Abstract:

Problem Identification:
In the modern hospital, Physicians spend more time with the electronic medical record than they do at the bedside. This practice has contributed to a decline in physical exam skills and can adversely affect patient care. There is no standardized curriculum to teach physical exam skills to U.S. residents. There are also limited tools to assess exam skill. Direct observation, while valuable, does not routinely occur and is qualitative and subjective. We adapted the framework of the MRCP Practical Assessment of Clinical Examination Skills in the UK (MRCP-PACES(UK)) to create a novel assessment and teaching activity for U.S. graduate medical trainees.

Description:
Interns rotated through one cardiovascular and one pulmonary station. At each station, two faculty preceptors examined a patient and agreed on the physical findings. Interns were then given 10 minutes to examine the patient, present their findings to the faculty, and answer questions about differential diagnosis and management. Interns were assessed in five areas using a 3-point scale: exam technique, identification of physical signs, differential diagnosis, clinical judgment, and maintaining patient welfare. Faculty then provided 5 minutes of feedback and bedside teaching in real time. Scores were compared between those who had rotated through a dedicated clinical skills curriculum (CS interns) and those who had not received the curriculum (non-CS interns). Inter-rater reliability was calculated for each station.

Results:
28 interns (23 CS and 5 non-CS) each rotated through one cardiac and one pulmonary station. Four volunteer patients and eight faculty preceptors participated. CS interns scored higher on the assessment but the difference was not significant. The inter-rater reliability for the cardiovascular and pulmonary stations was 0.78 (p <0.001) and 0.789 (p<0.001) respectively. On a post-activity survey, interns highly rated the teaching they received after the assessment. Patients remarked that it was a pleasant experience and would participate again.

Discussion:
This pilot study demonstrates the feasibility of conducting a PACES-style assessment for U.S. trainees. While the study was not powered to determine a difference between CS and non-CS interns, the inter-rater reliability was high, suggesting that this methodology is a valid way to assess physical exam performance.

Keywords:

Physical exam assessment, bedside teaching, PACES.