Performance of Cardiovascular Physical Exam Skills by Internal Medicine Residents.

OBJECTIVE: Few studies have assessed the ability of internal medicine residents to perform a cardiovascular physical examination using real patients. METHODS: First year internal medicine interns from two large academic medical centers in Maryland examined the same patient with aortic insufficiency as part of the Assessment of Physical Examination and Communication Skills (APECS). Interns were assessed on five clinical domains: physical exam technique, identifying physical signs, generating a differential diagnosis, clinical judgement, and maintaining patient welfare. Spearman's correlation test was used to describe associations between clinical domains. Preceptor comments were examined to identify common errors in physical exam technique and identifying physical signs. RESULTS: One-hundred and nine interns examined the same patient with aortic insufficiency across 14 APECS sessions. Only 58 interns (53.2%) correctly identified the presence of a diastolic murmur, and only 52 interns (47.7%) included aortic insufficiency on their differential diagnosis. There was a significant and positive correlation between physical exam technique and identification of the correct physical findings (r=0.42, p<0.001). Both technique (r=0.34, p=0.003) and identifying findings (r=0.42, p<0.001) were significantly associated with generating an appropriate differential diagnosis. Common errors in technique included auscultating over the gown, timing the cardiac cycle with the radial pulse, and failing to palpate for the apical impulse. CONCLUSIONS: Internal medicine interns had variable skills in performing and interpreting the cardiovascular physical exam. Improving cardiovascular exam skills would likely lead to increased identification of relevant cardiovascular findings, inform clinical decision making and improve overall patient care.

Internal medicine intern performance on the gastrointestinal physical exam.

OBJECTIVES: The gastrointestinal (GI) physical exam provides critical information about underlying disease states. However, since assessment of physical examination skills is rarely conducted as part of internal medicine residency training, little is known about resident performance on the GI physical exam. METHODS: During a clinical skills assessment that took place between November 2019 and February 2020, internal medicine interns examined the same patient with chronic liver disease while being observed by faculty preceptors. We compared the exam maneuvers performed with those expected by the faculty evaluators. We noted which maneuvers were performed incorrectly, whether physical exam technique correlated with identification of physical exam findings, and if performance on the physical exam was associated with building an appropriate differential diagnosis. This four-hour assessment was required for internal medicine interns within two different residency programs in the Baltimore area. RESULTS: More than half of the 29 participating interns (n=17, 58.6 %) received a "needs improvement" score on their physical exam technique. Technique was highly correlated with identifying the correct physical signs (r=0.88, p<0.0001). The most commonly excluded maneuvers were assessing for splenomegaly and hepatomegaly. The most commonly missed findings were splenomegaly and hepatomegaly. Most interns included chronic liver disease as part of their differential diagnosis even if they received "needs improvement" scores on physical exam technique or identifying physical signs. CONCLUSIONS: Internal medicine interns would benefit from learning an organized approach to the gastrointestinal exam. This would likely lead to increased identification of important gastrointestinal findings.

Improvement of Medical Student Performance in Telemedicine Standardized Patient Encounters Following an Educational Intervention.

BACKGROUND AND OBJECTIVES: The Association of American Medical Colleges identifies telemedicine competence as an important skill for graduating medical students, but which educational methods are effective in improving student performance is unclear. We aimed to assess the impact of two educational interventions on student performance in telemedicine standardized patient encounters. METHODS: Sixty second-year medical students participated in the telemedicine curriculum during their required longitudinal ambulatory clerkship. Students first completed a preintervention telemedicine standardized patient (SP) encounter in October 2020. They subsequently were assigned to two intervention groups (ie, a role-play intervention, N=30; a faculty demonstration, N=30) and completed a teaching case. In December 2020, they completed a postintervention telemedicine SP encounter. Each case was a unique clinical scenario. SPs scored the encounters across six domains based on a standardized performance checklist. We compared the median scores for these domains and the median total score pre- and postintervention (using Wilcoxon signed rank and rank-sum tests) and the difference in median score by intervention type. RESULTS: Students scored highly in history-taking and communication performance but had low physical exam (PE) and assessment/plan scores. Postintervention, median scores in PE (ie, median score difference 2, interquartile ranges [IQR] 1-3.5, P<.001), assessment/plan (ie, median score difference 0.5, IQR 0-2, P=.005), and overall performance improved significantly (ie, median score difference 3, IQR 0-5, P<.001). CONCLUSIONS: Early medical students had low performance at baseline in telemedicine PE and assessment/plan skills, but both a role-play intervention and faculty demonstration led to significant increases in student performance.

Telemedicine Clinical Skills Needs Assessment in Early Medical Students.

BACKGROUND AND OBJECTIVES: As clinicians increasingly rely on telemedicine, medical students will need to learn how to appropriately use telemedicine in patient care. A formal approach to curriculum development is needed to identify gaps and needs in early medical student performance. METHODS: In October 2020, 120 second-year medical students completed a telemedicine visit with a standardized patient with chronic essential hypertension. Students were assessed across five domains (history-gathering, communication, vitals, physical exam, and assessment/management). An anonymous, voluntary survey was distributed to assess self-efficacy in telemedicine skills. RESULTS: Students perform well in history-gathering and communication (98% of student scored 4 or 5 out of 5 on history, 100% of students received a 7 or 8 out of 8 on communication). Students perform poorly in obtaining vital signs (23% scored 3 or 4 out of 4) and assessment/management (14% scored 3 or 4 out of 4). Students received their lowest scores in physical examination (2% score 4 or 5 out of 5). The number of telemedicine visits completed with patients prior to the standardized patient exercise had no impact on student performance during the exercise. Student response rate on the postexercise survey was 88%. Self-efficacy was lowest in physical examination telemedicine skills compared to other domains. CONCLUSIONS: Findings suggest that early medical students are able to gather history and communicate over telemedicine, but perform poorly on telemedicine physical examination skills. More robust curriculum development addressing telemedicine physical examinations skills is needed early in medical training.