A novel bedside cardiopulmonary physical diagnosis curriculum for internal medicine postgraduate training

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Abstract

Background

Physicians spend less time at the bedside in the modern hospital setting which has contributed to a decline in physical diagnosis, and in particular, cardiopulmonary examination skills. This trend may be a source of diagnostic error and threatens to erode the patient-physician relationship. We created a new bedside cardiopulmonary physical diagnosis curriculum and assessed its effects on post-graduate year-1 (PGY-1; interns) attitudes, confidence and skill.

Methods

One hundred five internal medicine interns in a large U.S. internal medicine residency program participated in the Advancing Bedside Cardiopulmonary Examination Skills (ACE) curriculum while rotating on a general medicine inpatient service between 2015 and 2017. Teaching sessions included exam demonstrations using healthy volunteers and real patients, imaging didactics, computer learning/high-fidelity simulation, and bedside teaching with experienced clinicians. Primary outcomes were attitudes, confidence and skill in the cardiopulmonary physical exam as determined by a self-assessment survey, and a validated online cardiovascular examination (CE).

Results

Interns who participated in ACE (ACE interns) by mid-year more strongly agreed they had received adequate training in the cardiopulmonary exam compared with non-ACE interns. ACE interns were more confident than non-ACE interns in performing a cardiac exam, assessing the jugular venous pressure, distinguishing ‘a’ from ‘v’ waves, and classifying systolic murmurs as crescendo-decrescendo or holosystolic. Only ACE interns had a significant improvement in score on the mid-year CE.

Conclusions

A comprehensive bedside cardiopulmonary physical diagnosis curriculum improved trainee attitudes, confidence and skill in the cardiopulmonary examination. These results provide an opportunity to re-examine the way physical examination is taught and assessed in residency training programs.

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Most cited references 31

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Clinical skills in junior medical officers: a comparison of self-reported confidence and observed competence.

Martin J. Field, F Gordon, Emily J. Hibbert … (2004)

The intern year is a key time for the acquisition of clinical skills, both procedural and cognitive. We have previously described self-reported confidence and experience for a number of clinical skills, finding high levels of confidence among Australian junior doctors. This has never been correlated with an objective measure of competence. We aimed to determine the relationship between self-reported confidence and observed competence for a number of routine, procedural clinical skills. A group of 30 junior medical officers in their first postgraduate year (PGY1) was studied. All subjects completed a questionnaire concerning their confidence and experience in the performance of clinical skills. A competency-based assessment instrument concerning 7 common, practical, clinical skills was developed, piloted and refined. All 30 PGY1s then completed an assessment using this instrument. Comparisons were then made between the PGY1s' self-reported levels of confidence and tutors' assessments of their competence. A broad range of competence levels was revealed by the clinical skills assessments. There was no correlation between the PGY1s' self-ratings of confidence and their measured competencies. Junior medical officers in PGY1 demonstrate a broad range of competence levels for several common, practical, clinical skills, with some performing at an inadequate level. There is no relationship between their self-reported level of confidence and their formally assessed performance. This observation raises important caveats about the use of self-assessment in this group.

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

David W. Nelson, John R Boker, Nathan W. Churchill … (2006)

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. 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. 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). 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.

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In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time?

Lauren Block, Robert Habicht, Albert Wu … (2013)

The 2003 and 2011 Accreditation Council for Graduate Medical Education (ACGME) common program requirements compress busy inpatient schedules and increase intern supervision. At the same time, interns wrestle with the effects of electronic medical record systems, including documentation needs and availability of an ever-increasing amount of stored patient data. In light of these changes, we conducted a time motion study to determine how internal medicine interns spend their time in the hospital. Descriptive, observational study on inpatient ward rotations at two internal medicine residency programs at large academic medical centers in Baltimore, MD during January, 2012. Twenty-nine interns at the two residency programs. The primary outcome was percent of time spent in direct patient care (talking with and examining patients). Secondary outcomes included percent of time spent in indirect patient care, education, and miscellaneous activities (eating, sleeping, and walking). Results were analyzed using multilevel regression analysis adjusted for clustering at the observer and intern levels. Interns were observed for a total of 873 hours. Interns spent 12 % of their time in direct patient care, 64 % in indirect patient care, 15 % in educational activities, and 9 % in miscellaneous activities. Computer use occupied 40 % of interns' time. There was no significant difference in time spent in these activities between the two sites. Interns today spend a minority of their time directly caring for patients. Compared with interns in time motion studies prior to 2003, interns in our study spent less time in direct patient care and sleeping, and more time talking with other providers and documenting. Reduced work hours in the setting of increasing complexity of medical inpatients, growing volume of patient data, and increased supervision may limit the amount of time interns spend with patients.

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Author and article information

Contributors

Brian Thomas Garibaldi: bgariba1@jhmi.edu

Timothy Niessen: niessen@jhmi.edu

Allan Charles Gelber: agelber@jhmi.edu

Bennett Clark: bclark12@jhmi.edu

Yizhen Lee: yizhen15@gmail.com

Jose Alejandro Madrazo: jmadraz1@jhmi.edu

Reza Sedighi Manesh: rsedigh1@jhmi.edu

Ariella Apfel: aapfel1@jhmi.edu

Brandyn D. Lau: blau2@jhmi.edu

Gigi Liu: gliu2@jhmi.edu

Jenna VanLiere Canzoniero: jcanzon1@jhmi.edu

C. John Sperati: jsperati@jhmi.edu

Hsin-Chieh Yeh: hyeh1@jhmi.edu

Daniel J. Brotman: brotman@jhmi.edu

Thomas A. Traill: ttraill@jhmi.edu

Danelle Cayea: dcayea1@jhmi.edu

Samuel C. Durso: sdurso@jhmi.edu

Rosalyn W. Stewart: rstewart@jhmi.edu

Mary C. Corretti: mcorret1@jhmi.edu

Edward K. Kasper: ekasper@jhmi.edu

Sanjay V. Desai: sanjayvdesai@jhmi.edu

Journal

Journal ID (nlm-ta): BMC Med Educ

Journal ID (iso-abbrev): BMC Med Educ

Title: BMC Medical Education

Publisher: BioMed Central (London )

ISSN (Electronic): 1472-6920

Publication date (Electronic): 6 October 2017

Publication date PMC-release: 6 October 2017

Publication date Collection: 2017

Volume: 17

Electronic Location Identifier: 182

Affiliations

[1 ]ISNI 0000 0001 2171 9311, GRID grid.21107.35, Division of Pulmonary and Critical Care, , Johns Hopkins University School of Medicine, ; 1830 East Monument Street, Baltimore, MD 21287 USA

[2 ]ISNI 0000 0001 2171 9311, GRID grid.21107.35, Department of Medicine, , Johns Hopkins University School of Medicine, ; 600 North Wolfe Street, Baltimore, MD 21287 USA

[3 ]ISNI 0000 0001 2171 9311, GRID grid.21107.35, Division of Rheumatology, , Johns Hopkins University School of Medicine, ; 5200 Eastern Avenue, Baltimore, MD 21224 USA

[4 ]ISNI 0000 0001 2171 9311, GRID grid.21107.35, Division of Cardiology, , Johns Hopkins University School of Medicine, ; 600 North Wolfe Street, Baltimore, MD 21287 USA

[5 ]Department of General Internal Medicine, 2024 E Monument St, Baltimore, MD 21205 USA

[6 ]ISNI 0000 0001 2171 9311, GRID grid.21107.35, Department of Surgery, , Johns Hopkins University School of Medicine, ; 600 North Wolfe Street, Baltimore, MD 21287 USA

[7 ]ISNI 0000 0001 2171 9311, GRID grid.21107.35, Division of Nephrology, , Johns Hopkins University School of Medicine, ; 600 North Wolfe Street, Baltimore, MD 21287 USA

[8 ]ISNI 0000 0001 2171 9311, GRID grid.21107.35, Division of Geriatric Medicine, , Johns Hopkins University School of Medicine, ; 5200 Eastern Avenue 7th Floor, Baltimore, MD 21224 USA

Article

Publisher ID: 1020

DOI: 10.1186/s12909-017-1020-2

PMC ID: 6389200

PubMed ID: 28985729

SO-VID: 4572af2b-9474-4561-aaf6-62039f3ec85d

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 5 May 2017

Date accepted : 25 September 2017

Funding

Funded by: FundRef http://dx.doi.org/10.13039/100007261, New York Academy of Medicine;

Award ID: Jeremiah A. Barondess Fellowship in the Clinical Transaction

Award Recipient : Brian Thomas Garibaldi

Funded by: Johns Hopkins University Institute for Excellence in Education

Award ID: Berkheimer Faculty Scholar Award

Award Recipient : Brian Thomas Garibaldi

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ScienceOpen disciplines: Education

Keywords: medical education,physical examination skills,cardiopulmonary exam,bedside medicine

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ScienceOpen disciplines: Education

Keywords: medical education, physical examination skills, cardiopulmonary exam, bedside medicine

A novel bedside cardiopulmonary physical diagnosis curriculum for internal medicine postgraduate training

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Abstract

Background

Methods

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Conclusions

Related collections

Journal of Medical Education Research

Most cited references 31

Clinical skills in junior medical officers: a comparison of self-reported confidence and observed competence.

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

In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time?

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