Physical Diagnosis Course Research Articles

The Physical Exam and Other Forms of Fiction

The traditional physical diagnosis course taught in the first two years of medical school has changed little in over half a century, and it deserves some scrutiny, if only because it is quite out of step with what students see when they begin on the wards during their clinical years. They are surprised to find that the house staff and attending staff carry very few of the instruments the student has acquired: reflex hammers are occasionally spotted, but ophthalmoscopes are quite rare. Even more vexing for the student is the realization that the currency on the ward, the “clinical skill” they were so anxious to acquire, does not involve the patient as much as it involves finesse and efficiency on the computer in ordering tests, in discharging patients and in completing notes-throughput. Indeed, one could make the case that it is time to dispense with the physical exam course altogether because the physical exam is being dispensed with altogether. It would appear that the two-dimensional rendering of the patient through imaging occupies us more than the three dimensional reality of the patient.

Use of Radiologic Imaging to Enhance Physical Diagnosis Instruction in the Preclinical Curriculum

To expose students in the premedical years to imaging and its indications, to enhance their understanding of pathologic processes by allowing direct visualization, and to teach physical diagnosis through an integrated, multispecialty approach. A total of 166 second-year medical students participated in a novel imaging session that accompanied the physical diagnosis course they were concurrently enrolled in. Students were provided a didactic orientation to imaging and taught how to use Picture Archiving and Communications System software. The students then participated in interactive imaging sessions in which they were able to scroll through entire imaging cases of real, anonymized patients with accompanying clinical scenarios and physical examination findings. Of 89 students responding to an online curricular feedback questionnaire, 41% believed that the imaging correlated with the other information taught in the course and 46% found it was helpful to their learning. The majority of students (64%) believed that the sessions helped challenge them to think about physical diagnosis in a different way. Physical diagnosis on the wards requires a multispecialty approach and the early introduction of this technique through the integrated mode of teaching we present will benefit students in their clinical years and future careers.

The Current Status of Medical Student Urological Education in the United States

The current status of urological education in medical schools in the United States was investigated. A questionnaire regarding medical student teaching was sent to the program directors of the 118 urological residency programs in the United States. Of the 118 individuals 95 (81%) completed and returned the questionnaire. Three urology programs were not affiliated with medical schools and had no contact with medical students. In 29 programs (32%) there were no urology faculty lectures in the preclinical years. At 46 schools (50%) there was no urology lecture in the physical diagnosis course. Compared to a decade ago program directors believed that exposure to urology was about the same at 41 schools (45%), increased at 20 (22%) but decreased at 31 (34%). Finally, 60 program directors (65%) stated that it was possible for a student to graduate from the school without any clinical exposure to urology. This survey identifies alarming trends that, if left uncorrected, could adversely affect patient care in the future, particularly as the population of the United States ages. In addition, these trends may jeopardize the number and quality of future urological residency applicants.

Developing an action plan for integrating sleep topics into the medical school curriculum.

Sleep disorders are prevalent although they go unrecognized by clinicians, partially because of limited exposure to sleep medicine topics during medical school. Sleep topics can be integrated during both the preclinical and clinical years of the medical school curriculum by developing an integration strategy and action plan. Components of the action plan include examining the current medical school curriculum and the teaching infrastructure. Understanding curricular governance issues and how curriculum time is allocated will allow development of an effective integrative strategy. Sleep topics can be integrated into neuroscience, neuroanatomy, physiology, and behavioral science courses during the preclinical years. The sleep history and physical can be integrated into the physical diagnosis course. Sleep disorders can be introduced in clinical correlation courses. Integration strategies during the clinical years may include computer-based simulations. Careful assessment of the existing curriculum, curricular governance processes, and available educational resources will optimize the probability of successfully integrating sleep topics into the medical school curriculum.

How well do second-year students learn physical diagnosis? Observational study of an Objective Structured Clinical Examination (OSCE).

BackgroundLittle is known about using the Objective Structured Clinical Examination (OSCE) in physical diagnosis courses. The purpose of this study was to describe student performance on an OSCE in a physical diagnosis course.MethodsCross-sectional study at Harvard Medical School, 1997–1999, for 489 second-year students.ResultsAverage total OSCE score was 57% (range 39–75%). Among clinical skills, students scored highest on patient interaction (72%), followed by examination technique (65%), abnormality identification (62%), history-taking (60%), patient presentation (60%), physical examination knowledge (47%), and differential diagnosis (40%) (p < .0001). Among 16 OSCE stations, scores ranged from 70% for arthritis to 29% for calf pain (p < .0001). Teaching sites accounted for larger adjusted differences in station scores, up to 28%, than in skill scores (9%) (p < .0001).ConclusionsStudents scored higher on interpersonal and technical skills than on interpretive or integrative skills. Station scores identified specific content that needs improved teaching.

Error Patterns of 3rd-Year Medical Students on the Cardiovascular Physical Examination

Background: Recent research documents widespread deficits in the physical examination skills of practicing physicians. Purpose: This study explored physical examination skills of 3rd-year medical students after completion of a course in physical diagnosis. Methods: Standardized patient physical examination checklist data were analyzed for a cohort of 2,038 medical students for a patient presenting with classic signs and symptoms of an acute myocardial infarction. A follow-up paper case and survey explored reasons underlying omissions. Results: Students systematically omitted 3 of 10 component maneuvers critical to the evaluation of a patient with shortness of breath and chest pain. The same pattern of omissions was observed across 8 medical schools and over 2 successive years. The paper case follow-up study ruled out time constraints and performance anxiety as the cause. Survey data revealed that students may omit a maneuver due to inability to recall pertinence (blood pressure in both arms) or difficulty discriminating findings (heart sounds at different locations), or because of inadequate technical mastery (percussion of the lungs). Conclusions: These data suggest fundamental inadequacies in the current paradigm for teaching physical examination skills. Standardized patient checklist data can provide an informative window into the efficacy of teaching practices.

Lessons Learned: Implementation of a Web-enhanced Physical Diagnosis Course

Lessons Learned: Implementation of a Web-enhanced Physical Diagnosis Course

The University of Utah School of Medicine.

The University of Utah School of Medicine.

University of Minnesota Medical School - Minneapolis.

University of Minnesota Medical School - Minneapolis.

University of North Carolina at Chapel Hill School of Medicine.

University of North Carolina at Chapel Hill School of Medicine.

Analysis of current practices in recruitment of residents for Physical Medicine and Rehabilitation: survey of PM&R department chairs.

The purpose of this study was to survey the current opinion of Physical Medicine & Rehabilitation (PM&R) chairs on issues of resident recruitment. There was a 92% response rate after two mailings. A majority (62%) of chairs reported more difficulty now than two years ago in obtaining an adequate number of American medical graduates for their residency programs. This was true regardless of program size, type, or location. The three highest ranking reasons for this difficulty were as follows: competition from primary internal medicine; primary care emphasis in medical school curriculums; competition from family medicine. The majority of chairs (87%) reported no increased difficulty in recruiting international medical graduates. The three most frequently used recruiting methods were as follows: clinical rotation electives; using faculty as student advisors; teaching in the physical diagnosis course. The chairs' opinion of the three most important reasons residents choose a specific program include the following: having a committed and interested faculty; having happy current residents; having an established program with successful graduates. A reduction in the number of residents in their programs during the next four years was predicted by 27% of the chairs. The chairs also felt that we currently have too many residency slots, preferring numbers of 600 to 1,300 (mean, 1,010). The chairs had no clear choices in methods to downsize programs if that were to be mandated by the federal government but appeared the least interested in doing so by reducing every program by a flat percentage.

Community health screening as a teaching laboratory in physical diagnosis.

The West Virginia School of Osteopathic Medicine (WVSOM) provides sophomore medical students with an opportunity to perform history and physical examinations on actual patients through two free health screening clinics. Both a men's and a women's clinic are part of the physical diagnosis course and are preceded by lecture and laboratory teaching on the genitourinary system. Students are assigned to a patient whom they interview and examine under supervision by a faculty physician and clinic nurse. Women each receive a Papanicolaou (Pap) smear, digital rectal examination (DRE), and manual breast examination. Men each receive an examination for inguinal hernia, manual testicular examination, and DRE. Blood is drawn by the student for prostate-specific antigen determination. The health screening clinics are well accepted by the students and the community. They provide an excellent opportunity to expand our prevention education and early intervention services to the community.

An assessment of oral cancer prevention curricula in U.S. medical schools.

Oral cancer is readily detectable through routine examination, but five-year survival rates remain low. Physicians bear the same responsibilities as dentists in the early detection of oral cancers, because high-risk patients utilize medical services more often than dental services. Because physicians' practices are largely influenced by their training, this study assessed the level of oral cancer education provided to undergraduate U.S. medical students. Health history and physical diagnosis course curricula were assessed for relevant content. The response rate from the U.S. medical schools was 63.2%. When compared with the "gold standard," the average score was 43% of the optimum. Seven percent of the schools did not require inspection of the mouth, 29% required inspection of all oral structures, and intraoral palpation was advocated by 43% of the schools. Although most schools included questions about alcohol and tobacco use, only 13% asked about sunlight exposure. Preliminary oral cancer training in medical schools regarding physical assessment and elicitation of signs, symptoms, and high-risk behaviors lacks both adequacy and comprehensiveness.

Smoking history-taking skills: a simple guide to teach medical students.

Many doctors rate themselves as ineffective smoking cessation counsellors. It is logical to initiate training efforts with medical students. We incorporated smoking history-taking in the physical diagnosis course at the University of North Carolina at Chapel Hill using a simple method to teach smoking history-taking skills and to assess its effectiveness as an educational intervention. The principal intervention was the distribution of a one-sheet Smoking-History Taking and Counseling Guide, adapted from the American Lung Association's Freedom From Smoking for You and Your Family self-help manual. The second intervention was a single prompt for 50% of the course preceptors. Students' smoking history-taking skills were evaluated in the Objective Structured Clinical Examination (OSCE) at the end of the course. Students who received the guide did significantly better on the OSCE, even after controlling for having discussed taking a smoking history with their preceptors. A simple guide combined with a one-time prompting of preceptors has a positive effect on the acquisition of smoking history-taking skills by the medical students. This strategy may also be useful for teaching and evaluating smoking-cessation counselling skills, for which good smoking history-taking is a necessary basis.

Medical Student Career Choice: Do Physical Diagnosis Preceptors Influence Decisions?

The authors attempted to measure the influence of a physical diagnosis course and its preceptors on the career decisions of second-year medical students. They designed pre- and post-course questionnaires for 204 second-year medical students in a University of Texas Health Science Center at San Antonio Advanced Physical Diagnosis course. They found that 48% of students changed their career choice during the study period, 75% believed their preceptor was a very good role model, and 39% thought their preceptor influenced their career choice. Students who believed their preceptor was a good role model were 31 times more likely to consider their preceptors' career (confidence interval [CI] 95, 4.1-236). In results from students precepted by primary care physicians, there was a nonsignificant trend toward choosing a primary care career (Odds Ratio [OR]) 1.6 [CI95, 0.7-3.3]). Factors associated with a final career choice of primary care were a primary care career choice at baseline (OR 8.5 [CI95, 3.8-19.0]) and a belief that physical diagnosis skills would be important to a future career (OR 4.7 [CI95, 1.1-20.0]). By multivariable analysis, only a primary care career choice at baseline remained significant (OR 8.7 [CI95, 3.5-21.3]). The authors concluded that good role models can influence students to consider alternative career choices, but this effect is still overshadowed by a student's baseline career choice.(ABSTRACT TRUNCATED AT 250 WORDS)

An advanced course in physical diagnosis for residents.

An advanced course in physical diagnosis for residents.

Development, implementation, and evaluation of an advanced physical diagnosis course for senior medical students

To develop, implement, and evaluate a new course curriculum designed to increase senior medical students' knowledge, psychomotor skills, interpretative abilities, and clinical utility regarding physical examination techniques. From February 1991 through February 1993, 53 fourth-year students at the Medical College of Wisconsin participated in a one-month elective, Advanced Physical Diagnosis (APD), which was taught by faculty members of the Division of General Internal Medicine. The APD course included the following modules: (1) organ-specific didactic and interactive practice sessions; (2) physical-examination-based case conferences; and (3) professorial rounds, consisting of rounds on inpatient medical services and the use of professional patients, i.e., outpatients with specific, incontrovertible physical findings. An objective structured clinical examination (OSCE) was developed to evaluate the examination skills of the APD students. A pre- and post-course OSCE format was used with both the APD students and a control group of students rotating on the general medicine ward service. In addition, the APD students evaluated their own skills in physical examination and evaluated the course and each of its components by anonymously completing an extensive end-of-course survey. The pre-course OSCE detection rate of incontrovertible physical findings was similar between the control and APD students (Mantel-Haenszel chi 2 = 2.4, p > .1); the post-course OSCE showed significant improvement in the detection rates for the APD students compared with the control students (Mantel-Haenszel chi 2 = 45.8, p < .0001). The APD students felt strongly that the course had improved their physical examination skills and highly recommended the elective to their colleagues. Both the OSCE results and the students' self-assessments indicate that the pilot curriculum for the APD course improved the students' physical examination skills. The curriculum can be expanded and also exported to other institutions. Such a course may help promote and refine the use of physical diagnosis in the delivery of quality, timely, and cost-efficient health care.

An advanced course in physical diagnosis

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Creation and assessment of a structured review course in physical diagnosis for medical residents.

To evaluate the effects of a course in physical diagnosis on the knowledge, skills, and attitudes of internal medicine trainees. A controlled, prospective assignment of housestaff to a year-long curricular program, linked to a set of pre- and posttests. Houseofficers who could not attend the teaching sessions functioned as control subjects. An internal medicine training program at an urban medical school. 56 (86.1%) of 65 eligible internal medicine housestaff (post-graduate years 1 through 3) participated in the intervention and assessment. A comparison group of 14 senior medical students participated in the pretest. 12 monthly lectures emphasizing skills useful in emergencies or validated by the literature. The pre- and posttests included: 1) a multiple-choice questionnaire to assess knowledge; 2) professional standardized patients to assess selected skills; and 3) Likert-type questionnaires to assess self-motivated learning and attitude toward diagnosis not based on technology. The residents expressed interest in the program and on a six-point scale rated the usefulness of lectures and standardized patients as 3.5 +/- 1.3 and 4.3 +/- 1, respectively. For no system tested, however, did they achieve more than 55.2% correct answers (range: 24.2%-55.2%, median = 41.04), and their performance did not differ from that of the fourth-year medical students. There was no significant difference in pre/posttest improvement between the control and intervention groups. These data confirm the deficiencies of physical diagnostic skills and knowledge among physicians in training. These deficiencies were not corrected by the classroom lecture series. Improvement in these skills may require a more intense experiential program made part of residency requirements.

Teaching cardiovascular examination skills: Results from a randomized controlled trial

purpose: To evaluate the effectiveness of a teaching program designed to improve interns' cardiovascular examination skills. participants: All 56 interns rotating on a mandatory 4-week inpatient cardiology service during 1 academic year (July 1989–June 1990). methods: We randomly assigned interns to receive either an eight-session physical diagnosis course (“teaching group”) taught on the cardiology-patient simulator (“Harvey”) or to receive no supplemental teaching (“control group”). Before and immediately after the teaching or control period, the interns were evaluated on three preprogrammed simulations (mitral regurgitation, MR; mitral stenosis, MS; aortic regurgitation, AR). Immediately after the control or the intervention period, the interns also evaluated patient volunteers. results: There were no baseline differences in the interns' ability to correctly identify the disease simulations. Both the intervention and the control interns showed similar, moderate improvement in their diagnostic ability on the simulator. The intervention interns improved on MR from 42% correct to 54% correct; on MS from 8% correct to 23% correct; and on AR from 46% correct to 58% correct. The intervention and the control interns performed similarly on patient volunteers: for MR, 20% correct versus 31%; for AR, 29% correct versus 33%; and for aortic sclerosis, 64% correct versus 33%, respectively. conclusions: The interns had difficulty correctly identifying three valvular heart disease simulations before and after an educational intervention employing a cardiovascular-patient simulator. At no time did the proportion of correct responses exceed 64%. Our teaching intervention during internship was either of insufficient intensity or of insufficient duration to produce significant improvement in cardiovascular diagnostic skills.