54. Assessing cardiac physical examination competence using simulation technology and real patientss

Abstract

Assessment of residents’ physical examination skills often involves the use of standardized patients lacking physical abnormalities. Simulation technology offers the potential benefit of mimicking physical abnormalities. The current study was undertaken to examine the relationship between physicians’ competence in cardiac physical examination as assessed using simulation technology compared to real patients. 
 An OSCE was created using 3 modalities of cardiac patients: real patients (RP) with cardiac abnormalities, standardized patients (SP) combined with a computer-based audio-video simulation of auscultatory abnormalities and a cardiopulmonary patient simulator (CPS). The same four cardiac diagnoses were tested with each modality.
 Participants were 28 internists, within 3 years of passing the Royal College of Physicians and Surgeons of Canada’s (RCPSC) Comprehensive Examination in Internal Medicine. At each station, two RCPSC examiners independently rated a participant’s physical examination technique and provided a global rating of clinical competence. The accuracy of a participant’s cardiac diagnosis for each patient was scored separately by two investigators.
 The inter-rater reliability between examiners, for the global rating outcome, was 0.76 for RP stations, 0.78 for SP stations and 0.75 for CPS stations. The correlations between participants’ global ratings on each modality were: RP vs. SP, r=0.19; RP vs. CPS, r=0.22; SP vs. CPS, r=0.57 (p < 0.01).
 A number of methodological limitations were highlighted during the study, including difficulties in truly matching patients within and between modalities, differential weighting of components into the examiners’ global ratings based on modality and limitations of case specificity. No modality provided a clear “gold standard” to assess residents’ cardiac physical examination competence. In the context of assessment, until these limitations are addressed, simulation modalities may not be directly interchangeable with real patients.
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