Using virtual patients to improve cardiac examination competency in medical students.

BACKGROUND: Cardiac examination (CE) skills are in decline. Most prior studies employed audio recordings, evaluating only one aspect of CE (i.e., auscultation) that precluded correlation with visible observations. To address these deficiencies, we developed a curriculum using virtual patient examinations (VPEs); bedside recordings of patients with visible and audible cardiovascular findings presented as interactive multimedia. HYPOTHESIS: The purpose of this study was to evaluate whether VPEs improve CE skills, and whether any improvements are retained. We assessed CE competency overall and in 4 categories: inspection, auscultation, knowledge, and integration of audio and visual skills. METHODS: Students (n = 24) undergoing the 8-wk Internal Medicine (IM) clerkship rotation and receiving supervised instruction with VPEs (intervention group) were compared with students (n = 58) undergoing IM clerkship rotation without supplemental CE instruction (control group). The groups were tested at the beginning and the end of their rotations. RESULTS: The Intervention group improved significantly in overall mean scores: from 58.7 to 73.5 (p = 0.0001). The Control group did not improve: from 60.1 to 59.5 (p = 0.788). The Intervention group improved inspection, auscultation, and knowledge (all p

Competency in cardiac examination skills in medical students, trainees, physicians, and faculty: a multicenter study.

BACKGROUND: Cardiac examination is an essential aspect of the physical examination. Previous studies have shown poor diagnostic accuracy, but most used audio recordings, precluding correlation with visible observations. The training spectrum from medical students (MSs) to faculty has not been tested, to our knowledge. METHODS: A validated 50-question, computer-based test was used to assess 4 aspects of cardiac examination competency: (1) cardiac physiology knowledge, (2) auditory skills, (3) visual skills, and (4) integration of auditory and visual skills using computer graphic animations and virtual patient examinations (actual patients filmed at the bedside). We tested 860 participants: 318 MSs, 289 residents (225 internal medicine and 64 family medicine), 85 cardiology fellows, 131 physicians (50 full-time faculty, 12 volunteer clinical faculty, and 69 private practitioners), and 37 others. RESULTS: Mean scores improved from MS1-2 to MS3-4 (P = .003) but did not improve or differ significantly among MS3, MS4, internal medicine residents, family medicine residents, full-time faculty, volunteer clinical faculty, and private practitioners. Only cardiology fellows tested significantly better (P<.001), and they were the best in all 4 subcategories of competency, whereas MS1-2 were the worst in the auditory and visual subcategories. Participants demonstrated low specificity for systolic murmurs (0.35) and low sensitivity for diastolic murmurs (0.49). CONCLUSIONS: Cardiac examination skills do not improve after MS3 and may decline after years in practice, which has important implications for medical decision making, patient safety, cost-effective care, and continuing medical education. Improvement in cardiac examination competency will require training in simultaneous audio and visual examination in faculty and trainees.

Confidential testing of cardiac examination competency in cardiology and noncardiology faculty and trainees: a multicenter study.

BACKGROUND: Many reported studies of medical trainees and physicians have demonstrated major deficiencies in correctly identifying heart sounds and murmurs, but cardiologists had not been tested. We previously confirmed these deficiencies using a 50-question multimedia cardiac examination (CE) test featuring video vignettes of patients with auscultatory and visible manifestations of cardiovascular pathology (virtual cardiac patients). Previous testing of 62 internal medical faculty yielded scores no better than those of medical students and residents. HYPOTHESIS: In this study, we tested whether cardiologists outperformed other physicians in cardiac examination skills, and whether years in practice correlated with test performance. METHODS: To obviate cardiologists' reluctance to be tested, the CE test was installed at 19 US teaching centers for confidential testing. Test scores and demographic data (training level, subspecialty, and years in practice) were uploaded to a secure database. RESULTS: The 520 tests revealed mean scores (out of 100 ± 95% confidence interval) in descending order: 10 cardiology volunteer faculty (86.3 ± 8.0), 57 full-time cardiologists (82.0 ± 3.3), 4 private-practice cardiologists (77.0 ± 6.8), and 19 noncardiology faculty (67.3 ± 8.8). Trainees' scores in descending order: 150 cardiology fellows (77.3 ± 2.1), 78 medical students (63.7 ± 3.5), 95 internal medicine residents (62.7 ± 3.2), and 107 family medicine residents (59.2 ± 3.2). Faculty scores were higher in those trained earlier with longer practice experience. CONCLUSIONS: Academic and volunteer cardiologists outperformed other medical faculty, as did cardiology fellows. Lower scores were observed in more recently trained faculty. Remote testing yielded scores similar to proctored tests in comparable groups previously studied. No significant improvement was seen after medical school with residency training.

Innovative web-based multimedia curriculum improves cardiac examination competency of residents.

BACKGROUND: Proper diagnosis of cardiac disorders is a core competency of internists. Yet numerous studies have documented that the cardiac examination (CE) skills of physicians have declined compared with those of previous generations of physicians, attributed variously to inadequate exposure to cardiac patients and lack of skilled bedside teaching. With growing concerns about ensuring patient safety and quality of care, public and professional organizations are calling for a renewed emphasis on the teaching and evaluation of clinical skills in residency training. OBJECTIVE: The objective of the study was to determine whether Web training improves CE competency, whether residents retain what they learn, and whether a Web-based curriculum plus clinical training is better than clinical training alone. Journal of Hospital Medicine 2008;3:124-133. (c) 2008 Society of Hospital Medicine. DESIGN: This was a controlled intervention study. PARTICIPANTS: The intervention group (34 internal and family medicine interns) participated in self-directed use of a Web-based tutorial and three 1-hour teaching sessions taught by a hospitalist. Twenty-five interns from the prior year served as controls. MEASUREMENTS: We assessed overall CE competency and 4 subcategories of CE competency: knowledge, audio skills, visual skills, and audio-visual integration. RESULTS: The over mean score of the intervention group significantly improved, from 54 to 66 (P = .002). This improvement was retained (63.5, P = .05). When compared with end-of-year controls, the intervention group had significantly higher end-of-year CE scores (57 vs. 63.5, P = .05), knowledge (P = .04), and audio skills (P = .01). At the end of the academic year, all improvements were retained (P