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Teaching and Learning in Medicine: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/htlm20
Effect of Bedside Physical Diagnosis Training on ThirdYear Medical Students' Physical Exam Skills a
b
a
Lloyd Roberts , Wei-Hsin Lu , Roderick A. Go & Feroza Daroowalla a
a
Department of Medicine , Stony Brook University Medical Center , Stony Brook , NY , USA
b
Office of the Dean, School of Medicine , Stony Brook University Medical Center , Stony Brook , NY , USA Published online: 09 Jan 2014.
Click for updates To cite this article: Lloyd Roberts , Wei-Hsin Lu , Roderick A. Go & Feroza Daroowalla (2014) Effect of Bedside Physical Diagnosis Training on Third-Year Medical Students' Physical Exam Skills, Teaching and Learning in Medicine: An International Journal, 26:1, 81-85, DOI: 10.1080/10401334.2013.857329 To link to this article: http://dx.doi.org/10.1080/10401334.2013.857329
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Teaching and Learning in Medicine, 26(1), 81–85 C 2014, Taylor & Francis Group, LLC Copyright ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2013.857329
Effect of Bedside Physical Diagnosis Training on Third-Year Medical Students’ Physical Exam Skills Lloyd Roberts Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
Wei-Hsin Lu Office of the Dean, School of Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
Roderick A. Go and Feroza Daroowalla
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Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
patients, and the consequences of unnecessary testing: increasing medical costs, patient anxiety waiting for test results, and blocking access to testing for those patients that truly need it.4,5 Although bedside teaching is considered a valuable teaching tool, little research has been done to determine if teaching at the patient’s bedside improves medical students’ physical examination skills. J¨unger et al. piloted a course that included sessions on communications training, procedural skills, and bedside teaching; it did demonstrate an overall improvement in objective structured clinical examination (OSCE) scores, but most of those students were in the 4th year of their training and had already completed clerkships in internal medicine (IM).6 Smith et al. offered intensive instruction in physical examination skills to 3rd-year medical students and demonstrated an improvement in modified overall OSCE scores. In their study, the intervention had two arms for patient selection at each session: an organ-systems approach and an “abnormal physical exam findings” approach.7 Although the students in the intervention groups demonstrated a significant improvement in physical examination skills compared to students in the control groups, the student’s physical examination skills were assessed by faculty evaluators, which was extremely labor intensive. Faculty availability and the potential of introducing an element of faculty bias in assessing student performance limits the evaluation methods used in this study for replication at other institutions.7 At our institution, for the past several years 3rd- and 4th-year medical students have voiced concern that beyond the 2nd year Introduction to Clinical Medicine course, they have had limited experience with practicing their physical examination skills and being observed and getting feedback on their examination skills. This is in large part due to the team structure on the wards: each “rounding team” typically consists of an attending, an IM resident, two or three interns, one or two subinterns (4th-year medical students), two 3rd-year medical students, and sometimes a dental student or physician assistant student. The large team size puts the 3rd-year medical student at the bottom of the
Background: Graduating medical students, when surveyed, noted a deficit in training in physical examination skills. Purposes: In an attempt to remedy this deficit we implemented a pilot program for 3rd-year medical students consisting of twice-weekly bedside diagnosis rounds as part of their 8-week medicine clerkship. Methods: To assess the success of this program we reviewed students’ objective structured clinical exam (OSCE) scores at the completion of the clerkship compared with prior years’ students who did not have the bedside physical diagnosis training. Results: Students who were trained (n = 109) had an overall higher OSCE physical exam score (p < .01) than students without the training (n = 85). Conclusions: Bedside physical diagnosis rounds appear to have elevated the overall OSCE score for 3rd-year medical students. Keywords
clinical education, assessment of clinical performance, curriculum development and evaluation
INTRODUCTION Acquiring the skills of physical diagnosis is an essential part of medical school training. There is a growing concern, however, regarding deficiencies of physical examination skills among graduate medical trainees.1,2 As suggested in the literature, these deficiencies may result from the limited amount of bedside teaching provided to physicians in training3 and the reliance on new technologies to diagnose the patient.2 The positive aspects of teaching bedside physical examination include role modeling professional behavior, teaching the human dimension of medical practice including good communication skills, and demonstrating real-life physical examination findings.3 Neglecting physical exam education results in diminished bonding with
Correspondence may be sent to Lloyd Roberts, Department of Medicine, Stony Brook University Medical Center, HSC T-16, Room 020, Stony Brook, NY 11794, USA. E-mail: Lloyd.Roberts@ stonybrookmedicine.edu
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perceived pecking order, and consequently they are hesitant to demonstrate their examination skills in front of a large group during work rounds. In addition, attending physicians have a limited amount of time to focus on physical diagnosis skills with medical students during morning work rounds, as their primary focus during that time is to develop the daily care management plan for each patient and facilitate patient discharges. By default, a large portion of the medical students’ teaching during work rounds is performed by the IM residents, who have less expertise and training than the IM teaching attendings. Having a bedside physical diagnosis module taught by IM attendings will provide the medical students with teachers with a higher level of expertise. To address this need we established a training program for 3rd-year medical students as part of their required 8-week IM clerkship rotation that combined an abnormal physical exam findings approach with an organ systems approach at one site. Our objectives were twofold: (a) to provide a safe environment where medical students could practice and demonstrate their bedside physical examination skills, and (b) to allow for medical students to have exposure to a more uniform set of basic inpatient physical examination findings. We hypothesized that instituting a bedside physical diagnosis skills training program into the inpatient IM clerkship will improve medical students’ physical examination performance on the end-of-clerkship OSCE, which is part of the regular evaluation of student performance in the clerkship. This study was approved by the school’s human subjects Institutional Review Board.
METHODS Participants One hundred ninety-four 3rd-year medical school students participated in this study. During the 2nd year of medical school, all students (in both the control and intervention groups) take a yearlong physical diagnosis course called Introduction to Clinical Medicine, where baseline physical examination skills are taught. Research Design and the Clinical Setting A quasi-experimental, posttest-only nonequivalent control group design was used. The control group (n = 85) consisted of students from IM clerkship rotations from July 2007 through September 2009. The intervention group (n = 109) were students from IM clerkship rotations from October 2009 through June 2011. There was a subset of students who did their IM clerkship rotation at an affiliated site and was not included in this study. The students in this study rotated through the same hospital with the same group of teaching attendings throughout the study period, which may address concerns about historical bias. The hospital is a 597-bed tertiary care center that offers a wide range of specialized services and provides care for a variety
of common disorders in a suburban environment. It is reasonable to assume that because of the large number and variety of cases seen at this teaching hospital each year, the percentages of each medical condition seen are relatively similar from year to year. Therefore, for the purpose of this study we assumed that the students in the control group were exposed to a patient population with similar distribution of medical conditions as compared to the experimental group. All students in the IM clerkship at this site were assigned to a team on the General Medicine wards. The medical conditions that they would see on any given day are dependent on their team’s patient census. Consequently, the students in this study will likely not have the same exposure to a uniform set of basic medical conditions upon completion of their IM clerkship. Student Physical Examination Skills and the Intervention Students in the intervention group participated in the training program that consisted of twice-weekly bedside diagnosis rounds, whereas the students in the control group did not. Each session was approximately 1 hour long and was staffed by the same core group of volunteer medicine attending physicians. A majority of the volunteer attendings were junior faculty members board certified in IM with less than 5 years of clinical experience. These attendings were given guidelines to demonstrate and observe students doing a complete or focused physical exam on an in-patient but did not receive any special training in teaching bedside physical exam skills or other guidelines. The ratio of attending to students was usually 1:4. During the hourlong bedside session, the attending and students would typically see three to four patients. Each patient encounter would include the attending demonstrating a brief, focused history-taking and then demonstrating the physical examination skill relevant for that patient (e.g., full cardiac exam for patient with a heart murmur; focused cardio-pulmonary exam for patient with congestive heart failure). Students were then given the opportunity to ask questions, and each student from the group of four would practice that set of exam skills on the patient. During each session each student will have at least demonstrated performing one physical exam skill, and at the end of the clerkship each student will have practiced on at least 36 patients (12 bedside diagnosis sessions/clerkship × average 3 patients/session = 36 patient encounters/clerkship). Each student’s patient encounter would average between 5 to 10 minutes; therefore each student would average 252 minutes of patient encounter time for the entire bedside diagnosis module (average 7 minutes/patient × 36 patient encounters/clerkship = 252 minutes/clerkship). Patients seen were chosen because of an interesting physical finding (e.g., heart murmur, rash, wheezing). Effort was made to select patients with physical findings that were new to the students on that rotation. Each group’s experience with patients varied; consequently, all of the students were not exposed to the same physical exam findings.
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BEDSIDE PHYSICAL DIAGNOSIS TRAINING
Evaluation of the Training Program Students were required to complete an OSCE consisting of four simulated patient cases during the IM clerkship. The OSCE cases had extensively trained standardized patients (SPs) present commonly seen symptoms (i.e., chest pain, cough/chest pain, chronic shortness of breath, fatigue/hyperactivity). Each case takes approximately 10 to 15 minutes, which would include the student role-playing the case with the SP, followed by an evaluation by the SP of that interaction. The five areas evaluated by the SP were patient satisfaction, history-taking skills, physical examination skills, physician–patient interaction, and fundamentals of physical examination behavior. Students were evaluated and scored by the SPs using a checklist of actions or behaviors expected to be performed correctly or appropriately by the student. Each area had approximately five to six checklist items worth 1 point each, and the total possible score for the physical examination components on all cases was 23 points. All control and intervention group students completed the same OSCE cases. There is an honor system in place that prevents students from passing on the OSCE case information from one group to another. In addition, students are unaware of the items on the checklists, and therefore even if students from one group pass along information regarding the OSCE cases to another group, they are still graded by the SP based on his or her performance and behaviors according to the checklist. Data Analysis An independent samples t-test was conducted to compare the physical examination (PE) scores on all four OSCE cases and the overall OSCE PE score between students in the intervention and control groups. A paired-samples t-test was conducted to evaluate the effect of the bedside physical diagnosis training program on student self-report of attitudes regarding physical examination comfort level and skill assessment. RESULTS Table 1 shows the mean OSCE PE scores for both the intervention and control groups. T-test results indicated a significant
difference between the intervention and control groups on Case 3, t(192) = 3.84, p = .001; Case 4, t(192) = 4.81, p = .001; and the overall PE score, t(192) = 2.69, p = .01. There was no statistically significant difference in the results for Cases 1 and 2, t(192) = –1.34, p = .18; t(192) = –0.74, p = .46, respectively. DISCUSSION Third-year medical students who took part in the bedside physical diagnosis training program demonstrated higher overall physical examination skills as measured on the OSCE than those students who did not undergo the training, although the improvement was small, with the overall OSCE PE score moving from 11.35 to 12.57 out of a possible 23 points. This improvement was driven by the statistically significant change in the OSCE cases that focused on chronic shortness of breath and fatigue/hyperactivity. There were no differences in the physical examination OSCE scores for the cases of chest pain and cough/chest pain between students in the intervention and control groups. One likely explanation is our current approach during the bedside diagnosis module to find cases based on both availability of abnormal findings and attempts to cover all body systems by the completion of each clerkship rotation. This has resulted in student deficiencies in exposure to bedside physical examination findings for certain body systems. This lack of consistency among all students may explain why we failed to note an improvement on the OSCE for the “chest pain” and “cough/chest pain” cases. There are other possible explanations for our findings. In developing a diagnosis and plan for patients, students may rely less on the physical examination findings such as chest pain and cough/chest pain, and more on patient history, resulting in less attention to physical examination. Another possibility is that because the skills for evaluation of the symptoms of chest pain and cough are fairly basic (lung and heart exam), there is less room for improvement in a bedside physical examination training program. This is borne out by the relatively high scores that the control group received in these cases.
TABLE 1 Mean OSCE physical exam scores for intervention and control groups Control Groupa OSCE CASE Case 1: Chest Pain (Total Possible Points: 6) Case 2: Cough/Chest Pain (Total Possible Points: 6) Case 3: Chronic Shortness of Breath (Total Possible Points: 5) Case 4: Fatigue/Hyperactivity (Total Possible Points 6) Overall OSCE PE Performance (Total Possible Score for All 4 Cases: 23 Points) Note: OSCE = objective structured clinical exam; PE = physical exam. a n = 85. bn = 109.
Intervention Groupb
M
SD
M
SD
p
3.37 3.78 2.45 1.74 11.35
1.49 0.84 1.07 1.26 2.76
3.06 3.68 3.16 2.67 12.57
1.73 0.99 1.41 1.40 3.42
.18 .46 .001 .001 .01
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Although the reliability and validity of the OSCE to measure physical examination skills has been previously well documented,7–9 some checklists utilized by the SPs may be insufficiently sensitive to measure differences in physical examination skills. Similar results were found by Smith et al. in their evaluation of a 3rd-year medical student bedside physical examination course with an improvement in overall OSCE scores but lack of statistical improvement in some individual case scores.7 It is not well established that performance on a standardized patient OSCE correlates with performance with real patients. A recent review of 113 articles in the field of simulation in medical education found only a few studies that demonstrated an improvement in clinical outcomes.10 A better metric of the long-term benefits may be to study whether students continue to incorporate and improve on their physical exam skills in subsequent years of medical school and graduate training. We have learned from this study to modify the course content and offer body systems-based instruction for each session (e.g., pulmonary, cardiac, etc.). The sessions are scheduled in advance so the students are aware which body system will be covered on a given week, and faculty with specialty training in that body system are scheduled to lecture and offer bedside instruction on that given day. This should provide more consistent teaching across all students and allow for a standardized course curriculum. This will also ensure that all students during the clerkship will receive a uniform set of bedside examination training on all major body systems. By focusing on one body system on a given day taught by an expert in that body system, it is hoped that students will acquire an improved ability to recognize and interpret abnormal physical findings, which is the goal of a bedside physical diagnosis course module. With our current course approach utilizing both available “abnormal physical findings” for that day and “body systems,” not all students will experience bedside physical examination training in all body systems by the completion of their clerkship. Modifying the course content by body system will also allow for alteration of the OSCE cases by body system, which will better assess the physical examination skills that the students have been taught. This approach has been demonstrated to be successful in the 3rd-year medicine clerkship at other medical schools.7 For the students, this new bedside physical diagnosis training likely had several advantages over the prior standard IM clerkship curriculum. Advantages included more exposure to physical findings, additional instruction regarding the physiology behind the physical findings, formulation of differential diagnoses, and increased direct patient interaction. Faculty motivation to volunteer their time to train medical students was twofold: (a) their frustration with medical students’ lack of physical examination skills as noted during morning work rounds, and (b) their desire to give medical students an opportunity to observe attending physicians demonstrate physical examination skills with a subsequent opportunity to practice these skills on actual patients.
There are several limitations to this study. First, due to the nature of clinical bedside medicine and its dependence on the inpatient population, each rotation of medical students will have exposure to different physical findings, although when we examined our list of covered conditions, we noted almost universal exposure to some common physical findings including cardiac murmurs, abnormal lung sounds, volume overload, and various rashes. Second, there may also exist an element of history bias: the students in the intervention group were better able to assess their OSCE patients presenting with fatigue and shortness of breath because they had more inpatient ward exposure to patients with those symptoms rather than their experience with the bedside physical examination module causing their improved OSCE scores. It would be quite difficult to control for this element of history bias, as there is no way to control which inpatient cases medical students are exposed to on their inpatient general medicine teams. Third, there was not a standardized training program that the attending physicians underwent before teaching the bedside physical examination program, so not all of the students had the same quality of teaching. This could affect their performance on the OSCE as well. Fourth, students’ OSCE scores were based on standardized patient evaluations. Although the standardized patients are given a set of criteria in order to score each student, there is some degree of subjectivity among the SPs; in fact, there have been studies that demonstrated problems with SP interrater reliability and validity.11 Fifth, the students were aware that the OSCE cases are standardized patients who are actors and not true patients, thus they would not expect to find physical abnormalities when they examined the SPs. Consequently, this could affect the students’ OSCE PE scores. Finally, this study was conducted at one institution and therefore may not be generalizable to other medical schools.
CONCLUSION The addition of bedside physical diagnosis training to the 3rd-year medical student IM clerkship modestly improved students’ physical examination skills with respect to patients’ presenting with fatigue and shortness of breath, as measured by the standardized patient OSCE. Students did not demonstrate any significant improvement in physical examination skills for patients presenting with chest pain and/or cough. This improvement certainly falls short of our expectations by the addition of the bedside physical diagnosis training module. The trend toward improvement in physical examination skills demonstrated to us the benefit of adding a bedside physical diagnosis module to the medicine clerkship. However, to strengthen the students’ skills in recognizing and interpreting abnormal physical examination findings as evidenced by a stronger performance on the OSCE exam, we have modified the training module to offer body-systemsbased instruction for each session. Further study is needed to
BEDSIDE PHYSICAL DIAGNOSIS TRAINING
determine if this change is sustainable as students progress through their training. REFERENCES
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1. Fletcher RH, Fletcher SW. Has medicine outgrown physical diagnosis? Annals of Internal Medicine 1992;117;9:786–7. 2. Jauhar S. The demise of the physical exam. New England Journal of Medicine 2006;354:548–51. 3. Ramani S, Orlander JD, Strunin L, Barber TW. Whither bedside teaching? A focus-group study of clinical teachers. Academic Medicine 2003;78:384–90. 4. Brendan MR. Physical examination in the care of medical inpatients: An observational study. Lancet 2003;362:1100–5. 5. McDermott W. Medicine: The public good and one’s own. Perspectives in Biology and Medicine 1978;21:167–87.
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6. J¨unger J, Sch¨afer S, Roth C, Schellberg D, Friedman B-DM, Nikendei C. Effects of basic clinical skills training on objective structured clinical examination performance. Medical Education 2005;39:1015–20. 7. Smith M, Burton W, Mackay M. Development, impact, and measurement of enhanced physical diagnosis skills. Advances in Health Sciences and Education 2009;14:547–56. 8. Rawlings ADKB. Use of a modified OSCE to assess nurse practitioner students. British Journal of Nursing 2008;17:754–9. 9. Berg D, Sebastian J, Heudebert G. Development, implementation, and evaluation of an advanced physical diagnosis course for senior medical students. Academic Medicine 1994;69:758–64. 10. Okuda Y, Bryson EO, DeMaria S, Jacobson L, Quinones J, Shen B, et al. The utility of simulation in medical education: What is the evidence? Mt Sinai Journal of Medicine 2009;76:330–43. 11. Iramaneerat C, Yudkowsky R. Rater errors in a clinical skills assessment of medical students. Evaluation & the Health Professions 2007;30:266–83.
Teaching and Learning in Medicine: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/htlm20
Effect of Bedside Physical Diagnosis Training on ThirdYear Medical Students' Physical Exam Skills a
b
a
Lloyd Roberts , Wei-Hsin Lu , Roderick A. Go & Feroza Daroowalla a
a
Department of Medicine , Stony Brook University Medical Center , Stony Brook , NY , USA
b
Office of the Dean, School of Medicine , Stony Brook University Medical Center , Stony Brook , NY , USA Published online: 09 Jan 2014.
Click for updates To cite this article: Lloyd Roberts , Wei-Hsin Lu , Roderick A. Go & Feroza Daroowalla (2014) Effect of Bedside Physical Diagnosis Training on Third-Year Medical Students' Physical Exam Skills, Teaching and Learning in Medicine: An International Journal, 26:1, 81-85, DOI: 10.1080/10401334.2013.857329 To link to this article: http://dx.doi.org/10.1080/10401334.2013.857329
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Teaching and Learning in Medicine, 26(1), 81–85 C 2014, Taylor & Francis Group, LLC Copyright ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2013.857329
Effect of Bedside Physical Diagnosis Training on Third-Year Medical Students’ Physical Exam Skills Lloyd Roberts Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
Wei-Hsin Lu Office of the Dean, School of Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
Roderick A. Go and Feroza Daroowalla
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Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
patients, and the consequences of unnecessary testing: increasing medical costs, patient anxiety waiting for test results, and blocking access to testing for those patients that truly need it.4,5 Although bedside teaching is considered a valuable teaching tool, little research has been done to determine if teaching at the patient’s bedside improves medical students’ physical examination skills. J¨unger et al. piloted a course that included sessions on communications training, procedural skills, and bedside teaching; it did demonstrate an overall improvement in objective structured clinical examination (OSCE) scores, but most of those students were in the 4th year of their training and had already completed clerkships in internal medicine (IM).6 Smith et al. offered intensive instruction in physical examination skills to 3rd-year medical students and demonstrated an improvement in modified overall OSCE scores. In their study, the intervention had two arms for patient selection at each session: an organ-systems approach and an “abnormal physical exam findings” approach.7 Although the students in the intervention groups demonstrated a significant improvement in physical examination skills compared to students in the control groups, the student’s physical examination skills were assessed by faculty evaluators, which was extremely labor intensive. Faculty availability and the potential of introducing an element of faculty bias in assessing student performance limits the evaluation methods used in this study for replication at other institutions.7 At our institution, for the past several years 3rd- and 4th-year medical students have voiced concern that beyond the 2nd year Introduction to Clinical Medicine course, they have had limited experience with practicing their physical examination skills and being observed and getting feedback on their examination skills. This is in large part due to the team structure on the wards: each “rounding team” typically consists of an attending, an IM resident, two or three interns, one or two subinterns (4th-year medical students), two 3rd-year medical students, and sometimes a dental student or physician assistant student. The large team size puts the 3rd-year medical student at the bottom of the
Background: Graduating medical students, when surveyed, noted a deficit in training in physical examination skills. Purposes: In an attempt to remedy this deficit we implemented a pilot program for 3rd-year medical students consisting of twice-weekly bedside diagnosis rounds as part of their 8-week medicine clerkship. Methods: To assess the success of this program we reviewed students’ objective structured clinical exam (OSCE) scores at the completion of the clerkship compared with prior years’ students who did not have the bedside physical diagnosis training. Results: Students who were trained (n = 109) had an overall higher OSCE physical exam score (p < .01) than students without the training (n = 85). Conclusions: Bedside physical diagnosis rounds appear to have elevated the overall OSCE score for 3rd-year medical students. Keywords
clinical education, assessment of clinical performance, curriculum development and evaluation
INTRODUCTION Acquiring the skills of physical diagnosis is an essential part of medical school training. There is a growing concern, however, regarding deficiencies of physical examination skills among graduate medical trainees.1,2 As suggested in the literature, these deficiencies may result from the limited amount of bedside teaching provided to physicians in training3 and the reliance on new technologies to diagnose the patient.2 The positive aspects of teaching bedside physical examination include role modeling professional behavior, teaching the human dimension of medical practice including good communication skills, and demonstrating real-life physical examination findings.3 Neglecting physical exam education results in diminished bonding with
Correspondence may be sent to Lloyd Roberts, Department of Medicine, Stony Brook University Medical Center, HSC T-16, Room 020, Stony Brook, NY 11794, USA. E-mail: Lloyd.Roberts@ stonybrookmedicine.edu
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perceived pecking order, and consequently they are hesitant to demonstrate their examination skills in front of a large group during work rounds. In addition, attending physicians have a limited amount of time to focus on physical diagnosis skills with medical students during morning work rounds, as their primary focus during that time is to develop the daily care management plan for each patient and facilitate patient discharges. By default, a large portion of the medical students’ teaching during work rounds is performed by the IM residents, who have less expertise and training than the IM teaching attendings. Having a bedside physical diagnosis module taught by IM attendings will provide the medical students with teachers with a higher level of expertise. To address this need we established a training program for 3rd-year medical students as part of their required 8-week IM clerkship rotation that combined an abnormal physical exam findings approach with an organ systems approach at one site. Our objectives were twofold: (a) to provide a safe environment where medical students could practice and demonstrate their bedside physical examination skills, and (b) to allow for medical students to have exposure to a more uniform set of basic inpatient physical examination findings. We hypothesized that instituting a bedside physical diagnosis skills training program into the inpatient IM clerkship will improve medical students’ physical examination performance on the end-of-clerkship OSCE, which is part of the regular evaluation of student performance in the clerkship. This study was approved by the school’s human subjects Institutional Review Board.
METHODS Participants One hundred ninety-four 3rd-year medical school students participated in this study. During the 2nd year of medical school, all students (in both the control and intervention groups) take a yearlong physical diagnosis course called Introduction to Clinical Medicine, where baseline physical examination skills are taught. Research Design and the Clinical Setting A quasi-experimental, posttest-only nonequivalent control group design was used. The control group (n = 85) consisted of students from IM clerkship rotations from July 2007 through September 2009. The intervention group (n = 109) were students from IM clerkship rotations from October 2009 through June 2011. There was a subset of students who did their IM clerkship rotation at an affiliated site and was not included in this study. The students in this study rotated through the same hospital with the same group of teaching attendings throughout the study period, which may address concerns about historical bias. The hospital is a 597-bed tertiary care center that offers a wide range of specialized services and provides care for a variety
of common disorders in a suburban environment. It is reasonable to assume that because of the large number and variety of cases seen at this teaching hospital each year, the percentages of each medical condition seen are relatively similar from year to year. Therefore, for the purpose of this study we assumed that the students in the control group were exposed to a patient population with similar distribution of medical conditions as compared to the experimental group. All students in the IM clerkship at this site were assigned to a team on the General Medicine wards. The medical conditions that they would see on any given day are dependent on their team’s patient census. Consequently, the students in this study will likely not have the same exposure to a uniform set of basic medical conditions upon completion of their IM clerkship. Student Physical Examination Skills and the Intervention Students in the intervention group participated in the training program that consisted of twice-weekly bedside diagnosis rounds, whereas the students in the control group did not. Each session was approximately 1 hour long and was staffed by the same core group of volunteer medicine attending physicians. A majority of the volunteer attendings were junior faculty members board certified in IM with less than 5 years of clinical experience. These attendings were given guidelines to demonstrate and observe students doing a complete or focused physical exam on an in-patient but did not receive any special training in teaching bedside physical exam skills or other guidelines. The ratio of attending to students was usually 1:4. During the hourlong bedside session, the attending and students would typically see three to four patients. Each patient encounter would include the attending demonstrating a brief, focused history-taking and then demonstrating the physical examination skill relevant for that patient (e.g., full cardiac exam for patient with a heart murmur; focused cardio-pulmonary exam for patient with congestive heart failure). Students were then given the opportunity to ask questions, and each student from the group of four would practice that set of exam skills on the patient. During each session each student will have at least demonstrated performing one physical exam skill, and at the end of the clerkship each student will have practiced on at least 36 patients (12 bedside diagnosis sessions/clerkship × average 3 patients/session = 36 patient encounters/clerkship). Each student’s patient encounter would average between 5 to 10 minutes; therefore each student would average 252 minutes of patient encounter time for the entire bedside diagnosis module (average 7 minutes/patient × 36 patient encounters/clerkship = 252 minutes/clerkship). Patients seen were chosen because of an interesting physical finding (e.g., heart murmur, rash, wheezing). Effort was made to select patients with physical findings that were new to the students on that rotation. Each group’s experience with patients varied; consequently, all of the students were not exposed to the same physical exam findings.
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BEDSIDE PHYSICAL DIAGNOSIS TRAINING
Evaluation of the Training Program Students were required to complete an OSCE consisting of four simulated patient cases during the IM clerkship. The OSCE cases had extensively trained standardized patients (SPs) present commonly seen symptoms (i.e., chest pain, cough/chest pain, chronic shortness of breath, fatigue/hyperactivity). Each case takes approximately 10 to 15 minutes, which would include the student role-playing the case with the SP, followed by an evaluation by the SP of that interaction. The five areas evaluated by the SP were patient satisfaction, history-taking skills, physical examination skills, physician–patient interaction, and fundamentals of physical examination behavior. Students were evaluated and scored by the SPs using a checklist of actions or behaviors expected to be performed correctly or appropriately by the student. Each area had approximately five to six checklist items worth 1 point each, and the total possible score for the physical examination components on all cases was 23 points. All control and intervention group students completed the same OSCE cases. There is an honor system in place that prevents students from passing on the OSCE case information from one group to another. In addition, students are unaware of the items on the checklists, and therefore even if students from one group pass along information regarding the OSCE cases to another group, they are still graded by the SP based on his or her performance and behaviors according to the checklist. Data Analysis An independent samples t-test was conducted to compare the physical examination (PE) scores on all four OSCE cases and the overall OSCE PE score between students in the intervention and control groups. A paired-samples t-test was conducted to evaluate the effect of the bedside physical diagnosis training program on student self-report of attitudes regarding physical examination comfort level and skill assessment. RESULTS Table 1 shows the mean OSCE PE scores for both the intervention and control groups. T-test results indicated a significant
difference between the intervention and control groups on Case 3, t(192) = 3.84, p = .001; Case 4, t(192) = 4.81, p = .001; and the overall PE score, t(192) = 2.69, p = .01. There was no statistically significant difference in the results for Cases 1 and 2, t(192) = –1.34, p = .18; t(192) = –0.74, p = .46, respectively. DISCUSSION Third-year medical students who took part in the bedside physical diagnosis training program demonstrated higher overall physical examination skills as measured on the OSCE than those students who did not undergo the training, although the improvement was small, with the overall OSCE PE score moving from 11.35 to 12.57 out of a possible 23 points. This improvement was driven by the statistically significant change in the OSCE cases that focused on chronic shortness of breath and fatigue/hyperactivity. There were no differences in the physical examination OSCE scores for the cases of chest pain and cough/chest pain between students in the intervention and control groups. One likely explanation is our current approach during the bedside diagnosis module to find cases based on both availability of abnormal findings and attempts to cover all body systems by the completion of each clerkship rotation. This has resulted in student deficiencies in exposure to bedside physical examination findings for certain body systems. This lack of consistency among all students may explain why we failed to note an improvement on the OSCE for the “chest pain” and “cough/chest pain” cases. There are other possible explanations for our findings. In developing a diagnosis and plan for patients, students may rely less on the physical examination findings such as chest pain and cough/chest pain, and more on patient history, resulting in less attention to physical examination. Another possibility is that because the skills for evaluation of the symptoms of chest pain and cough are fairly basic (lung and heart exam), there is less room for improvement in a bedside physical examination training program. This is borne out by the relatively high scores that the control group received in these cases.
TABLE 1 Mean OSCE physical exam scores for intervention and control groups Control Groupa OSCE CASE Case 1: Chest Pain (Total Possible Points: 6) Case 2: Cough/Chest Pain (Total Possible Points: 6) Case 3: Chronic Shortness of Breath (Total Possible Points: 5) Case 4: Fatigue/Hyperactivity (Total Possible Points 6) Overall OSCE PE Performance (Total Possible Score for All 4 Cases: 23 Points) Note: OSCE = objective structured clinical exam; PE = physical exam. a n = 85. bn = 109.
Intervention Groupb
M
SD
M
SD
p
3.37 3.78 2.45 1.74 11.35
1.49 0.84 1.07 1.26 2.76
3.06 3.68 3.16 2.67 12.57
1.73 0.99 1.41 1.40 3.42
.18 .46 .001 .001 .01
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L. ROBERTS, W.-H. LU, R. A. GO, F. DAROOWALLA
Although the reliability and validity of the OSCE to measure physical examination skills has been previously well documented,7–9 some checklists utilized by the SPs may be insufficiently sensitive to measure differences in physical examination skills. Similar results were found by Smith et al. in their evaluation of a 3rd-year medical student bedside physical examination course with an improvement in overall OSCE scores but lack of statistical improvement in some individual case scores.7 It is not well established that performance on a standardized patient OSCE correlates with performance with real patients. A recent review of 113 articles in the field of simulation in medical education found only a few studies that demonstrated an improvement in clinical outcomes.10 A better metric of the long-term benefits may be to study whether students continue to incorporate and improve on their physical exam skills in subsequent years of medical school and graduate training. We have learned from this study to modify the course content and offer body systems-based instruction for each session (e.g., pulmonary, cardiac, etc.). The sessions are scheduled in advance so the students are aware which body system will be covered on a given week, and faculty with specialty training in that body system are scheduled to lecture and offer bedside instruction on that given day. This should provide more consistent teaching across all students and allow for a standardized course curriculum. This will also ensure that all students during the clerkship will receive a uniform set of bedside examination training on all major body systems. By focusing on one body system on a given day taught by an expert in that body system, it is hoped that students will acquire an improved ability to recognize and interpret abnormal physical findings, which is the goal of a bedside physical diagnosis course module. With our current course approach utilizing both available “abnormal physical findings” for that day and “body systems,” not all students will experience bedside physical examination training in all body systems by the completion of their clerkship. Modifying the course content by body system will also allow for alteration of the OSCE cases by body system, which will better assess the physical examination skills that the students have been taught. This approach has been demonstrated to be successful in the 3rd-year medicine clerkship at other medical schools.7 For the students, this new bedside physical diagnosis training likely had several advantages over the prior standard IM clerkship curriculum. Advantages included more exposure to physical findings, additional instruction regarding the physiology behind the physical findings, formulation of differential diagnoses, and increased direct patient interaction. Faculty motivation to volunteer their time to train medical students was twofold: (a) their frustration with medical students’ lack of physical examination skills as noted during morning work rounds, and (b) their desire to give medical students an opportunity to observe attending physicians demonstrate physical examination skills with a subsequent opportunity to practice these skills on actual patients.
There are several limitations to this study. First, due to the nature of clinical bedside medicine and its dependence on the inpatient population, each rotation of medical students will have exposure to different physical findings, although when we examined our list of covered conditions, we noted almost universal exposure to some common physical findings including cardiac murmurs, abnormal lung sounds, volume overload, and various rashes. Second, there may also exist an element of history bias: the students in the intervention group were better able to assess their OSCE patients presenting with fatigue and shortness of breath because they had more inpatient ward exposure to patients with those symptoms rather than their experience with the bedside physical examination module causing their improved OSCE scores. It would be quite difficult to control for this element of history bias, as there is no way to control which inpatient cases medical students are exposed to on their inpatient general medicine teams. Third, there was not a standardized training program that the attending physicians underwent before teaching the bedside physical examination program, so not all of the students had the same quality of teaching. This could affect their performance on the OSCE as well. Fourth, students’ OSCE scores were based on standardized patient evaluations. Although the standardized patients are given a set of criteria in order to score each student, there is some degree of subjectivity among the SPs; in fact, there have been studies that demonstrated problems with SP interrater reliability and validity.11 Fifth, the students were aware that the OSCE cases are standardized patients who are actors and not true patients, thus they would not expect to find physical abnormalities when they examined the SPs. Consequently, this could affect the students’ OSCE PE scores. Finally, this study was conducted at one institution and therefore may not be generalizable to other medical schools.
CONCLUSION The addition of bedside physical diagnosis training to the 3rd-year medical student IM clerkship modestly improved students’ physical examination skills with respect to patients’ presenting with fatigue and shortness of breath, as measured by the standardized patient OSCE. Students did not demonstrate any significant improvement in physical examination skills for patients presenting with chest pain and/or cough. This improvement certainly falls short of our expectations by the addition of the bedside physical diagnosis training module. The trend toward improvement in physical examination skills demonstrated to us the benefit of adding a bedside physical diagnosis module to the medicine clerkship. However, to strengthen the students’ skills in recognizing and interpreting abnormal physical examination findings as evidenced by a stronger performance on the OSCE exam, we have modified the training module to offer body-systemsbased instruction for each session. Further study is needed to
BEDSIDE PHYSICAL DIAGNOSIS TRAINING
determine if this change is sustainable as students progress through their training. REFERENCES
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6. J¨unger J, Sch¨afer S, Roth C, Schellberg D, Friedman B-DM, Nikendei C. Effects of basic clinical skills training on objective structured clinical examination performance. Medical Education 2005;39:1015–20. 7. Smith M, Burton W, Mackay M. Development, impact, and measurement of enhanced physical diagnosis skills. Advances in Health Sciences and Education 2009;14:547–56. 8. Rawlings ADKB. Use of a modified OSCE to assess nurse practitioner students. British Journal of Nursing 2008;17:754–9. 9. Berg D, Sebastian J, Heudebert G. Development, implementation, and evaluation of an advanced physical diagnosis course for senior medical students. Academic Medicine 1994;69:758–64. 10. Okuda Y, Bryson EO, DeMaria S, Jacobson L, Quinones J, Shen B, et al. The utility of simulation in medical education: What is the evidence? Mt Sinai Journal of Medicine 2009;76:330–43. 11. Iramaneerat C, Yudkowsky R. Rater errors in a clinical skills assessment of medical students. Evaluation & the Health Professions 2007;30:266–83.
