Physical Exam Skills Research Articles

Use of wearable point-of-view live streaming technology for virtual physical exam skills training.

Implication StatementWe piloted a virtual teaching tool comprised of a chest-mounted smartphone streaming point-of-view footage over videoconferencing software to deliver a physical exam skills session. Compared to medical students taught via third person view through pre-recorded video followed by preceptor-led discussion, a higher proportion of students taught via point-of-view wearable technology reported improved knowledge of demonstrated skills and feeling engaged, comfortable interacting with their tutor, and better able to visualize demonstrated exam maneuvers. This accessible, affordable, and easily replicable innovation can potentially enhance virtual clinical skills teaching and enable novel distant clinical learning opportunities for healthcare professions students and educators.

Developing a curriculum to improve cardiology fellows\u2019 training in pregnancy and cardiovascular disease

BackgroundExposure to pregnant women with cardiovascular disease (CVD) during cardiology fellowship training is limited and without a standard curriculum in the United States. The authors sought to evaluate a dedicated curriculum to teach management of CVD in pregnancy to improve general cardiology fellowship training.MethodsThe authors developed a dedicated CVD in pregnancy curriculum for the general cardiology fellows at a large academic medical center in the fall of 2019. Fellows’ knowledge was assessed via a board-style examination and exposure and attitudes related to the care of pregnant women with CVD were evaluated with a needs assessment questionnaire before and after the curriculum.ResultsOf the 17 fellows who participated in the curriculum, 12 completed the needs assessment pre-curriculum and 9 post-curriculum. The mean (SD) number of pregnant women with CVD cared for by each fellow in the inpatient and outpatient settings were 0.75 (1.29) and 0.56 (0.73), respectively. After the curriculum, all fellows reported awareness of available resources to treat pregnant women with CVD, while a majority disagreed that they receive regular exposure to pregnant patients with CVD in their training. The authors observed significant increases in fellows’ confidence in their knowledge of normal cardiovascular physiology of pregnancy, physical exam skills, and ability to care for pregnant women with valvular disease and arrhythmias from pre to post-curriculum. A total of 15 fellows completed the board-style exam pre-curriculum and 15 post-curriculum. Fellows’ performance on the board-style examination improved slightly from before to after the curriculum (64.0 to 75.3% correct, p = 0.02).ConclusionsA dedicated curriculum improved cardiology fellows’ knowledge to recognize and treat CVD in pregnancy and improved confidence in caring for this unique patient population.

Assessment of communication and physical exam skills: A comparison of students, faculty and standardized patients

The objective of this retrospective study was twofold: it aimed to investigate dental students' communication and physical exam self-assessment skills by comparing students' self-evaluations with those completed by faculty and standardized patients (SPs). Second, it aimed to compare faculty and SPs assessment of students' communication skills. At the end of their first year of training, students (n=127), participated in one SP encounter about an initial dental consultation. Students completed self-assessment before receiving feedback from faculty (n=19) and SPs (n=19). The data source included evaluation forms submitted by students, faculty and SPs. The Wilcoxon signed rank test was used to compare the overall scores between groups. Agreement between evaluations items were analyzed with McNemar's test (p<0.05). Overall, there were no statistically significant differences in how students and faculty graded for either communication (p=0.6724) or physical exam (p=0.1921) skills. However, both students and faculty provided less favorable marks than SPs for communication skills with a statistically significant difference in the overall grading between both students and SPs (p=0.0146) and between faculty and SPs (p=0.0045). While there was disagreement between students and faculty versus SPs, they weren't meaningful differences in scores and the dissimilarities mainly consisted of ratings of explanation skills. We suggest that, when applicable, dental student's self-evaluations may represent an alternative to faculty assessments of communication and physical exam skills. Nonetheless, we recommend that SPs be included in the assessment of communication skills to provide students with comprehensive feedback that more realistically represents the natural patient-provider relationship.

Comparison of Clerkship Directors' Expectations of Physical Examination Skills with Point-of-care Ultrasound Skills Using the RIME Framework.

Background: The expectations of point-of-care ultrasound (PoCUS) in undergraduate clerkship at the University of Ottawa has not been described. We compared clerkship directors' expectations of physical examination skills with PoCUS skills, before and after completing the clerkship rotation. Methods: A pilot-tested, expert developed, bilingual on-line survey consisting of 15 questions was sent to all clerkship directors (23) in December 2019. The survey included questions regarding the expectations of medical students with respect to physical examination and PoCUS using the RIME Framework: none, reporter, interpreter, manager, educator. Results: The response rate was 60.9% (14/23). With regards to physical exam skills, 82.8% of directors had no expectations or expected students to be reporters when starting clerkship. At graduation, 77.5% of directors expected students to be interpreters, managers, or educators. For PoCUS, 100.0% of directors had no expectations or expected students to be reporters when starting clerkship. At clerkship completion, 33.0% of directors felt that students should be interpreters or managers for PoCUS skills. Conclusions: Clerkship directors have low expectations of PoCUS skills for entering and graduating clerks when compared with their physical examination skills despite formal pre-clerkship PoCUS objectives. Enhanced communication and targeted education of directors could improve the PoCUS curriculum.

152 Transition to residency - Evaluation of a novel bootcamp for incoming paediatric residents

Primary Subject areaMedical EducationBackgroundIn 2020, medical students experienced a sudden change in their learning context due to the COVID-19 pandemic. University policies and public health recommendations removed medical students from their clinical learning environments. Given this shift from work-based learning, incoming residents and educators alike were wary of the impact on residency readiness. With the current context in mind, and with an approaching CBD launch, the UBC Pediatrics training program developed a bootcamp curriculum in an attempt to ease residency transition. This month-long rotation included instruction and experiential learning in all CanMED roles, with heavy focus on medical expert, communication and collaboration skills required of new residents. Wellness topics were also included given the additional stressors associated with the pandemic.Objectives1). Develop a novel bootcamp curriculum for incoming pediatrics residents with a focus on all CanMED roles in the context of the unique learning constraints during the COVID-19 pandemic. 2). Use cross-sectional survey data to assess comfort levels of new pediatrics residents in all CanMED roles prior to, and after, participating in bootcamp. 3). Discuss implications for medical educators in transitioning new residents into their role, given current limitations imposed by the pandemic.Design/MethodsWe created and distributed a cross-sectional survey to 19 incoming pediatric residents through a secure online platform (RedCAP). Using a 5-point likert scale, survey questions focused on assessing resident comfort levels with competencies from all CanMED roles prior to, and after, participating in bootcamp. Free text comments were included to expand on quantitative data.ResultsResponse rate was 100% (19/19) for pre-bootcamp surveys, and 84% (16/19) for post-bootcamp surveys. Prior to residency, respondents reported feeling uncomfortable with physical exam skills, pediatric hospital medicine and procedures. After the bootcamp block, participants noted increased comfort with medical management in acute care settings (for example, approach to pediatric cardiac arrest), procedural skills such as LPs, and managing common on call problems (for example, electrolyte disturbances and antibiotics). In free text comments, simulation training was highlighted as being particularly important for building communication and teamwork skills. Trainees seemed to find enjoyment in learning new wellness techniques such as mindfulness and narrative medicine. Residents also noted increased social connection within the group.ConclusionOur results suggest that during a period of heightened vulnerability, purposeful attention to transitioning new residents into their new role through a bootcamp rotation provided increased comfort and confidence in many CanMED roles. Furthermore, residents endorsed increased cohesion and acknowledged the social benefits of participating in team-based learning, a particularly important and potentially protective outcome given current limitations imposed by the pandemic.

Current Scope of Online Ophthalmology Education and Curriculum Impact Due to COVID-19

Abstract Objective Abrupt changes in ophthalmology education caused by the COVID-19 pandemic have resulted in novel online curriculum development. The aims of this study were to identify (1) the scope of online curricula implemented both prior to and during the COVID-19 pandemic; (2) perception of educators on these online modalities; and (3) early lessons from online implementation that may guide future curricular planning. Methods Implementation of online curricula was evaluated by using a national online survey of Ophthalmology Directors of Medical Student Education (DMSE) via Qualtrics software. Participants Medical Student Educators of the Association of University Professors of Ophthalmology (AUPO) were surveyed. Results Fifty responses were collected, representing a 64.9% response rate. Prior to the COVID-19 pandemic, 44% of institutions had no online components in their courses, but 78.3% of institutions reported increasing online components in response to the pandemic. Required courses were significantly associated both with having implemented online components before the pandemic and implementing online-only versions of these courses in response to the pandemic. The three most popular modalities used for online teaching were lectures, interactive cases, and problem-based learning, with a median satisfaction of 4.0, 4.32, and 4.35, (out of five) respectively. The least popular modalities used were online teaching of physical exam skills and telemedicine, both with a median satisfaction of 2.5. Median overall educator satisfaction with online teaching was four (out of five). The most common weakness related to online teaching was the lack of effective physical exam skills training. Conclusion Our data demonstrate that most institutions successfully shifted their ophthalmology curriculum to a virtual and online version in response to the COVID-19 pandemic. DMSEs adapted quickly, transitioning in-person clinical courses, and extracurricular activities to online formats. Overall, educator satisfaction with online curricula was high. Integration of online curricula provides the opportunity to enrich institutional curriculums and overcome limitations imposed by decreasing curriculum time. This study reveals an early window into the utilization, strengths, and weaknesses of online ophthalmology education, which can serve as a guiding point to enhance ophthalmology curriculum development.

Implementation of a Fine Needle Aspirate Simulation Model.

Being able to appropriately perform fine needle aspiration (FNA) collecting techniques and sample preparation is essential in obtaining a diagnostic sample, which is a critical skill for veterinary practitioners. Collection and preparation of cytologic samples are skills gained through practice. Experience leads to refinement of technique and improved diagnostic quality. Using live patients for mass skills training is not feasible; therefore, an aspiration simulation model and laboratory session was developed to reinforce physical exam skills, appropriate selection of sample collection supplies, and collection technique. Materials for the models include Ping-Pong balls, silicone, instant vanilla pudding mix, water, and stuffed animals. The laboratory session allows veterinary students to practice lesion identification, isolation, aspiration, and successful preparation. Subsequent submission of the collected sample involves being able to expel and spread the sample on a slide and proper labeling. While the simulation experience was initially developed for a short course with 12 students, it has recently been incorporated into the required clinical pathology clinical year rotation for up to 100 fourth-year veterinary students. The model is inexpensive and efficient and allows for technique development and immediate instructor assessment and feedback.

The flipped classroom: a novel approach to physical examination skills for osteopathic medical students.

Medical students are faced with the challenge of synthesizing large volumes of information quickly. With the increasing accessibility of technology, a "flipped classroom" allows students to learn foundational material independently. Class time is instead devoted to in-depth skill building with instructors, promoting an active learning environment. This method of content delivery is also relevant given the current COVID-19 pandemic. To comprehensively evaluate the benefit of adopting a flipped classroom approach in teaching physical exam skills (PES) to first-year osteopathic medical students. A cohort study was conducted comparing first-year osteopathic students in the class of 2022 (n=201), who had taken the PES course traditionally, with the class of 2023 (n=203), who experienced the flipped classroom approach. Objective metrics such as cumulative grades, objective structural clinical examination performance (OSCE), and practical exam performance were compared using nonparametric Mann-Whitney U rank sum tests. Subjective measures such as student course evaluations were used to analyze course perceptions using independent sample t-tests assuming unequal variances. A faculty survey was administered to faculty who taught both cohorts to assess instructor attitudes toward the flipped classroom approach. Due to the COVID-19 pandemic, Spring 2020 quarter data was not included, given the transition of all classes to an online learning environment. The flipped classroom approach significantly improved objective student performance for the Fall (p=0.009) and Winter (p<0.001) student cumulative grades and the History-Taking OSCE (p=0.010). Performance on Fall and Winter practical exam scores had no significant association with the flipped classroom. General student perceptions of the course remained unchanged between both cohorts. Faculty survey results from 10 faculty members showed that six (60%) faculty members preferred the traditional classroom, while four (40%) preferred the flipped classroom. The flipped classroom approach showed some statistically significant improvement in student PES. Further studies are needed to evaluate the benefits of a flipped classroom approach using skills-based assessments styles to measure student performance, with a focus on standardization of in-classroom groupwork.

A Multifaceted Resident-Led Physical Exam Course.

Physicians frequently report poor confidence applying the physical exam for medical decision making. We developed a novel, multifaceted, resident-led curriculum to teach medical students the physical exam for clinical practice. We created a two-week elective comprised of didactics, journal discussions, bedside ultrasound, and physical exam rounds for fourth year medical students at the University of South Carolina School of Medicine - Greenville. JAMA: The Rational Clinical Exam and Evidence-Based Physical Diagnoses, by Steven McGee, MD, were used to develop content. The curriculum focused on cardiac, pulmonary, abdominal, endocrine, and neurologic exams. Faculty and residents facilitated all portions of the course. Chi-squared testing was used to calculate confidence intervals on pre- and post-course assessments. Twenty-two fourth year medical students enrolled in the elective over the course of three years. Seventeen faculty, three chief residents, and 13 residents provided instruction. Residents provided roughly half of the total instruction hours. Students demonstrated statistically significant improvement on multiple choice pre-course and post-course assessments (56.8% vs 77.1%, p < 0.001). 95.5% of students reported feeling "confident" in their physical exam skills after the course. After participating in the course, students demonstrated improved skill and comfort using the physical exam for clinical decision making.

Clinical Competence Assessed Using Simulation: Development of a Standardized Tool to Assess Nutrition-Focused Physical Exam Skill Competence for Registered Dietitian Nutritionists

ObjectiveThis study details development and testing of a tool designed to evaluate clinical competence by registered dietitian nutritionists (RDNs) on the nutrition-focused physical exam (NFPE). The process demonstrated in this study can be adapted for assessment of other clinical skills in competency-based education programs, such as Accreditation Council on Education in Nutrition and Dietetics’ Future Model of Dietetics Education. Design and SettingThe tool was tested for content validity, then used to assess the videotaped performance of the NFPE with standardized patients in a simulated clinical environment. ParticipantsSeven expert raters assessed the relevance of the tool's items for content validity. For other tests, the tool was used by 3 dietetics faculty to score a group of 18 RDNs. Variables and AnalysisContent validity was tested using the item-level Content Validity Index. Interrater reliability and internal consistency of the tool were calculated and assessed. ResultsThe interrater reliability results indicated excellent agreement between raters, both overall (kappa statistic = 0.86; 95% confidence interval, 0.86–0.87; P < 0.001) and on individual items. Cronbach α statistic was calculated at α = .91, indicating excellent internal consistency. ConclusionsThe tool represents an instrument that can assess competence in the NFPE among RDNs and may be used as a template for development of other competency-based education assessment tools.

Student Hotline Improves Remote Clinical Skills and Access to Rural Care.

During the COVID-19 pandemic, medical schools needed to redirect students to alternative educational opportunities. The University of Nevada, Reno School of Medicine addressed this issue by forming a partnership with rural counties in northern Nevada to create a multicounty COVID-19 hotline clinical experience. Medical students staffed the hotline and assisted the underserved rural populations of northern Nevada by providing counseling and education via telehealth. With the support of preceptors, students completed screening forms with patients, utilized audio-only physical exam skills and clinical decision making to triage potential patients to the appropriate level of care. We utilized retrospective pre- and postassessments to assess medical students' comfort level with several hotline tasks before and after their experience as a hotline volunteer. Results indicate significant improvements after hotline training and experience in students' comfort level with answering questions about SARS-CoV-2 (P=.006); screening patients for SARS-CoV-2 (P=.0446); assessing exam findings using audio only format ( P=.0429); triaging patients (P=.0103); and addressing financial access to care barriers ( P=.0127). Participation in the multicounty COVID-19 hotline improved students' comfort levels in all areas, with significant improvement in answering questions about SARS-CoV-2, conducting audio-only exams, screening and triaging patients, and addressing financial barriers to care. Participation allowed students to further hone their clinical skills during a pandemic. This experience can serve as a model for similar projects for other academic institutions to train their medical students while providing outreach, particularly to underserved populations such as rural communities.

Florida State University College of Medicine.

Florida State University College of Medicine.

Loyola University Chicago Stritch School of Medicine.

Loyola University Chicago Stritch School of Medicine.

Wright State University Boonshoft School of Medicine.

Wright State University Boonshoft School of Medicine.

The George Washington University School of Medicine and Health Sciences.

The George Washington University School of Medicine and Health Sciences.

University of Rochester School of Medicine and Dentistry

University of Rochester School of Medicine and Dentistry

Penn State College of Medicine.

Penn State College of Medicine.

Refugee Health Curriculum in Undergraduate Medical Education (UME): A Scoping Review

Phenomenon: An increasing number of refugees in recent years has led to changes in healthcare delivery. Historically, health care providers did not receive systematic and longitudinal training in refugee health. There is increasing interest among educators in developing educational opportunities for medical students to gain more training on how to care for this population. The aim of this scoping review was to identify and analyze existing literature on educational content and methods of delivery in Undergraduate Medical Education (UME) curricula related to refugees. Approach: The authors conducted a scoping review. Our search was conducted in seven electronic bibliographic databases. The search strategy was restricted to English language and scholarly articles. Three members of the research team tabulated and summarized extracted data. A qualitative thematic analysis was conducted to present findings. Findings: Of the 717 publications found, 24 met our inclusion criteria. The articles included in this review were published between 2003 and 2019. Thirteen (57.6%) were descriptive papers, three (11.5%) qualitative, four (15.3%) quantitative, and one (3.8%) mixed methods. Other publications included one commentary, one letter to the editor, and one review paper. Three main descriptive themes were identified: (1) Content related to refugees’ curriculum, (2) Teaching strategies, and (3) Learning outcomes. Insights: Studies included in our review suggest that delivering refugee health curricula to medical students improve self-perception of cross-cultural knowledge, communication, and physical exam skills that are necessary to deliver proper healthcare. Medical schools should focus on developing a longitudinal and standardized approach to teaching refugee health through the use of interactive and diverse learning methods while engaging with the community to ensure a better provision of health care for vulnerable populations.

Simulations for Teaching and Evaluating Nutrition-Focused Physical Exam Skills

ObjectiveTo develop, implement, and evaluate a patient simulation to assess Nutrition-Focused Physical Exam (NFPE) skills among dietetics students. MethodsThree student cohorts (n = 47) in a combined internship and master's program participated. Curricula included: (1) formal instruction with practice resources, (2) baseline NFPE evaluation performed on a classmate, and (3) final NFPE evaluation performed on a standardized patient. Trained observers evaluated students using the NFPE Skills Assessment tool. Self-rated performance was assessed by the 8-item survey completed at baseline and after the final evaluation. Paired t tests analyzed differences in observed NFPE skill, and 1-tailed Wilcoxon signed-rank test analyzed differences in survey responses. ResultsNutrition-Focused Physical Exam skill improvements were observed for each cohort (P < .05). Surveys demonstrated increased comfort touching patients (P < .001), and improved self-rated abilities to assess subcutaneous fat, muscle stores, fluid accumulation, and micronutrient deficiency (P < .001). Conclusions and ImplicationsSimulations were an effective method for increasing observed and perceived NFPE skills among dietetics students. These findings justify the investigation of these methods within a larger sample of students from multiple programs with rigorous study design.

Assessing physical examination skills using direct observation and volunteer patients.

Feedback based on direct observation of the physical examination (PE) is associated with enhanced educational outcomes, yet attending physicians do not frequently observe graduate trainees performing the PE. We recruited volunteer patients (VPs), each with an abnormality of the cardiovascular, respiratory, or neurological system. Interns examined each VP, then presented a differential diagnosis and management plan to two clinician educators, who, themselves, had independently examined the VPs. The clinician educators assessed interns along five domains and provided post-examination feedback and teaching. We collected data on intern performance, faculty inter-rater reliability, correlation with a simulation-based measure of clinical skill, and resident and VP perceptions of the assessment. A total of 72 PGY-1 interns from a large academic training program participated. Performance on the cardiovascular and respiratory system was superior to performance on the neurologic exam. There was no correlation between results of an online test and directly observed cardiovascular skill. Interns preferred feedback from the direct observation sessions. VPs and faculty also rated the experience highly. Inter-rater reliability was good for the respiratory exam, but poor for the cardiovascular and neurologic exams. Direct observation of trainees provides evidence about PE skill that cannot be obtained via simulation. Clinician educators' ability to provide reliable PE assessment may depend on the portion of the PE being assessed. Our experience highlights the need for ongoing training of clinician educators in direct observation, standard setting, and assessment protocols. This assessment can inform summative or formative assessments of physical exam skill in graduate medical education.