Physical Examination Teaching Research Articles

Relationship of Physical Examination Technique to Associated Clinical Skills: Results from a Direct Observation Assessment

Background: The purpose of this research was to use direct observation of the physical examination to elucidate the role physical examination technique plays in diagnostic accuracy. Physical examination is important for quality clinical care and requires multiple interrelated skills. The relationship of physical examination technique to related skills is poorly understood. Current methods of teaching and assessing physical examination skills provide few opportunities to evaluate physical examination technique and accuracy. Methods: The authors developed a clinical examination assessment using volunteer patients and direct observation. Trained faculty preceptors rated resident performance in 7 domains: 1) physical examination technique, 2) identification of physical signs, 3) clinical communication, 4) differential diagnosis, 5) clinical judgment, 6) managing patient concerns, and 7) maintaining patient welfare. The Pearson correlation coefficient was used to determine relationships between performance in each of these domains. Data on residents’ self-assessed competency in the physical examination and perceptions of feedback received during the assessment were collected. Results: From December 2018 to February 2020, 113 interns from 2 internal medicine residency programs participated in the assessment. Physical examination technique was significantly correlated with accurate identification of physical signs, differential diagnosis and clinical judgment. Time spent in graduate medical education was negatively correlated with performance. Interns more highly rated the feedback received from this assessment than traditional clinical skills feedback. Conclusions: Our findings emphasize the necessity of multi-dimensional physical examination assessment. Observed deterioration of physical examination skill during internship may reflect contemporary practice patterns, which deprioritize the physical examination. Future research on physical examination education should focus on the interface between physical examination technique and related clinical skills.

A Resident-driven Initiative to Increase Bedside Teaching on Interdisciplinary Rounds.

We developed an organizational structure to complete a long-term resident-led project. Interventions included daily bedside examination teaching on rounds, afternoon examinations, goal communication, topic recording, and a teaching "tip sheet." Using an institutional QI framework, we utilized iterative plan-do-study-act cycles to implement interventions and surveys to assess outcomes, with rounding efficiency as a balancing measure. The survey response rate was 57%. Bedside teaching frequency increased from a mean of 10% to 61%, perceived time at the bedside increased from 37% to 59%, and rounding satisfaction improved from a rating of 6.7/10 to 7.4/10. Efficiency was not impacted. We improved inpatient rounds bedside physical examination teaching and satisfaction without sacrificing efficiency. This project demonstrates the feasibility and success of a resident-driven education initiative to successfully motivate fellow residents and colleagues across disciplines to enact change. The organizational structure may serve as a model for resident-led QI projects across institutions.

Neurological teaching in times of crisis.

Background/Objective: The changes to medical studies that became necessary as part of the Corona pandemic have also forced considerable adjustments in Neurology. Classroom teaching had to be converted almost entirely to digital formats within a short period of time. The present study provides an overview of the respective changes and associated complications as well as opportunities in teaching Neurology.Methodology: Lecturers in Neurology at all University hospitals in Germany were asked about their approach and the individual changes in their curriculum. Of a total of 39 locations, 23 answered the online questionnaire (see attachment 1).Results: While frontal teaching and lectures could be carried out digitally without any problems, difficulties arose especially in learning physical examination and bedside teaching. Most of the participants stated that they had not found satisfactory e-learning formats to replace teaching at the patients bed.Conclusion: The ad hoc changes in teaching Neurology resulted in significant additional effort for the part of lecturers, but were generally well accepted by students. The Corona pandemic thus ultimately offers an opportunity to enrich teaching in Neurology.

Standardizing nurse practitioner student evaluation during high-stakes clinical examinations

Nurse practitioners (NPs) require clinical competence in advanced health assessment skills to differentiate between normal, variations of normal, and abnormal patient findings. High-stakes clinical examinations, using live hands-on simulation scenarios and standardized patients (SPs) or other human role players, are accepted teaching and evaluation tools for NP students. Providing objective, valid, and reliable feedback to students during high-stakes clinical examinations is of considerable value for ongoing skill development. The study examined opportunities to improve the quality of student evaluation in simulation testing modes. A purposive sample of 17 video recordings of health students' comprehensive examination of an SP or physical examination teaching associate (PETA) from a nursing graduate level health assessment course was evaluated. Using a standardized rubric, students were scored live and after a comprehensive examination of a SP/PETA and via a secure web-based video platform by the faculty and an independent reviewer. Evaluator group examination score comparisons revealed that distributions of examination scores within evaluator groups were not similar. Median examination scores were significantly different between groups; faculty median examination scores significantly higher than SPs/PETAs. Efficiency of student evaluation may be increased by improving reviewer training, reducing checklist length, and adopting electronic scoring. Development of an exemplary teaching video providing explanation and detail for expected student skill performance will allow reviewers to practice and improve competence in reliable scoring, reduce time and effort of scorers, and increase accuracy of scoring.

‘Nipples to knees’ in the ‘Me Too’ era

We live in an era of increased societal awareness of sexual harassment and frequent reporting by patients of inappropriate conduct. In this article, we reflect on traditional teaching of physical examination involving full exposure and intimate examinations, and whether this is still necessary, or appropriate, in clinical practice today. We discuss the balance between appropriate physical examination and inappropriate patient exposure resulting in perceived or actual harassment. We argue that ethical values and societal values change with time, and there is an onus on medical educators to reflect societal sensitivities in their teaching.

Combining classroom and workplace teaching to deliver physical examination teaching: A theoretical approach

This article was migrated. The article was not marked as recommended. Medical educators work to better prepare students for clinical work by constantly evolving medical curricula. The 'integrated curriculum' was designed to be repetitive but progressive with the aim to reduce disconnect between basic science and clinical practice. The problems arose when classroom teaching and clinical exposure happen as isolated events rather than being part of the same learning experience. This piece presents a theoretical overview of the benefits and drawbacks of combining classroom and workplace teaching to deliver physical examination teaching. The Adult learning theory proposes that this methods of teaching would promote their interest in meaningful learning. Furthermore, combining cognitivism and constructivism approaches to create and then build on schemata offers an effective way to transfer learning. There is however recognition of the limitations that primarily focus of the individuality of students with which teachers can struggle to respond.

Co-teaching in an Undergraduate Clinical Skills Course: Physicians and Social Behavioural Scientists Use a Shared Mental Model to Highlight Complementary Aspects of Medical Interviewing and Physical Exam Skills.

This article was migrated. The article was marked as recommended. Introduction: Interdisciplinary co-teaching by physicians (MD) and social behavioural scientists (SBS) has emerged as an innovative teaching practice in clinical skills courses, but little is known about how co-teachers operationalize instruction. The purpose of this study was to explore the shared mental model of co-teachers concerning medical interviewing and physical examination instruction. Methods: Twelve individual semi-structured interviews were conducted at Brown University. Participants were asked, " What and how do MD and SBS faculty contribute to teaching medical interviewing and physical examination skills?" Transcripts were subjected to thematic analysis. Discourse analysis was also used to determine if what faculty individually described as contributing to instruction was observed by the co-teacher. Results: Physician and SBS faculty emphasized different but complementary aspects of medical interviewing and physical examination skills. Physicians focused on content, targeting clinical reasoning, differential diagnosis, economy of movement, efficiency, synthesis, and technical skills. SBS faculty focused on process,emphasizing active listening, presence, non-verbal communication, rapport building, empathy, and patient comfort. Discussion: Co-teachers consistently articulated their relative contributions to teaching medical interviewing and physical examinations. Their shared mental model emphasized the importance of both content and process, creating a learning environment supporting the development of both biomedical and patient-centred perspectives.

How do novices learn physical examination skills? A systematic review of the literature

ABSTRACTBackground: Physical Examination (PE) skills are vital for patient care, and many medical students receive their first introduction to them in their pre-clinical years. A substantial amount of curriculum time is devoted to teaching these skills in most schools. Little is known about the best way to introduce PE skills to novice learners.Objective: Our objective was to conduct a systematic review of how medical students are first taught PE skills and the evidence supporting these strategies.Design: We searched ERIC, SCOPUS, MEDLINE, PubMed and EMBASE for descriptions of complete PE curricula for novice learners. Inclusion criteria were: (1) English language; (2) subjects were enrolled in medical school and were in the preclinical portion of their training; (3) description of a method to teach physical examination skills for the first time; (4) description of the study population; (5) Description of a complete PE curriculum. We used the Medical Education Research Study Quality Instrument (MERSQI) score to evaluate the quality of evidence provided.Results: Our search returned 5,418 articles; 32 articles met our inclusion criteria. Two main types of curricula were reported: comprehensive ‘head-to-toe’ PE curricula (18%) and organ system-based curricula (41%). No studies compared these directly, and only two evaluated trainees’ clinical performance. The rest of the articles described interventions used across curricula (41%). Median MERSQI score was 10.1 Interquartile range 8.1–12.4. We found evidence for the use of non-faculty teaching associates, technology-enhanced PE education, and the addition of clinical exposure to formal PE teaching.Conclusions: The current literature on teaching PE is focused on describing innovations to head-to-toe and organ system-based curricula rather than their relative effectiveness, and is further limited by its reliance on short-term outcomes. The optimal strategy for novice PE instruction remains unknown.

Overcoming the barriers of teaching physical examination at the bedside: more than just curriculum design

BackgroundPhysicians in training must achieve a high degree of proficiency in performing physical examinations and must strive to become experts in the field. Concerns are emerging about physicians’ abilities to perform these basic skills, essential for clinical decision making. Learning at the bedside has the potential to support skill acquisition through deliberate practice. Previous skills improvement programs, targeted at teaching physical examinations, have been successful at increasing the frequency of performing and teaching physical examinations. It remains unclear what barriers might persist after such program implementation. This study explores residents’ and physicians’ perceptions of physical examinations teaching at the bedside following the implementation of a new structured bedside curriculum: What are the potentially persisting barriers and proposed solutions for improvement?MethodsThe study used a constructivist approach using a qualitative inductive thematic analysis that was oriented to construct an understanding of the barriers and facilitators of physical examination teaching in the context of a new bedside curriculum. Participants took part in individual interviews and subsequently focus groups. Transcripts were coded and themes were identified.ResultsData analyses yielded three main themes: (1) the culture of teaching physical examination at the bedside is shaped and threatened by the lack of hospital support, physicians’ motivation and expertise, residents’ attitudes and dependence on technology, (2) the hospital environment makes bedside teaching difficult because of its chaotic nature, time constraints and conflicting responsibilities, and finally (3) structured physical examination curricula create missed opportunities in being restrictive and pose difficulties in identifying patients with findings.ConclusionsDespite the implementation of a structured bedside curriculum for physical examination teaching, our study suggests that cultural, environmental and curriculum-related barriers remain important issues to be addressed. Institutions wishing to develop and implement similar bedside curricula should prioritize recruitment of expert clinical teachers, recognizing their time and efforts. Teaching should be delivered in a protected environment, away from clinical duties, and with patients with real findings. Physicians must value teaching and learning of physical examination skills, with multiple hands-on opportunities for direct role modeling, coaching, observation and deliberate practice. Ideally, clinical teachers should master the art of combining both patient care and educational activities.

Teaching Physical Examination to Medical Students on Inpatient Medicine Teams: A Prospective, Mixed-Methods Descriptive Study.

Physical examination (PE) is a core clinical competency, and the internal medicine clerkship is a premiere venue for students to develop PE skills. However, clinical rotations often lack opportunities for real-time instruction. We sought to measure the frequency, content, and factors affecting PE instruction during the internal medicine clerkship. We conducted a prospective mixed-methods study at a single academic center. Data were gathered by a student researcher who directly observed inpatient teams over 3 months. We quantified the frequency of PE teaching activities and analyzed daily written observations using qualitative content analysis. PE was most frequently discussed during bedside rounds and least often during workroom rounds. Direct observation of students' examinations rarely occurred. Multiple factors in the learning environment were posited to affect PE instruction. In brief, we found that residents and attending physicians who are part of internal medicine teaching services do not routinely emphasize PE instruction.

Emphasizing High Value, Cost-Effective Care in Physical Examination Instruction - A Qualitative Content Analysis of Interviews with Expert Educators.

This article was migrated. The article was marked as recommended. Introduction Physical examination and cost consciousness are critical competencies for medical trainees, but the intersection of these two skill domains is not described. We aimed to elucidate the role of physical examination in providing high value, cost conscious care (HVC) and to explore how clinical skills curricula could integrate principles of HVC. Methods We conducted a qualitative study of semi-structured interviews with 20 experts in the instruction and clinical applications of physical examination. We identified experts through purposeful sampling and snowball sampling. Audio-recorded interviews were coded using qualitative content analysis. Coded passages were categorized and reported as key themes and recommendations. Results Experts affirmed physical examination's indispensable role in clinical reasoning. When integrated with history-taking and additional diagnostic data, physical examination can further the aims of HVC. However, experts noted that the pace and demands of contemporary clinical practice present barriers to the idealized application of physical examination. In turn, participants discussed how to improve clinical skills curricula, both broadly and to promote HVC. Discussion To advance HVC through physical examination curricula, the clinical relevance of bedside skills needs to be emphasized across the training spectrum. Key strategies include revisiting evidence-based medicine principles and integrating physical examination instruction with teaching clinical reasoning.

Novel Use of Ultrasound to Teach Reproductive System Physical Examination Skills and Pelvic Anatomy.

To determine whether integration of ultrasound (US) into a reproductive system examination clinical skills lab can increase confidence in palpating key reproductive structures during testicular and bimanual pelvic examinations, reduce anxiety about conducting testicular and bimanual pelvic examinations, and improve performance on multiple-choice questions based on structure identification using US images. Second-year medical students enrolled in the Life Cycle preclinical course participated in this cross-sectional study. A single learning activity was developed to pair the teaching of the reproductive system physical examination with the use of US in the clinical skills lab. The evaluation of the teaching session consisted of a pre-post analysis of student self-reported knowledge, confidence, and anxiety. The response rate for the pre survey was 82% (n = 96), and the rate for the post survey was 79% (n = 93). Students' confidence in their ability to identify reproductive system structures on US images increased from pre to post survey. Their confidence in their ability to palpate the epididymis, uterus, and ovary during a physical examination improved, and their anxiety about conducting testicular and bimanual pelvic examinations decreased. Student satisfaction with the session was high. Students' performance on multiple-choice questions based on structure identification using US images was at 96% or higher. Our study findings support the integration of US into a reproductive system examination clinical skills lab. Medical students acquire competency and confidence in reproductive system physical examination skills with US integration.

Bedside direct observation of medical student-performed physical examination is highly rated in student satisfaction.

This article was migrated. The article was marked as recommended. Objectives: To evaluate satisfaction among third year medical students with a bedside teaching exercise comprised of direct observation of student-performed physical examination skills and related feedback. Methods: An observational, cross-sectional study design was employed to study third year medical students undergoing the Neurology clerkship at the Ohio State University College of Medicine between June and October 2015. Immediately following the bedside physical examination teaching exercise, student satisfaction data was obtained in anonymous survey (n=21). In addition, student satisfaction data from the class cohort (n=51), regarding various learning formats in the curriculum, were collected at the end of a 16-week block of rotations including the Neurology clerkship. Data were summarized using descriptive statistics. Results: Most students felt that their level of confidence increased as a result (85.0%, n=17/21), and they felt they would use what they had learned in the future (95%, n=19/21). Only about half of the students felt strongly that reflection on the learning experience was sought (47.6%, n= 10/21). At the end of the 16 weeks block, the Neurology examination exercise was rated among the most highly in student satisfaction (3.35/4, SD=0.89) as compared to procedural workshops (2.76/4, SD= 0.76), other small group topic format (2.78/4, SD= 0.85), and traditional lecture (2.39/ 4, SD= 0.89). Conclusions: The bedside direct observation of physical examination performed by medical students is highly rated in student satisfaction, and students are most satisfied with this format of teaching among all formats studied. Increased opportunity for reflection in this setting represents an area for further development.

Hypothesis-driven physical examination curriculum.

Medical students traditionally learn physical examination skills as a rote list of manoeuvres. Alternatives like hypothesis-driven physical examination (HDPE) may promote students' understanding of the contribution of physical examination to diagnostic reasoning. We sought to determine whether first-year medical students can effectively learn to perform a physical examination using an HDPE approach, and then tailor the examination to specific clinical scenarios. Medical students traditionally learn physical examination skills as a rotelist of manoeuvres CONTEXT: First-year medical students at the University of Minnesota were taught both traditional and HDPE approaches during a required 17-week clinical skills course in their first semester. The end-of-course evaluation assessed HDPE skills: students were assigned one of two cardiopulmonary cases. Each case included two diagnostic hypotheses. During an interaction with a standardised patient, students were asked to select physical examination manoeuvres in order to make a final diagnosis. Items were weighted and selection order was recorded. First-year students with minimal pathophysiology performed well. All students selected the correct diagnosis. Importantly, students varied the order when selecting examination manoeuvres depending on the diagnoses under consideration, demonstrating early clinical decision-making skills. An early introduction to HDPE may reinforce physical examination skills for hypothesis generation and testing, and can foster early clinical decision-making skills. This has important implications for further research in physical examination instruction.

The effective study of Miller pyramid demonstration applied in the teaching of shoulder physical examination for visiting orthopaedic surgeons

Objective To explore the effect of Miller pyramid demonstration in the teaching of shoulder physical examination for visiting orthopaedic surgeons and aim at finding a more effective teach-ing method in this area. Method 96 visiting surgeons in our department were chosen and divided even into two groups randomly from 2011 to 2013. Traditional teaching method was applied in group A, while Miller pyramid demonstration which combined theory with practice was used in group B. Basic knowledge, manipulative skill and clinical diagnosis were assessed in group A and group B respectively. Finally, the results were statistical analyzed using t-test with SPSS 19.0 software. Results In the basic professional knowledge test, the average score of Group B was better than Group A[(92.8±5.0) vs. (83.0±8.5)]; in terms of operational skills assessment, the average score of Group B was better than Group A [(94.0±4.1) vs. (79.3±3.9)]; in the clinical diagnosis of the application, the average score of Group B was better than Group A [(90.6±2.3) vs. (85.1±1.9)]. There were significant differences between the two groups (P<0.05). Conclusion Miller pyramid demonstration was more effective than traditional teaching method in the teaching of shoulder physical examination for visiting orthopaedic surgeons. Key words: Miller pyramid; Teaching in orthopaedics; Physical examination; Shoulder

Using Ultrasound to Enhance Medical Students' Femoral Vascular Physical Examination Skills.

To determine whether the addition of ultrasound to traditional physical examination instruction improves junior medical students' abilities to locate the femoral pulse. Initially, 150 second-year medical students were taught the femoral pulse examination using traditional bedside teaching on standardized patients and online didactic videos. Students were then randomized into 2 groups: group 1 received ultrasound training first and then completed the standardized examination; and group 2 performed the standardized examination first and then received ultrasound training. On the standardized patients, the femoral artery was marked with invisible ink before the sessions using ultrasound. Compared to these markers, students were then evaluated on the accuracy of femoral artery pulse palpation and the estimated location of the femoral vein. All students completed a self-assessment survey after the ultrasound sessions. Ultrasound training improved the students' ability to palpate the femoral pulse (P= .02). However, ultrasound did not facilitate correct estimation of the femoral vein's anatomic location (P = .09). Confidence levels in localizing the femoral artery and vein were equal between groups at baseline, and both increased after the ultrasound sessions. The addition of ultrasound teaching to traditional physical examination instruction enhanced medical student competency and confidence with the femoral vascular examination. However, understanding of anatomy may require emphasis on precourse didactic material, but further study is required.

Effect of early clinical skills teaching on 3rd year medical students' learning: The student perspective

Abstract Objectives The main purpose of the early introduction of Clinical Skills Learning (CSL) to pre-clinical years is to allow medical students to gain experience in clinical examination skills, basic medical procedures, history-taking and clinical communication. The objective of this study was to determine the effectiveness of the early teaching of clinical skills in preparing medical students for their clinical years. Methods A validated questionnaire assessing the value of CSL on students in their first clinical year was distributed to 3rd year medical students. The questionnaire consisted of 8 items with a five-point Likert scale and one open-ended question. Results The response rate to the questionnaire was approximately 62%. Nearly 97 (70.8%) students suggested that CSL was a favourable teaching strategy. A high percentage of students (90.5%) agreed that CSL was a useful pre-clinical module to prepare them for their clinical years. The students gave positive feedback on the teaching of history-taking and physical examination, exposure to the hospital environment and acquisition of communication skills with supervisors and patients. No student perceived the CSL module as poor. Conclusions Early CSL was well-perceived by students in preparing them for their clinical years. CSL is a vital part of the pre-clinical curriculum and should be further enriched with frequent hospital visits to enhance students' confidence level and performance when interacting with patients during their clinical years.

Performance in physical examination on the USMLE Step 2 Clinical Skills examination.

To provide descriptive information about history-taking (HX) and physical examination (PE) performance for U.S. medical students as documented by standardized patients (SPs) during the Step 2 Clinical Skills (CS) component of the United States Medical Licensing Examination. The authors examined two hypotheses: (1) Students perform worse in PE compared with HX, and (2) for PE, students perform worse in the musculoskeletal system and neurology compared with other clinical domains. The sample included 121,767 student-SP encounters based on 29,442 examinees from U.S. medical schools who took Step 2 CS for the first time in 2011. The encounters comprised 107 clinical presentations, each categorized into one of five clinical domains: cardiovascular, gastrointestinal, musculoskeletal, neurological, and respiratory. The authors compared mean percent-correct scores for HX and PE via a one-tailed paired-samples t test and examined mean score differences by clinical domain using analysis of variance techniques. Average PE scores (59.6%) were significantly lower than average HX scores (78.1%). The range of scores for PE (51.4%-72.7%) was larger than for HX (74.4%-81.0%), and the standard deviation for PE scores (28.3) was twice as large as the HX standard deviation (14.7). PE performance was significantly weaker for musculoskeletal and neurological encounters compared with other encounters. U.S. medical students perform worse on PE than HX; PE performance was weakest in musculoskeletal and neurology clinical domains. Findings may reflect imbalances in U.S. medical education, but more research is needed to fully understand the relationships among PE instruction, assessment, and proficiency.

Physical examination instruction in US pharmacy curricula

ObjectiveCompare physical examination instruction and competency expectations between US pharmacy schools. MethodsPharmacy Practice Department Chairs or their equivalents at all US pharmacy schools were surveyed regarding physical exam instruction and evaluation within their respective curricula. Opinions were also gathered regarding physical exam competency expectations and the need to formally evaluate this skill prior to graduation and for purposes of US licensure and federal healthcare provider recognition. The survey instrument was pretested prior to dissemination. ResultsThe survey response rate was 56%. Instructional and assessment methods used in teaching and evaluating physical exam skills were similar among responding US pharmacy programs. However, there is variability in the extent of physical exam instruction and evaluation as well as opinions related to physical exam competency expectations prior to graduation and for purposes of US pharmacy licensure and federal healthcare provider credentialing. Overall, 83% of programs require students to demonstrate correct exam techniques via a competency exam; however, only 52% of schools require students to apply physical findings to therapeutic decision-making. Respondents from new schools were more likely to support formal competency evaluation of physical exam skills via objective structured clinical exam for purposes of US licensure and healthcare provider credentialing compared to established schools (p < 0.05). ConclusionDifferences in competency expectations and the extent of physical exam instruction and evaluation in US pharmacy schools illustrate the need for a minimum national standard for this pharmacy practice skill.

G193(P) Consolidation of a Deanery Teaching Program for Paediatric Trainees Sitting the Membership for the Royal College of Paediatrics & Child Health Clinical Examination in the United Kingdom

AimMembership for the Royal College of Paediatric & Child Health (MRCPCH) is an essential qualification that all paediatric trainees in the United Kingdom must obtain to progress with their specialty...