Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Md.
Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Md.
Am J Med. 2022 Jun;135(6):775-782.e10. doi: 10.1016/j.amjmed.2021.11.021. Epub 2021 Dec 31.
The purpose of this research was to use direct observation of the physical examination to elucidate the role physical examination technique plays in diagnostic accuracy. Physical examination is important for quality clinical care and requires multiple interrelated skills. The relationship of physical examination technique to related skills is poorly understood. Current methods of teaching and assessing physical examination skills provide few opportunities to evaluate physical examination technique and accuracy.
The authors developed a clinical examination assessment using volunteer patients and direct observation. Trained faculty preceptors rated resident performance in 7 domains: 1) physical examination technique, 2) identification of physical signs, 3) clinical communication, 4) differential diagnosis, 5) clinical judgment, 6) managing patient concerns, and 7) maintaining patient welfare. The Pearson correlation coefficient was used to determine relationships between performance in each of these domains. Data on residents' self-assessed competency in the physical examination and perceptions of feedback received during the assessment were collected.
From December 2018 to February 2020, 113 interns from 2 internal medicine residency programs participated in the assessment. Physical examination technique was significantly correlated with accurate identification of physical signs, differential diagnosis and clinical judgment. Time spent in graduate medical education was negatively correlated with performance. Interns more highly rated the feedback received from this assessment than traditional clinical skills feedback.
Our findings emphasize the necessity of multi-dimensional physical examination assessment. Observed deterioration of physical examination skill during internship may reflect contemporary practice patterns, which deprioritize the physical examination. Future research on physical examination education should focus on the interface between physical examination technique and related clinical skills.
本研究旨在通过对体格检查的直接观察，阐明体格检查技术在诊断准确性中的作用。体格检查对于高质量的临床护理至关重要，需要多种相互关联的技能。体格检查技术与相关技能的关系尚未得到很好的理解。目前教授和评估体格检查技能的方法提供了很少的机会来评估体格检查技术和准确性。
作者使用志愿患者和直接观察开发了一种临床检查评估方法。经过培训的教师指导者在 7 个领域评估住院医师的表现：1）体格检查技术，2）识别身体体征，3）临床沟通，4）鉴别诊断，5）临床判断，6）处理患者的担忧，以及 7）维护患者的福利。使用 Pearson 相关系数确定这些领域中每项表现之间的关系。收集了有关住院医师对体格检查自我评估能力的信息，以及他们对评估过程中收到的反馈的看法。
从 2018 年 12 月到 2020 年 2 月，来自 2 个内科住院医师培训计划的 113 名住院医师参加了评估。体格检查技术与准确识别身体体征、鉴别诊断和临床判断显著相关。在住院医师培训期间，花费的时间与表现呈负相关。住院医师对这种评估的反馈评价高于传统的临床技能反馈。
我们的发现强调了多维体格检查评估的必要性。实习期间体格检查技能的明显下降可能反映了当代实践模式，这种模式优先考虑临床技能而不是体格检查。未来的体格检查教育研究应集中在体格检查技术与相关临床技能的界面上。
