding unnecessary and low yield maneuvers. The absence of assessment of physical exam skills using real patients in United States licensing exams communicates to learners that these skills are not important. However, steps to introduce a culture of assessment to drive learning are being introduced. One area Ireland could learn from the United States is incorporating more technology into the bedside exam. Enhanced physical examination skills in both countries could reduce reliance on expensive investigations and improve diagnostic accuracy.

Clinical Teaching: An Evidence-based Guide to Best Practices from the Council of Emergency Medicine Residency Directors

Clinical teaching is the primary educational tool use to train learners from day one of medical school all the way to the completion of fellowship. However, concerns over time constraints and patient census have led to a decline in bedside teaching. This paper provides a critical review of the literature on clinical teaching with a focus on instructor teaching strategies, clinical teaching models, and suggestions for incorporating technology. Recommendations for instructor-related teaching factors include adequate preparation, awareness of effective teacher attributes, using evidence-based-knowledge dissemination strategies, ensuring good communication, and consideration of environmental factors. Proposed recommendations for potential teaching strategies include the Socratic method, the One-Minute Preceptor model, SNAPPS, ED STAT, teaching scripts, and bedside presentation rounds. Additionally, this article will suggest approaches to incorporating technology into clinical teaching, including just-in-time training, simulation, and telemedical teaching. This paper provides readers with strategies and techniques for improving clinical teaching effectiveness.

Reorganizing the History of Present Illness to Improve Verbal Case Presenting and Clinical Diagnostic Reasoning Skills of Medical Students: The All-Inclusive History of Present Illness

The Institute of Medicine states that most diagnostic errors are caused by flaws in clinician diagnostic thinking. Accurately inferring the correct diagnosis from the patient history is the best way to improve diagnostic accuracy and efficiency. Such an improvement is contingent upon training early phase medical learners how to organize data from a patient history to arrive at the most likely diagnosis of the patient's chief health concern (CC). We describe how organizing the traditional history of present illness into what our trainees have come to call the "All-Inclusive History of Present Illness" (AIHPI) by applying the Bayesian statistical concepts of chronologically sequencing, as suggested by Skeff, both relevant historical risks and known medical events generate a series of pre-event probabilities of the most likely disease causing a patient's CC. Our trainees have enthusiastically recognized that the AIHPI organization process helps them improve both their ability to deliver well-organized, succinct verbal case presentations and the efficiency of generating and communicating what they think is the most likely disease causing a patient's CC.

Effect of student-directed solicitation of evaluation forms on the timeliness of completion by preceptors in the United States

PURPOSE

Summative evaluation forms assessing a student's clinical performance are often completed at the end of a clinical experience from a faculty preceptor. In our institution, despite the use of an electronic system, completion timeliness has been suboptimal potentially limiting our ability to monitor student progress. The aim of the present study was to determine if a student-centered approach to summative evaluation form collection at the end of a pediatrics clinical experience will enhance timeliness of completion for third year medical students at Pennsylvania State College of Medicine.

METHODS

This was a pre- and post-intervention educational quality improvement project focused on 156 (82 pre-intervention, 74 post-intervention) third year medical students at Pennsylvania State College of Medicinecompleting their four-week pediatric clerkship. Utilizing Research Electronic Data Capture (REDCap) informatics support, student-directed evaluation form solicitation was encouraged. Wilcoxon rank sum test was applied to compare pre-intervention (May 1, 2017 to March 2, 2018) and post-intervention (April 2, 2018 to December 21, 2018) percentages of forms completed before rotation midpoint.

RESULTS

Seven hundred and forty evaluation forms were submitted during the pre-intervention phase and five-hundred and seventeen were submitted during the post-intervention phase. Form completion percentage before rotation midpoint increased after implementation of student-directed solicitation (9.6% versus 39.7%, P<0.05).

CONCLUSION

Our clerkship relies on subjective summative evaluations to track student progress, employ improvement strategies, and determine criteria for advancement; however, our preceptors struggled with timely submission. Allowing students to direct the solicitation of evaluation forms enhanced the timeliness of completion at our institution and should be considered in clerkships with similar difficulties.