The Modern Physical Exam – A Transatlantic Perspective from the Resident Level

Abstract

Issue: The physical examination has been in decline for many years and poorer skills contribute to medical errors and adverse events. Diagnostic error is also increasing with the complexity of medicine. Comparing the physical examination in Ireland and the United States with a focus on education, assessment, culture, and health systems may provide insight into the decline of the physical exam in the United States, uncover possible strategies to improve clinical skills, and limit diagnostic error. Evidence: The physical exam is a core component of both undergraduate and postgraduate medical education in Ireland. This is reflected by the time and effort invested by medical schools and medical societies in Ireland in teaching and assessing skills. This high standard of skills results in the physical exam being a key component of the diagnostic process and a gatekeeper to expensive investigations essential in a resource-limited health system such as Ireland. Use of the physical exam in the United States is hindered by the high-tech transformation of healthcare and a more litigious society. Known strategies to highlight the role of the physical exam in clinical practice include creating an evidence base to show that better physical exam skills improve outcomes, identifying accurate physical exam maneuvers, stressing the therapeutic alliance the physical exam brings to the patient encounter, and the incorporation of technology into the bedside exam. Implications: Contrasting the education and clinical use of the physical examination in the United States with Ireland allowed us to identify a number of strategies which could be used to promote the physical exam among learners in both countries. Highlighting simple and pragmatic physical exam maneuvers combined with evidence-based physical exam diagnostic data may renew confidence in the physical exam as a core diagnostic tool. Use of the hypothesis-driven approach may streamline a clinician’s physical exam during a patient encounter, focusing on the key examination components and avoiding unnecessary and low yield maneuvers. The absence of assessment of physical exam skills using real patients in United States licensing exams communicates to learners that these skills are not important. However, steps to introduce a culture of assessment to drive learning are being introduced. One area Ireland could learn from the United States is incorporating more technology into the bedside exam. Enhanced physical examination skills in both countries could reduce reliance on expensive investigations and improve diagnostic accuracy.     

Wheelchair skills training for occupational therapy students: comparison of university-course versus “boot-camp” approaches

Abstract

Objective: To test the hypothesis that occupational therapy students who receive wheelchair skills training education using a distributed-practice university-course approach versus a condensed-practice boot-camp approach results in greater improvements post-intervention in relevant outcomes.

Design: A quasi-experimental, nonequivalent control group design.

Setting: A university occupational therapy program.

Participants: Occupational therapy students (experimental group) and recent occupational therapy graduates (control group) (N?=?58).

Interventions: A 15-week, 45-hour wheelchair provision course in which a total of 24?hours were dedicated to wheelchair skills testing and training education (experimental group) versus an 8-hour wheelchair skills training boot-camp (control group).

Main outcome measures: Assessments were conducted pre- and post-intervention using the Wheelchair Skills Test Questionnaire (WST-Q), Wheelchair Use Confidence Scale for Manual Wheelchair Users (WheelCon) and Self-Efficacy on Assessing, Training and Spotting wheelchair skills (SEATS).

Results: Compared to baseline, the WST-Q, WheelCon and SEATS scores improved significantly for both groups (p?<?.001). There were no significant differences in change scores (post-intervention – baseline values) between the groups for WST-Q, WheelCon or SEATS scores, however, the experimental group demonstrated a trend (p?<?.051) of higher scores for all outcome measures.

Conclusions: Occupational therapy students who received wheelchair skills training using either a distributed-practice university-course or condensed-practice boot-camp approach demonstrated significant post-training improvements in their WST-Q, WheelCon and SEATS scores, but no significant differences were found between groups.

• Implications for Rehabilitation

• Both a distributed-practice university-course approach and a condensed-practice bootcamp approach for training wheelchair skills to occupational therapy students results in large post-intervention improvements in wheelchair skill, wheelchair confidence and self-efficacy to test, train, spot and document wheelchair skills.

• The pre-education (optional course) wheelchair skill, wheelchair confidence and self-efficacy to test, train, spot and document wheelchair skills scores found in this cohort of occupational therapy students confirms the need to include this wheelchair content in mandatory occupational therapy curricula.

     

Limited clinical reasoning skills used by novice physiotherapists when involved in the assessment and management of patients with shoulder problems: a qualitative study

Abstract

The aim of this study was to explore the clinical reasoning process used by novice physical therapists in specific patient problems. Nine physical therapists in the UK with limited experience of managing musculoskeletal problems were included. Semi-structured interviews were conducted on how novice physical therapists would assess and manage a patient with a shoulder problem; interviews were transcribed and analyzed using framework analysis. To be included as a final theme at least 50% of participants had to mention that theme. A large number of items (n=93) were excluded as fewer than 50% of participants referred to each item. Included items related to seven main themes: history (16), physical exam (13), investigations (1), diagnostic reasoning (1), clinical reasoning process (diagnostic pathway) (3), clinical reasoning process (management pathway) (5) and treatment options (1). Items mostly related to information gathering, although there was some use of hypothetico-deductive clinical reasoning there appeared to be limited understanding of the clinical implications of data gathered, and clinical reasoning through use of pattern recognition was minimal. Major weaknesses were apparent in the clinical reasoning skills of these novice therapists compared to previous reports of expert clinical reasoning, indicating areas for development in the education of student and junior physical therapists.     

Developing a Peer-Mentor Program for Medical Students

Background: Doctoring is a 2-year preclinical course designed to teach medical students fundamental clinical skills. Purpose: We designed, implemented, and evaluated an innovative and cost-effective peer-mentoring program embedded within Doctoring. Our Teaching Academy (TA) included a formal orientation for teaching “Fellows.” Methods: During academic years 2008–09 and 2009–10, 2nd-year students were systematically selected by course faculty and then trained as TA Fellows to peer-mentor 1st-year students. Both TA Fellows and 1st-year medical students completed anonymous written surveys. Results: Peer-mentors reported a significant increase of confidence in their ability to provide feedback (p < .001). First-year students reported a significant increase of confidence in their ability to conduct a medical interview and perform a physical exam (p < .001 for each). Conclusions: Student participation in a formal peer-mentor program embedded within a clinical skills course significantly increased, for both teachers and learners, confidence in their skills. Our program is easily transferrable to other courses and institutions.     

采用标准化病人评价全科学员的临床能力的影响因素分析

目的：分析采用标准化病人（SP）评价学员临床能力的可能影响因素,为科学考核、评估全科学员提供依据。方法：52名学员参加考试,SP站点的考核分3个环节,包括重点问诊和体检、病历书写和口试,分别测试学员的沟通技能、信息收集、综合接诊能力以及临床思维、诊疗决断能力。结果：性别对学员临床能力的测试没有影响;工作经历对学员的综合接诊能力有显著的影响（P＜0．01）;病例不同,学员沟通技能、病历书写及病例分析的考核成绩有显著差异（P＜0．01）;培训基地不同,信息收集和病历书写两项技能考核成绩的差异有统计学意义（P＜0．05）。结论：除学员的自身能力,工作经历、不同的考核病例及培训基地对学员临床能力的测试均有一定的影响。     

Increasing Patient Acceptance of Medical Student Participation: Using Interactive Theatre for Faculty Development

Background : Interactive theatre (IT) has been used to train faculty the skills and strategies to address challenging dynamics in educational settings. Purpose : This study described the development, implementation, and evaluation of an IT approach to improve preceptors' skills for increasing patients' acceptance of medical student participation in clinical care. Methods : Focus groups were conducted with faculty, residents, medical students, and clinic staff to discuss issues related to patients declining medical student participation. Findings were used to develop a faculty development session using an IT approach. At a Family Medicine grand rounds presentation, faculty and resident preceptors (n = 42) participated in the IT workshop and completed a pre–post survey assessing skills specific to increasing students' training opportunities in patient care and educational impact of the session. Results : Following the IT session, preceptors reported greater self-efficacy for helping patients feel more comfortable with medical students in the exam room (p =.031, d = 0.338) and increased comfort level with talking to patients about medical students performing sensitive exams (p =.010, d = 0.357). Eighty-eight percent of preceptors agreed or strongly agreed that the session was relevant to improving clinical precepting skills and helped them develop strategies for enhancing medical student involvement in care. Conclusions : Findings suggest that the interactive theatre approach to faculty development is an innovative and effective method to increase preceptors' comfort with discussing medical student involvement with patients.     

Retention of moral reasoning skills over the four years of medical education

Background: There has been increased interest in moral reasoning of medical students. No longitudinal studies have addressed retention of these skills.

Purpose: This study was conducted to demonstrate whether moral reasoning skills developed in a medical ethics course would be retained in subsequent years.

Methods: The Defining Issues Test was used for assessment of moral reasoning. First‐year students were pretested, taught a medical ethics course during the 1st semester, and posttested at the end of the 4 subsequent years.

Results: After documenting the significantly increased, p ≤.00025, moral reasoning skills, this study demonstrates retention of these moral reasoning skills at the end of 2nd year, p ≤ .00001; 3rd year, p ≤. 00001; and 4th year of medical education, p ≤ .00001.

Conclusion: This study demonstrates that the teaching of medical ethics can be rigorously measured and tested and that it can have a sustained positive influence on the moral reasoning skills of medical students.     

Strategies of High-Performing EMT-Basic Educational Programs

Introduction. The objective of this project was to identify the specific educational strategies used by emergency medical technician (EMT) educational programs that have attained consistently high success rates on the National Registry of Emergency Medical Technicians (NREMT) examination. Methods. NREMT data from 2001 to 2005 was analyzed in order to identify consistently high-performing EMT-Basic educational programs. Representatives from each program were invited to participate in a focus group. Using the nominal group technique (NGT), participants were asked to answer the following question: “What are specific strategies that lead to a successful EMT-Basic educational program?” Results. Ten out of the 12 EMS educational programs meeting the eligibility requirements participated. After completing the seven-step NGT process, 12 strategies were identified as leading to a successful EMT-Basic educational program: 1) accept students who are highly motivated to succeed; 2) assure institutional support; 3) administer multiple assessments; 4) develop standardized lesson plans; 5) have a passing standard that is above the minimum competency level; 6) hire qualified/certified instructors; 7) maintain effective communication between didactic, practical, andfield instructors; 8) maintain instructional consistency; 9) provide clearly defined objectives; 10) provide immediate feedback for written, practical evaluations to students; 11) require prerequisites; and12) teach test-taking skills. Conclusions. Twelve specific strategies were identified by high-performing EMT-Basic programs. From these, seven recommendations to improve programmatic pass rates on the NREMT certification exam were derived. Further study should be conducted to determine if implementation of these recommendations improves programmatic pass rates on the NREMT certification exam.     

Teaching the Musculoskeletal Examination: Are Patient Educators as Effective as Rheumatology Faculty?

Background: Effective education of clinical skills is essential if doctors are to meet the needs of patients with rheumatic disease, but shrinking faculty numbers has made clinical teaching difficult. A solution to this problem is to utilize patient educators.

Purpose: This study evaluates the teaching effectiveness of patient educators compared to rheumatology faculty using the musculoskeletal (MSK) examination.

Method: Sixty-two 2nd-year medical students were randomized to receive instruction from patient educators or faculty. Tutorial groups received instructions during three, 3-hr sessions. Clinical skills were evaluated by a 9 station objective structured clinical examination. Students completed a tutor evaluation form to assess their level of satisfaction with the process.

Results: Faculty-taught students received a higher overall mark (66.5% vs. 62.1%,) and fewer failed than patient educator-taught students (5 vs. 0, p = 0.02). Students rated faculty educators higher than patient educators (4.13 vs. 3.58 on a 5-point Likert scale).

Conclusion: Rheumatology faculty appear to be more effective teachers of the MSK physical exam than patient educators.     

Do Standardized Patients Have Concerns About Students Not Captured by Traditional Assessment Forms?

Construct: Traditionally, standardized patients (SPs) assess students' clinical skills principally through numerical rating forms—an approach that may not fully capture SPs' concerns. SPs are students' closest approximation to real patients. To maximally benefit students' clinical training and evaluation it is important to find ways to give voice to the totality of SPs' perspectives. Background: SPs have been shown to be a reliable and valid means to assess medical students' clinical skills in clinical skills examinations. We noticed, however, that SPs often express “off the record” concerns about students, which they do not include on traditional assessment forms. Approach: To explore these “off the record” concerns, we designed a Concerns item and added it to the traditional assessment form for an end-of-3rd-year clinical skills examination shared by three medical schools. We asked SPs to use this Concerns item to identify students about whom they had any “gut-level” concerns and provided them with a narrative opportunity to explain why. SPs were informed that the purpose of the item was to help students with difficulties and was not part of the student's grade. Results: We analyzed the concerns data using quantitative and qualitative methods. Of 551 students at three schools, 223 (～40%) had concerns recorded. Seventy students received two or more concerns. Qualitative analysis of SPs' comments revealed 3 major categories of concern: communication and interpersonal skills, history taking, and physical exam. Grouped under each were several subcategories. More than half of the written comments from the SPs related to the communication/interpersonal skills category and included subcategories commonly addressed in communications courses: lack of empathy, good listening skills, and lack of connection to the patient. They also included subcategories that in our experience are less commonly addressed: odd or off-putting mannerisms, lack of confidence, unprofessional behavior, domineering behavior, and biased behavior. Another 47% of concerns identified deficiencies in history taking and physical examination. Of the students with concerns noted by two or more SPs, SPs' narrative comments on 84%, 42%, and 48% of the students in the domains of communications, history, and physical exam respectively indicated potential problems not identified by scores on the traditional assessment form. Conclusion: The Concerns item is a narrative assessment method that may add value to traditional quantitative scoring by identifying and characterizing problematic student performance not captured by the traditional assessment form. It may thus contribute to giving fuller voice to the totality of SPs' perspective.     

Psychometric properties of the Roland-Morris Disability Questionnaire compared to the Oswestry Disability Index: a systematic review

Abstract

Objectives: To compare the psychometric properties of the Roland-Morris Disability Questionnaire and the Oswestry Disability Index used to measure physical ability in people with low back pain.

Methods: A literature search of computerised databases from 1980 through June 2009 was performed using search terms: clinical assessment tools, Roland-Morris, questionnaires, back, spine, back pain, Oswestry Disability Index, psychometrics, reliability, validity, specificity and sensitivity. Twenty-three articles were reviewed using an adult population over 18 years old with acute, sub-acute and chronic low back pain.

Results: The Roland-Morris Disability Questionnaire and the Oswestry Disability Index demonstrate good reliability in test–retest performance clinically at initial evaluation and up to 6 weeks following interventions. Two studies described the construct validity of the two measures as highly correlated with each other. Overall, it appears that both questionnaires have similar responsiveness rates of 0·76–0·78 but two studies report a responsiveness rate of 0·94 for the Oswestry.

Discussion/Conclusion: The Roland-Morris Disability Questionnaire is most sensitive for patients with mild to moderate disability while the Oswestry Disability Index is most effective for persistent severe disability. Clinically, both questionnaires should be considered depending on the patient's objective presentation of disability. The clinician needs to determine either 'mild to moderate' or 'severe persistent disability' after a thorough history and physical exam is completed so that the appropriate questionnaire can be administered. This helps support the clinician's assessment of function, determine a patient's level of disability and provide outcome information.     

Improving the utility of the fine motor skills subscale of the comprehensive developmental inventory for infants and toddlers: a computerized adaptive test

Abstract

Aim: This study aimed at improving the utility of the fine motor subscale of the comprehensive developmental inventory for infants and toddlers (CDIIT) by developing a computerized adaptive test of fine motor skills.

Methods: We built an item bank for the computerized adaptive test of fine motor skills using the fine motor subscale of the CDIIT items fitting the Rasch model. We also examined the psychometric properties and efficiency of the computerized adaptive test of fine motor skills with simulated computerized adaptive tests.

Results and conclusions: Data from 1742 children with suspected developmental delays were retrieved. The mean scores of the fine motor subscale of the CDIIT increased along with age groups (mean scores?=?1.36–36.97). The computerized adaptive test of fine motor skills contains 31 items meeting the Rasch model’s assumptions (infit mean square?=?0.57–1.21, outfit mean square?=?0.11–1.17). For children of 6–71 months, the computerized adaptive test of fine motor skills had high Rasch person reliability (average reliability >0.90), high concurrent validity (rs?=?0.67–0.99), adequate to excellent diagnostic accuracy (area under receiver operating characteristic?=?0.71–1.00), and large responsiveness (effect size?=?1.05–3.93). The computerized adaptive test of fine motor skills used 48–84% fewer items than the fine motor subscale of the CDIIT. The computerized adaptive test of fine motor skills used fewer items for assessment but was as reliable and valid as the fine motor subscale of the CDIIT.

• Implications for Rehabilitation

• We developed a computerized adaptive test based on the comprehensive developmental inventory for infants and toddlers (CDIIT) for assessing fine motor skills.

• The computerized adaptive test has been shown to be efficient because it uses fewer items than the original measure and automatically presents the results right after the test is completed.

• The computerized adaptive test is as reliable and valid as the CDIIT.

     

A condensed wheelchair skills training ‘bootcamp’ improves students’ self-efficacy for assessing,training, spotting,and documenting manual and power wheelchair skills

Abstract

Objectives: To determine the influence of a bootcamp training approach on students’ self-efficacy for assessing, training, spotting, documenting, and performing manual and power wheelchair skills.

Methods: In a pre-post design, students in their final year of an entry-to-practice master of occupational therapy program completed a two-day manual (6.5?h) and power (6.5?h) wheelchair skills bootcamp. Outcomes for self-efficacy (in assessing, training, spotting and documenting manual and power wheelchair skills; primary) and capacity (manual and power wheelchair skills; secondary) were collected at baseline and immediately after the bootcamp.

Results: Participants (n?=?44) were 27.3?±?4.3?years of age (41 female). Most students (81.8%) reported little previous experience using manual and power wheelchairs at baseline. Students’ self-efficacy for assessing, training, spotting, and documenting manual and power wheelchair skills improved by between 28.4% and 35.3%, representing a change from ‘somewhat confident’ to ‘fairly confident’. Students’ manual and power wheelchair skills capacity increased by 47.2% and 37.1% respectively.

Conclusions: Wheelchair skills training bootcamps may help prepare occupational therapy students to assess, train, spot, and document manual and power wheelchair skills of future clients, while improving students’ wheelchair skills capacity; thus may provide an option for integrating wheelchair skills training into the curriculum of time-intensive programs.

• Implications for rehabiliation

• A two-day condensed wheelchair skills training workshop improves occupational therapy

• students’ self-efficacy for assessing, training, spotting and documenting power and

• manual wheelchair skills.

• A two-day condensed wheelchair skills training workshop improves occupational

• therapy students’ power and manual wheelchair skills.

• Self-efficacy is an indicator of future behaviours. Therefore, improving students’ selfefficacy

• for assessing training and documenting wheelchair skills may influence their future practice.

     

The Attrition Condition: Use of a Preparatory Course to Reduce EMT Course Attrition and Improve Performance on North Carolina Certification Exams

Abstract

Introduction. A growing concern in emergency medical services (EMS) education is student attrition. Perchance, there is a population of nonmatriculate students lacking prerequisite academic skills or who are otherwise ill prepared for the unique requirements of the EMS profession. Consequently, addressing these issues could promote academic and occupational preparedness, thereby reducing emergency medical technician (EMT) course attrition. Objective. To measure the impact of a preparatory course designed to address academic and psychosocial skills affecting EMT course completion. Methods. We conducted a retrospective analysis of a 24-hour preparatory course using a before-and-after nonexperimental design. The course included the EMT preparatory curriculum, program orientation, work-force-preparedness skills, and an academic skills assessment. All students who were enrolled in an EMT course at a single study site between July 2008 and December 2011 were included. Chi-square analysis was performed on attrition categories defined by CoAEMSP (Academic, Disciplinary, Attendance, Health, Financial, Personal, Never Attended) and state exam categories (Airway, Medical, Trauma, Operations, Pediatrics, Preparatory, Assessment). A logistic regression model calculated the odds ratio (OR) of course completion as a function of preparatory course completion while controlling for demography. Results. The historical control group consisted of 117 (58.5%) students enrolled prior to implementation of the preparatory course, while the remaining 83 (41.5%) students in the intervention group completed the course. Overall attrition was 115 (57.5%) students, with lower rates observed in the intervention group (32.5 vs. 75.2%, p < 0.01). Among noncompleters, the majority originated from the control groups in attrition categories of Academic (4.8 vs. 39.3%, p < 0.01) and Never Attended (1.2 vs. 14.5%, p < 0.01). Students who took the preparatory course were more likely to achieve course completion (OR = 5.17, p < 0.01). The use of the preparatory course produced a higher first-time test-taker pass rate despite showing little difference in individual categories. Conclusions. Students who participated in an EMS preparatory course were 5 times more likely to achieve course completion and perform higher on most portions of the state exam; and the proportion of students that enrolled but never attended an EMT course was reduced. Unlike prior studies, we did not observe a paradoxical increase in other attrition categories after addressing academic preparedness. These findings may prove useful for EMS educators tasked with program planning.