Physical Diagnosis Course Research Articles

Student Self-Assessments and Peer Assessments of Video Recordings of Physical Examination Practicums in a Physical Diagnosis Course.

Self-assessments and peer assessments of video recordings of performance have been used in a variety of educational and professional training programs; however, there is no literature on the application of such performance assessments in physician assistant (PA) education. The purpose of this pilot study was to both explore the feasibility of adding video recordings of existing practicum examinations to a physical diagnosis course and evaluate students' self-assessments and peer assessments of the activity. Fifty first-semester students who were enrolled in a 7-semester PA program participated. Three 15-minute practicums were recorded on students' personal smartphones and uploaded to a private YouTube channel. Students completed self- and peer-review questionnaires after each practicum, as well as a separate reflective questionnaire at the end of the course to garner their feedback of the video-recorded practicums on their physical examination (PE) performance. Students assessed their peers' performances more favorably than their own. Students reported increased awareness of their own verbal and nonverbal communication strengths and weaknesses with the use of video-recorded practicums, as well as increased motivation to practice. The majority of students found these sessions to have improved their performance and decreased their anxiety with performing a complete PE at the end of the course. The use of periodic video recordings of PE practicums with both self-assessments and peer assessments increased the students' level of practice of these important skills, enhanced students' awareness of nontechnical aspects of patient examination, was well received by the majority of students, and may be implemented with minimal expense.

Longitudinal Ultrasound Curriculum Incorporation at West Virginia University School of Medicine: A Description and Graduating Students' Perceptions.

Sonography is a clinical tool being incorporated in multiple medical specialties with evidence of improved patient care and cost. Some schools have begun implementing ultrasound curricula. We hope to build upon that foundation and provide another potential framework of incorporation. There are several barriers, including curricular space, equipment and physical space, adequate faculty, and performing assessment. At West Virginia University, we began a longitudinal ultrasound curriculum in 2012 with incorporation of didactic and practical sessions into gross anatomy, our systems-based second-year curriculum, physical diagnosis course, and clinical rotations. We included both written and practical assessment from the onset. After the initial 4 years, the first graduates were surveyed on their perceptions of the curriculum. Responses were correlated with specialty choice and clinical campus site. Based on our survey (90% response rate), students felt sonography was useful for anatomical understanding and patient care. Overall, 93% of our respondents reviewed the curriculum favorably. Qualitative feedback was very positive, with students desiring more ultrasound education and more required components, specifically in clinical rotations. Based on these results, some changes have already been implemented, including decreased student-to-instructor ratios, more open scan time, and more required components. The breadth of formal assessment has increased. Multiple pilot programs for clinical rotations are being developed. There is an ongoing need for faculty development and continued assessment of ultrasound competency.

Pilot Point-of-Care Ultrasound Curriculum at Harvard Medical School: Early Experience.

IntroductionPoint-of-care ultrasound (POCUS) is expanding across all medical specialties. As the benefits of US technology are becoming apparent, efforts to integrate US into pre-clinical medical education are growing. Our objective was to describe our process of integrating POCUS as an educational tool into the medical school curriculum and how such efforts are perceived by students.MethodsThis was a pilot study to introduce ultrasonography into the Harvard Medical School curriculum to first- and second-year medical students. Didactic and hands-on sessions were introduced to first-year students during gross anatomy and to second-year students in the physical exam course. Student-perceived attitudes, understanding, and knowledge of US, and its applications to learning the physical exam, were measured by a post-assessment survey.ResultsAll first-year anatomy students (n=176) participated in small group hands-on US sessions. In the second-year physical diagnosis course, 38 students participated in four sessions. All students (91%) agreed or strongly agreed that additional US teaching should be incorporated throughout the four-year medical school curriculum.ConclusionPOCUS can effectively be integrated into the existing medical school curriculum by using didactic and small group hands-on sessions. Medical students perceived US training as valuable in understanding human anatomy and in learning physical exam skills. This innovative program demonstrates US as an additional learning modality. Future goals include expanding on this work to incorporate US education into all four years of medical school.

Interdisciplinary Workshop to Increase Collaboration Between Medical Students and Standardized Patient Instructors in Teaching Physical Diagnosis to Novices.

Traditionally, full-time faculty members have assumed major responsibility for teaching physical examination skills to first- and second-year medical students. Problems with faculty recruitment and adhering to a standardized way of teaching have challenged educators to seek alternatives to teaching the physical examination to novices. To address these problems, we created and implemented a novel curriculum that has standardized the teaching of physical examination skills to novice students by using standardized patient instructors (SPIs) and fourth-year medical students (MS-4s) working as an interdisciplinary team (known as a dyad). This dyad training workshop occurs early in the school year, before first-year medical students begin their physical diagnosis course. Prior to the workshop, SPIs and MS-4s receive prereading on which they are quizzed both individually and as a preassigned dyad, during the session. The workshop requires a total of 100 minutes and includes several discussions on formative learning theory, roles, and teamwork. In 2013, 16 SPIs (100%) and 44 MS-4s (77%) completed a 4-question questionnaire. The majority (> 80%) of respondents selected agree or strongly agree for all four questions. While initial feedback from SPIs and MS-4s was enthusiastically positive, evidence showed the dyad could be strengthened by (1) providing time to learn the theoretical scaffolding underlying working together, (2) meeting and planning approaches to teaching efforts, and (3) enabling medical students and standardized patient instructors to apply the theoretical constructs as the foundation to reflect on their teaching roles in effectively instructing novices in physical exam skills.

Is there an agreement among the items of the Korean physical therapist licensing examination, learning objectives of class subjects, and physical therapists' job descriptions?

Purpose:To determine the agreement among the items of the Korean physical therapist licensing examination, learning objectives of class subjects, and physical therapists’ job descriptions.Methods:The main tasks of physical therapists were classified, and university courses related to the main tasks were also classified. Frequency analysis was used to determine the proportions of credits for the classified courses out of the total credits of major subjects, exam items related to the classified courses out of the total number of exam items, and universities that offer courses related to the Korean physical therapist licensing examination among the surveyed universities.Results:The proportions of credits for clinical decision making and physical therapy diagnosis-related courses out of the total number credits for major subjects at universities were relatively low (2.06% and 2.58%, respectively). Although the main tasks of physical therapists are related to diagnosis and evaluation, the proportion of physiotherapy intervention-related items (35%) was higher than that of examination and evaluation-related items (25%) on the Korean physical therapist licensing examination. The percentages of universities that offer physical therapy diagnosis and clinical decision making-related courses were 58.62% and 68.97%, respectively.Conclusion:Both the proportion of physiotherapy diagnosis and evaluation-related items on the Korean physical therapist licensing examination, and the number of subjects related to clinical decision making and physical therapy diagnosis in the physical therapy curriculum, should be increased to ensure that the examination items and physical therapy curriculum reflect the practical tasks of physical therapists.

Integration of Point-of-Care Ultrasound Training into Undergraduate Medical Curricula--A Perspective from Medical Students.

The utility of point of care ultrasound training during medical school is becoming more and more evident. At the Loma Linda University School of Medicine, we have formally integrated ultrasound education into the curriculum of all four years. Exposure begins in the first few months of Year 1 and takes form in a variety of educational mediums through Year 4. Whether students receive training through mandatory sessions during physical diagnosis courses or extracurricular workshops provided through the Ultrasound Interest Group–-the experience equips learners of at all different skill levels with the confidence to apply what they have learned to patient care. The successful integration of ultrasound training into the medical curriculum can be attributed to progressive administration, devoted faculty and eager students. The perspective of medical students during the integration process is described in this paper.

Near-peer role modeling: Can fourth-year medical students, recognized for their humanism, enhance reflection among second-year students in a physical diagnosis course?

IntroductionHumanism is cultivated through reflection and self-awareness. We aimed to employ fourth-year medical students, recognized for their humanism, to facilitate reflective sessions for second-year medical students with the intention of positively influencing reflective process toward humanistic development.Methods/AnalysisA total of 186 students were randomly assigned to one of three comparison arms: eight groups of eight students (64 students) were facilitated by a fourth-year student who was a Gold Humanism Honor Society member (GHHS); eight groups (64 students) by a volunteer non-GHHS student; and seven groups (58 students) were non-facilitated. Before sessions, second-year students set learning goals concerning interactions with patients; fourth-year students received training materials on facilitation. Groups met twice during their 10 clinical site visits. At the last session, students completed a reflective assignment on their goal progress. Comparative mixed method analyses were conducted among the three comparison arms on reflection (reflective score on in-session assignment) and session satisfaction (survey) in addition to a thematic analysis of responses on the in-session assignment.ResultsWe found significant differences among all three comparison arms on students’ reflective scores (p=0.0003) and satisfaction (p=0.0001). T-tests comparing GHHS- and non-GHHS-facilitated groups showed significantly higher mean reflective scores for GHHS-facilitated groups (p=0.033); there were no differences on session satisfaction. Thematic analysis of students’ reflections showed attempts at self-examination, but lacked depth in addressing emotions. There was a common focus on achieving comfort and confidence in clinical skills performance.Discussion/ConclusionsNear peers, recognized for their humanism, demonstrated significant influence in deepening medical students’ reflections surrounding patient interactions or humanistic development. Overall, students preferred facilitated to non-facilitated peer feedback forums. This model holds promise for enhancing self-reflection in medical education, but needs further exploration to determine behavioral effects.

Physical Diagnosis and Clinical Integration Module for Nurturing Medical Students during their Pre-clerkship Education

Abstract Objective: The purpose of this study was to gain insight into the perceptions of medical students for physical diagnosis and clinical integration (PDCI) courses during their preclerkship education. Methods: The study was conducted at Oman Medical College, Sohar with senior medical students in clinical clerkships, who had taken PDCI courses as part of their preclerkship education. A total of 35 senior students consented to participate in the questionnaire-based study. The questionnaire was a pre-tested, self-administered tool with a 5-point Likert scale. The data were collected, tabulated, and statistically analyzed. Results: The clerkship students had consistently positive perceptions about the value and utility of the preclerkship PDCI courses. Conclusion: The PDCI course curriculum appears to be an effective method for enhancing student performance in the clinical clerkships.

Effects of ultrasound implementation on physical examination learning and teaching during the first year of medical education.

Increasing emphasis has been placed on point-of-care ultrasound in medical school. The overall effects of ultrasound curriculum implementation on the traditional physical examination skills of medical students are still unknown. We studied the effects on the Objective Standardized Clinical Examination (OSCE) scores of year 1 medical students before and after ultrasound curriculum implementation. An ultrasound curriculum was incorporated into the physical diagnosis course for year 1 medical students in the 2012-2013 academic year. We performed a prospective observational study comparing traditional OSCE scores of year 1 medical students exposed to the ultrasound curriculum (post-ultrasound) versus historic year 1 medical student controls (pre-ultrasound) with no ultrasound exposure. Questionnaire data were also obtained from year 1 medical students and physical diagnosis faculty to assess attitudes toward ultrasound implementation. The final overall OSCE scores were graded with a 5-point Likert-type scale from unsatisfactory to outstanding. There was a significant increase in outstanding scores in the post-ultrasound compared to the pre-ultrasound group (27.0% versus 10.9%; P< .001). The post-ultrasound group had significantly (P< .05) increased first-time pass rates on blood pressure measurements, the abdominal examination, and professionalism. Student and physical diagnosis faculty questionnaire data showed an overall positive response, with most agreeing or strongly agreeing that ultrasound should be included in the future year 1 medical student curriculum. Ultrasound implementation into a physical diagnosis curriculum for year 1 medical students is feasible and may improve their overall traditional physical examination skills.

Curricular factors associated with medical students' practice of the skin cancer examination: an educational enhancement initiative by the integrated skin exam consortium.

As medical school curricula become progressively integrated, a need exists to optimize education related to the skin cancer examination (SCE) for melanoma, a relevant competency gap that influences secondary prevention efforts. To identify curricular factors associated with medical students' confidence, intent, and performance regarding the SCE. Survey-based cross-sectional study from the Integrated Skin Exam Consortium at accredited US medical schools among a volunteer sample of second-year students representing 8 geographically varied public and private institutions. Students were administered a questionnaire to assess characteristics, curricular exposures, and educational and practical experiences related to skin cancer, as well as knowledge of melanoma risk and a detection method. Primary outcomes were confidence in performing the SCE, intent to perform an integrated skin examination, and actual performance of the SCE. Physical diagnosis session and clinical encounter were most predictive of confidence in performance of the SCE (odds ratios [ORs], 15.35 and 11.48, respectively). Other curricular factors associated with confidence included instruction time of at least 60 minutes on skin cancer (OR, 6.35), lecture on the SCE (OR, 7.54), knowledge of melanoma risk (OR, 3.71), and at least 1 opportunity to observe the SCE (OR, 2.70). Physical diagnosis session and at least 4 opportunities to observe the SCE were most predictive of intent to perform an integrated skin examination (ORs, 4.84 and 4.72, respectively). Other curricular factors associated with intent included knowledge of melanoma risk (OR, 1.83), clinical encounter (OR, 2.39), and at least 1 opportunity to observe the SCE (OR, 1.95). Clinical encounter, physical diagnosis session, and at least 1 opportunity to observe the SCE were most predictive of performance of the SCE (ORs, 21.67, 15.48, and 9.92, respectively). Other curricular factors associated with performance included instruction time of at least 60 minutes on skin cancer (OR, 2.42) and lecture on the SCE (OR, 5.04). To augment the practice of the SCE among medical students, course directors may design an integrated curriculum that includes at least 60 minutes of instruction related to melanoma and the SCE, a description of the integrated skin examination as part of the physical diagnosis course, and education on high-risk demographic groups and anatomic sites specific to men and women and on the ABCDEs of melanoma, and at least 1 opportunity to observe the SCE.

Evaluation of an Advanced Physical Diagnosis Course Using Consumer Preferences Methods: The Nominal Group Technique

BackgroundCurrent evaluation tools of medical school courses are limited by the scope of questions asked and may not fully engage the student to think on areas to improve. The authors sought to explore whether a technique to study consumer preferences would elicit specific and prioritized information for course evaluation from medical students. MethodsUsing the nominal group technique (4 sessions), 12 senior medical students prioritized and weighed expectations and topics learned in a 100-hour advanced physical diagnosis course (4-week course; February 2012). Students weighted their top 3 responses (top=3, middle=2 and bottom=1). ResultsBefore the course, 12 students identified 23 topics they expected to learn; the top 3 were review sensitivity/specificity and high-yield techniques (percentage of total weight, 18.5%), improving diagnosis (13.8%) and reinforce usual and less well-known techniques (13.8%). After the course, students generated 22 topics learned; the top 3 were practice and reinforce advanced maneuvers (25.4%), gaining confidence (22.5%) and learn the evidence (16.9%). The authors observed no differences in the priority of responses before and after the course (P=0.07). ConclusionsIn a physical diagnosis course, medical students elicited specific and prioritized information using the nominal group technique. The course met student expectations regarding education of the evidence-based physical examination, building skills and confidence on the proper techniques and maneuvers and experiential learning. The novel use for curriculum evaluation may be used to evaluate other courses—especially comprehensive and multicomponent courses.

A Core Physical Exam for Medical Students

Medical students are traditionally taught the physical exam as a comprehensive battery of maneuvers, yet they express uncertainty about which maneuvers are "core" and should be performed routinely on patients and which ones should be performed only when clinically indicated. The authors sought to determine whether educator consensus existed on the concept and the specifics of a core physical exam for students. The authors developed a 45-maneuver core physical exam to be performed by a medicine clerkship student on every newly admitted patient, with the expectation that it would be supplemented by clinically indicated additional maneuvers. From 2011 to 2012 they sent surveys to physical diagnosis course directors (PDCDs) and internal medicine clerkship directors (IMCDs) from all 132 U.S. allopathic medical schools to determine the extent of their agreement with the proposed 45 maneuvers and their opinions about the concept of a core exam. Seventy-one percent (94/132) of PDCDs and 63% (83/132) of IMCDs responded to the survey. In total, 84% (111/132) of all schools surveyed were represented by either their PDCD or IMCD. Of the 45 proposed maneuvers, 37 were deemed "core" by a majority of respondents. The majority of IMCDs preferred a slightly leaner 37-maneuver core exam than the majority of PDCDs, who voted for 41 maneuvers. Among PDCDs and IMCDs, there was openness to teaching medical students a streamlined core physical exam to which other maneuvers are added as clinically indicated. These educators closely agreed on the maneuvers this core exam should include.

Improving Communication With Patients

“Learning by doing” has been the mantra of clinical education since the days of Osler. Simulation (for example, in laparoscopy or in enhancing communication skills) is a relatively recent teaching innovation. It allows for a controlled setting andminimizationof patient risk anddiscomfort. Thehope for any formof simulation is that itwill be an effective pedagogic tool, avaluableadjunct toexperiencewithrealpatients.1Teaching physicians the skills to communicatewellwith patients at the end of life is a worthy goal, because it is profoundly beneficial to patients when done correctly.2,3 In this issueof JAMA, Curtis andcolleagues4describe their use of a 4-day simulation-based workshop using standardizedpatients to improve the end-of-life communication skills of 178 internal medicine trainees and 33 nurse practitioner or registered nurse trainees, compared with a control group of 198 internal medicine traineesand36nursepractitioneror registerednurse trainees. In an attempt to answer the question ofwhether this previously validated workshop method5 makes a difference to patients and others in the real world, the authors included a 10-month follow-up period during which participants were evaluated by actual patients and families as well as by supervising faculty; the goal was to determine how well participantsperformed in thedomainsof communicationand inproviding end-of-life care. Even though the workshop was associated with improved skills among theparticipants (as evaluatedby the standardized patients), the authors were unable to show that it helped in subsequent interactionswith real patients.After adjustment, comparing the interventionwith control, therewas nosignificantdifference in thequalityof communicationscore forpatients (difference,0.4points [95%CI,−0.1 to0.9];P = .15) or families (difference, 0.1 [95% CI, −0.8 to 1.0]; P = .81) and no difference in quality of end-of-life care score for patients (difference, 0.3 [95% CI, −0.3 to 0.8]; P = .34) or families (difference, 0.1 [95%CI, −0.7 to 0.8]; P = .88). Indeed, patients of the trainees in the intervention group were actually found to have significantly increased depression scores. There are many possible reasons for the unexpected results. Patients and families are not formally trained to evaluate communicationskills.Additionally, theacquisitionof skills was tested over the course of a 10-month period following workshop participation and not immediately following specific end-of-life discussions. It is possible that the improvement inparticipants’ skillswasnot enough tomake ameasurable difference to patients; conversely, it is possible that trainees did not recall training and so were not able to apply the communication skills. The finding of increased depression scores in patients of trainees in the intervention group is intriguing. The phenomenon was more common with the patients of interns than with patients of more senior trainees. Perhaps in the world of a busy intern, with many tasks competing for time and attention, and with work-hour restrictions, it is a challenge to reproduce what was learned in the setting of a controlled workshop. Accordingly, one conclusion from the study might be that end-of-life conversations should be left to more senior physicians. Ericsson’s idea of deliberate practice,6 in which motivated trainees emphasize specific learning objectives, receive timely and relevant feedback, self-reflect, andengage in focused repetition, can be applied well in a simulated controlled environment.7 But even with the best learning methods, simulation has inherent limitations: for example, hightech mannequins with audio recordings are not a perfect substitute for real patients when teaching cardiac examination skills.8 The study by Curtis et al4 raises the question of whether standardized patients can convincingly display and express feelings they are not really feeling. Can trainees in simulation experience empathy, knowing they are hearing a standardized patient script? If the trainee learns to speak and act in a manner that represents empathy, is that the same as beingtrulyempathetic?9Nonverbal communication (bodyposture, facial expression, and gestures) can be intentional, but it is just as often nonintentional and registered by others at a conscious or subconscious level. For the trainee to “act” the partmight not only be insufficient, itmight seem insincere to a real patient.10 Ultimately, there isprobablynoperfect substitute for trainees’ engaging in the deliberate practice of reevaluating themselves, raising the bar to learn more advanced skill sets, and receiving constant feedback from patients and supervisors. This may require both simulation and longitudinal experiences with real patients, for whom the complexity, nuances, and unique challenges of communication are preserved. The study by Curtis et al4 should make educators reflect onhowwell traineesaredoingwith theskills imparted to them. For example, everymedical school teaches some version of a physical diagnosis course in the first and second years. There usually is a substantial investment in standardized patients, not to mention faculty, space, and money. An end-of-course test affirms the acquisitionof knowledge, if not skill. Butwhat does it all mean in the real world of patient care? Patients and Related article page 2271 Opinion

Just enough, but not too much interactivity leads to better clinical skills performance after a computer assisted learning module

Background: Well-designed computer-assisted instruction (CAI) can potentially transform medical education. Yet little is known about whether specific design features such as direct manipulation of the content yield meaningful gains in clinical learning. We designed three versions of a multimedia module on the abdominal exam incorporating different types of interactivity.Methods: As part of their physical diagnosis course, 162 second-year medical students were randomly assigned (1:1:1) to Watch, Click or Drag versions of the abdominal exam module. First, students’ prior knowledge, spatial ability, and prior experience with abdominal exams were assessed. After using the module, students took a posttest; demonstrated the abdominal exam on a standardized patient; and wrote structured notes of their findings.Results: Data from143 students were analyzed. Baseline measures showed no differences among groups regarding prior knowledge, experience, or spatial ability. Overall there was no difference in knowledge across groups. However, physical exam scores were significantly higher for students in the Click group.Conclusions: A mid-range level of behavioral interactivity was associated with small to moderate improvements in performance of clinical skills. These improvements were likely mediated by enhanced engagement with the material, within the bounds of learners’ cognitive capacity. These findings have implications for the design of CAI materials to teach procedural skills.

In Memoriam Tribute to James A. Shaver, MD

Dr James A. Shaver, our friend and colleague, died of pneumonia on April 13, 2012, after a long history of chronic renal disease. At the time of his death, he was professor of medicine and the former chief of the division of cardiology at the University of Pittsburgh School of Medicine. Born in Ridgway, Pennsylvania, he was elected to Phi Beta Kappa at the University of Pennsylvania and to Alpha Omega Alpha at the Hahnemann Medical College, from which he graduated in 1959. Dr Shaver trained in internal medicine at the University of Pennsylvania and the University of Pittsburgh, where he also completed his cardiology fellowship. He joined the Pitt faculty in 1965 and rose through the ranks to become a full professor in 1977. He was director of the cardiac diagnostic laboratories and then became director of the division from 1971 to 1994. Dr Shaver also served as director of the Cardiovascular Fellowship Program from 1971 to 2006, training more than 325 fellows, many of whom went on to assume leadership positions of their own. Since he left the division directorship, he led the medical school second-year course in physical diagnosis and continued to play an active role as a consulting cardiologist and a charismatic teacher at all levels of medical education. Dr …

A-PEX: A Case-Based Integrated Physical Diagnosis/Anatomy Program for First Year Medical Students

To better prepare first year students to apply physical examination in clinical clerkships we created A-PEX, a case-based program integrated into both their physical diagnosis and anatomy courses. In these two different but mutually reinforcing contexts students applied physical examination to differential diagnosis and simulated procedures to solve clinical problems.

Columbia University College of Physicians and Surgeons

Columbia University College of Physicians and Surgeons

University of Utah School of Medicine

University of Utah School of Medicine

University of Missouri School of Medicine in Columbia

University of Missouri School of Medicine in Columbia

Adding New Tools to the Black Bag—Introduction of Ultrasound into the Physical Diagnosis Course

Ultrasound, a versatile diagnostic modality that permits real-time visualization at the patient's bedside, can be used as an adjunct in teaching physical diagnosis (PD). (1) to study the feasibility of incorporating ultrasound into PD courses and (2) determine whether learners can demonstrate image recognition and acquisition skills. Three hundred seven second-year medical students were introduced to cardiovascular and abdominal ultrasound scanning after training in the physical examination. This consisted of a demonstration of the ultrasound examination, followed by practice on standardized patients (SPs). Pre-post tests were administered to evaluate students' knowledge and understanding of ultrasound. Students performed an ultrasound examination during the PD final examination. Pre-post test data revealed significant improvements in image recognition. On the final exam, the highest scores (98.4%) were obtained for the internal jugular vein and lowest scores (74.6%) on the Focused Assessment with Sonography for Trauma images. Eighty-nine percent of students' surveyed felt ultrasound was a valuable tool for physicians. An introductory ultrasound course is effective in improving medical students' acquisition and recognition of basic cardiovascular and abdominal ultrasound images. This innovative program demonstrates the feasibility of incorporating portable ultrasound as a learning tool during medical school.