Bilello Leslie A, Dubosh Nicole M, Lewis Jason J, Hall Matthew M, Fisher Jonathan, Ullman Edward A
Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA,
Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ, USA.
Adv Med Educ Pract. 2018 Aug 17;9:583-588. doi: 10.2147/AMEP.S160701. eCollection 2018.
The art of physical examination is one of the most valuable diagnostic tools bestowed upon new generations of medical students. Despite traditional educational techniques and significant attention on a national level, both trainees and educators have noticed a decrease in physical examination proficiency. Simulation has been identified as a potential way to improve physical examination techniques within undergraduate medical education. We sought to determine the utility of a cardiac case-based simulation scenario to assess physical examination performance of fourth-year medical students during an emergency medicine (EM) clerkship.
Fourth-year medical students enrolled in a 4-week EM clerkship were prospectively evaluated during a case-based scenario using a simulation mannequin (Laerdal SimMan). The case involved a patient presenting with chest pain that evolved into cardiac arrest. All simulations were video recorded and two emergency physicians reviewed each video. The reviewers recorded whether or not each student completed the essential components of a focused physical examination.
Twenty-seven students participated in the simulation. The percentage of students completing each of the four components of the physical examination was as follows: cardiac auscultation 33.3% (95% CI 18.5-52.3), lung auscultation 29.6% (95% CI 15.7-48.7), pulse and extremity examination 55.6% (95% CI 37.3-72.4), and abdominal examination 3.70% (95% CI 0-19.8). None of the students completed all four of these components.
Our study showed that fourth-year medical students did not uniformly perform components of a focused physical examination during a high-acuity chest pain simulation scenario. Although our study showed limited physical examination performance, simulation allows evaluators to observe and provide constructive feedback and may lead to an improvement in these skills. These findings call for improved technology to increase authenticity of simulators and continued faculty development for more creative, meaningful integration of physical examination skills into high-acuity simulation cases.
体格检查技能是传授给新一代医学生的最有价值的诊断工具之一。尽管有传统的教育方法，且在国家层面也备受关注，但学员和教育工作者都注意到体格检查能力有所下降。模拟已被视为提高本科医学教育中体格检查技术的一种潜在方法。我们试图确定基于心脏病例的模拟场景在评估四年级医学生在急诊医学实习期间体格检查表现方面的效用。
对参加为期4周急诊医学实习的四年级医学生，在基于模拟人（Laerdal SimMan）的病例场景中进行前瞻性评估。病例为一名出现胸痛并发展为心脏骤停的患者。所有模拟均进行视频记录，两名急诊医生对每个视频进行审查。审查人员记录每个学生是否完成了重点体格检查的基本组成部分。
27名学生参与了模拟。完成体格检查四个组成部分的学生百分比分别如下：心脏听诊33.3%（95%可信区间18.5 - 52.3），肺部听诊29.6%（95%可信区间15.7 - 48.7），脉搏及四肢检查55.6%（95%可信区间37.3 - 72.4），腹部检查3.70%（95%可信区间0 - 19.8）。没有学生完成所有这四个组成部分。
我们的研究表明，四年级医学生在高敏锐度胸痛模拟场景中，并未一致地完成重点体格检查的各个组成部分。尽管我们的研究显示体格检查表现有限，但模拟使评估者能够观察并提供建设性反馈，可能会使这些技能得到提高。这些发现要求改进技术以提高模拟器的真实性，并持续开展教师培训，以便更有创造性、更有意义地将体格检查技能融入高敏锐度模拟病例中。
