Family physicians’ ability to detect a physical sign (hepatomegaly) from an unannounced standardized patient (incognito SP)

Abstract

Background: Little is known about the quality of the physical examination and its effectiveness in daily practice. Objective: To determine if family physicians (FPs) were able to detect an important physical sign (hepatomegaly) and to relate this result with other measures of quality. Methods: 57 of 104 invited FPs from the National Health Service of the Southern Barcelona Area agreed to schedule an unannounced Standardized Patient (SP) randomly into their daily practice. The SP presented with hepatomegaly and mild abdominal pain. After the visit clinical notes, medical orders, an audiotape of the visit and a checklist completed by the SP detailing items in the physical examination (PE) were analysed. The attainment of a number of quality standards was assessed. Results: The three major findings that resulted from this study were: (a) only 4 of the 57 FPs who examined the patient detected the hepatomegaly; (b) FPs performed better at history taking (84.24%) than at PE (26.35%); no correlation was found between the two; (c) diagnostic accuracy was associated with older age, years of experience, history taking skills and better performance at requesting diagnostic tests. Most FPs (88%) requested the appropriate tests. FPs who scored better on requesting diagnostic tests spent an average of four minutes more with the patient. None of the participants detected the SP.Conclusions: Clinical hepatomegaly is difficult to detect, even by well trained FPs. Senior doctors scored better on physical examination.