Performance of Cardiovascular Physical Exam Skills by Internal Medicine Residents

BACKGROUND

Few studies have assessed the ability of internal medicine residents to perform a cardiovascular physical examination using real patients.

METHODS

First year internal medicine interns from 2 large academic medical centers in Maryland examined the same patient with aortic insufficiency as part of the Assessment of Physical Examination and Communication Skills (APECS). Interns were assessed on 5 clinical domains: physical exam technique, identifying physical signs, generating a differential diagnosis, clinical judgment, and maintaining patient welfare. Spearman's correlation test was used to describe associations between clinical domains. Preceptor comments were examined to identify common errors in physical exam technique and identifying physical signs.

RESULTS

One hundred nine interns examined the same patient with aortic insufficiency across 14 APECS sessions. Only 58 interns (53.2%) correctly identified the presence of a diastolic murmur, and only 52 interns (47.7%) included aortic insufficiency on their differential diagnosis. There was a significant and positive correlation between physical exam technique and identification of the correct physical findings (r = 0.42, P < .001). Both technique (r = 0.34, P = .003) and identifying findings (r = 0.42, P < .001) were significantly associated with generating an appropriate differential diagnosis. Common errors in technique included auscultating over the gown, timing the cardiac cycle with the radial pulse, and failing to palpate for the apical impulse.

CONCLUSIONS

Internal medicine interns had variable skills in performing and interpreting the cardiovascular physical exam. Improving cardiovascular exam skills would likely lead to increased identification of relevant cardiovascular findings, inform clinical decision making and improve overall patient care.

Internal medicine intern performance on the gastrointestinal physical exam

OBJECTIVES

The gastrointestinal (GI) physical exam provides critical information about underlying disease states. However, since assessment of physical examination skills is rarely conducted as part of internal medicine residency training, little is known about resident performance on the GI physical exam.

METHODS

During a clinical skills assessment that took place between November 2019 and February 2020, internal medicine interns examined the same patient with chronic liver disease while being observed by faculty preceptors. We compared the exam maneuvers performed with those expected by the faculty evaluators. We noted which maneuvers were performed incorrectly, whether physical exam technique correlated with identification of physical exam findings, and if performance on the physical exam was associated with building an appropriate differential diagnosis. This four-hour assessment was required for internal medicine interns within two different residency programs in the Baltimore area.

RESULTS

More than half of the 29 participating interns (n=17, 58.6 %) received a "needs improvement" score on their physical exam technique. Technique was highly correlated with identifying the correct physical signs (r=0.88, p<0.0001). The most commonly excluded maneuvers were assessing for splenomegaly and hepatomegaly. The most commonly missed findings were splenomegaly and hepatomegaly. Most interns included chronic liver disease as part of their differential diagnosis even if they received "needs improvement" scores on physical exam technique or identifying physical signs.

CONCLUSIONS

Internal medicine interns would benefit from learning an organized approach to the gastrointestinal exam. This would likely lead to increased identification of important gastrointestinal findings.

Relationship of Physical Examination Technique to Associated Clinical Skills: Results from a Direct Observation Assessment

BACKGROUND

The purpose of this research was to use direct observation of the physical examination to elucidate the role physical examination technique plays in diagnostic accuracy. Physical examination is important for quality clinical care and requires multiple interrelated skills. The relationship of physical examination technique to related skills is poorly understood. Current methods of teaching and assessing physical examination skills provide few opportunities to evaluate physical examination technique and accuracy.

METHODS

The authors developed a clinical examination assessment using volunteer patients and direct observation. Trained faculty preceptors rated resident performance in 7 domains: 1) physical examination technique, 2) identification of physical signs, 3) clinical communication, 4) differential diagnosis, 5) clinical judgment, 6) managing patient concerns, and 7) maintaining patient welfare. The Pearson correlation coefficient was used to determine relationships between performance in each of these domains. Data on residents' self-assessed competency in the physical examination and perceptions of feedback received during the assessment were collected.

RESULTS

From December 2018 to February 2020, 113 interns from 2 internal medicine residency programs participated in the assessment. Physical examination technique was significantly correlated with accurate identification of physical signs, differential diagnosis and clinical judgment. Time spent in graduate medical education was negatively correlated with performance. Interns more highly rated the feedback received from this assessment than traditional clinical skills feedback.

CONCLUSIONS

Our findings emphasize the necessity of multi-dimensional physical examination assessment. Observed deterioration of physical examination skill during internship may reflect contemporary practice patterns, which deprioritize the physical examination. Future research on physical examination education should focus on the interface between physical examination technique and related clinical skills.

Strategies to Improve Bedside Clinical Skills Teaching

The bedside encounter between a patient and physician remains the cornerstone of the practice of medicine. However, physicians and trainees spend less time in direct contact with patients and families in the modern healthcare system. The current pandemic has further threatened time spent with patients. This lack of time has led to a decline in clinical skills, and a decrease in the number of faculty who are confident in teaching at the bedside. In this review we offer several strategies to get physicians and trainees back to the bedside to engage in clinical skills teaching and assessment. We recommend that providers pause before bedside encounters to be present with patients and learners and develop clear goals for a bedside teaching session. We suggest that clinical teachers practice an evidence-based approach, including a hypothesis-driven physical examination. We encourage the use of point-of-care technology to assist in diagnosis and allow learners to calibrate traditional physical exam skills with real-time visualization of pathology. Tools like point-of-care ultrasound can be powerful levers to get learners excited about bedside teaching, and to engage patients in their clinical care. We value telemedicine visits as unique opportunities to engage with patients in their home environment and to participate in patient-directed physical exam maneuvers. Finally, we recommend that educators provide feedback to learners on specific clinical exam skills, whether in the clinic, the wards, or during dedicated clinical skills assessments.