Physical examination skills are widely recognized as a basic competency of clinical method.1 Clerkship directors have repeatedly recognized physical diagnosis skills as a core competency.2 Developing proficiency in examination skills usually begins in the preclerkship years of the undergraduate medical experience and continues throughout postgraduate training. It is traditionally assumed that students will have the greatest opportunity to learn these skills during clinical clerkships. In an effort to facilitate the adoption of a standard core curriculum for clerkship students, the Clerkship Directors in Internal Medicine (CDIM) and the Society of General Internal Medicine (SGIM) published the Core Medicine Clerkship Curriculum Guide: A Manual for Faculty, which includes recommendations for learning specific mental and physical examination skills.3
Increasing awareness exists, however, that too many medical students are deficient in basic aspects of physical examination skills. When objectively measured, cardiac auscultation skills of clerkship students are weak and show only variable improvement with further years of training.4,5 One study demonstrated deficiencies in thyroid exam techniques of 80% of observed interns, and another showed deficiencies in students’ basic ophthalmoscopic observation skills.6,7 A survey of medical students, interns, and residents found that only a minority considered themselves to be “skilled” in physical examination skills, and the rates did not improve with increased years of training.8 Surveyed students also reported their schools’ lack of commitment to bedside teaching of physical examination skills and less than complete satisfaction with the improvement of their skills during clerkships.9
Such concerns raise important questions about clerkship faculty expectations for clinical learners’ performance of these skills and whether any consensus exists regarding general standards for the timing of their teaching and learning in the undergraduate medical curriculum. During the annual CDIM membership survey in 2004, we and the leadership of CDIM queried U.S. and Canadian Internal Medicine clerkship directors and faculty to learn their opinions about a selected list of commonly taught physical examination skills. Specifically, we wanted to know which skills on the list should be learned by medical students and when in their education they should be expected to learn those skills.
The CDIM membership survey contains yearly updates on clerkship characteristics and clerkship directors’ demographics as well as issues of interest to CDIM members. These include both the internal medicine clerkship directors at 123 U.S. and Canadian medical schools (institutional members) and individual faculty members. The latter group includes assistant clerkship directors, directors of other courses, and faculty members otherwise involved in medical student clerkship education. We and members of the CDIM Publications Committee prepared and administered the survey, which was approved by the CDIM Council.
The complete questionnaire consisted of 53 items. The first section of the questionnaire asked about demographic issues. Those of interest for this analysis included clerkship director age, year of medical school graduation, gender, full-time (versus part-time) faculty status, academic rank, percentage of time spent on the internal medicine clerkship, and the amount of time spent in clinical activities. Respondents were also asked to identify their academic track (e.g., clinician–educator, clinician–investigator) as well as their specific responsibility regarding the clerkship (e.g., clerkship director, associate director). Questions were multiple choice, fill in the blanks, or answered using a five-point Likert scale. Additional themes included in the survey pertained to students’ introduction to clinical medicine courses, the CDIM subinternship curriculum, and the use of evidence-based information resources in teaching physical examination skills.
The section of the questionnaire of central interest here was a list of 39 informally selected mental and physical examination skills. A larger number of skills was initially selected by one author (E.C.) as being commonly taught somewhere in the undergraduate medical curriculum. This list was then reviewed by a coauthor (M.E.) and was reduced to 50 skills. Through a consensus process of the CDIM Council, this list was further reduced to 39 skills. For each skill, clerkship directors were asked “When should medical students acquire proficiency (i.e., become reliable reporters) for the following physical exam skills?” A checklist format was used for ease of responding about each examination skill. Responders were asked to identify whether proficiency in each skill should be acquired before, during, or after clerkships.
The questionnaire was distributed in 2004 to all 123 institutional clerkship directors and to all 136 individual members of the CDIM, a total of 259 individuals. Respondents had the choice of completing either a mailed paper questionnaire or an electronic version on the CDIM Web site. CDIM staff collected and entered the respondent data. Responses were kept confidential. Questionnaires were coded to enable tracking of nonrespondents, but codes were separated from completed questionnaires.
Respondents’ characteristics and their responses concerning whether each skill should be taught before, during, or after the clerkship were tabulated. The total numbers of before, during, or after responses from each respondent were correlated with that respondent’s age. Subsequent analyses tabulated each skill by age groups defined as less than 55 years old and 55 years or older. Chi-square tests were used to test for associations between each respondent’s opinion on when the skill should be taught and for the respondent’s characteristics, such as age group and role as a clerkship director. Spearman rank correlations were used to assess the association between the total number of responses and a respondent’s characteristics, such as his or her age. All analyses were carried out in SAS 8.1 (SAS Inc., Cary, NC); graphs were made using GAUSS 6.0 (Aptech Systems, Inc., Black Diamond, Wash).
Questionnaires were completed by 157 of the 259 individuals surveyed, an overall response rate of 60%. This total was composed of 89 of the 123 (72%) institutional clerkship director members and 68 of the 136 individual members (50%). The average age of survey respondents was 44.5 years. Ninety-eight (62%) were men. Respondents represented the spectrum of academic ranks, including 30 (19%) professors, 61 (39%) associate professors, and 58 (37%) assistant professors. Most were clinician educators (113, 72%), were in nontenure tracks (92; 59%), and had considerable clinical responsibilities (average of 3.2 half-days in outpatient clinics and 8.8 weeks per year in inpatient attending service).
Respondents’ views of where in the medical school curriculum students should learn each physical examination skill are shown in Figure 1. Overall, respondents agreed that 31 (80%) of the 39 physical examination skills should be learned by the end of the clerkship year. The eight exceptions were retinal vasculature recognition, ocular venous pulsations, mitral valve prolapse murmur identification, adnexal mass on pelvic examination, prostate nodule palpation, knee cruciate ligament laxity, rotator cuff examination, and S1 peripheral neuropathy recognition. In terms of timing in the overall curriculum, respondents indicated that about a third of the skills should be learned before starting clerkships (mean 34%, SD 21%), about half should be learned during clerkships (mean 53%, SD 18%), and the remainder should be learned after clerkships.
Respondents were divided on when to learn skills to make normal physical examination observations. Out of 15 such skills, a majority of respondents agreed that 8 of these skills should be learned before the clerkship, whereas 7 of the 15 should be learned during the clerkship. Respondents generally agree that abnormal examination findings should be learned during clerkships (23 out of 24 skills). Overall, for only 18 of the 39 skills was there 80% respondent agreement on the timing of skill learning.
There was little difference of opinion between institutional and individual members regarding the timing of learning physical examination skills. For only one skill, prostate nodule palpation, was there a statistically significant difference (P = .01).
There was little variation in opinion based on respondents’ ages with correlations that were insignificant (r < 0.1, P > .2). The exception is that the oldest group (>55) generally indicated that a larger proportion of these skills should be learned either before or during the clerkship.
Subset analysis of skills organized by organ system revealed no correlation with respondents’ preferences for the timing of skills learning. One notable exception is reproductive examination skills; nearly all the respondents believed the skills in this set should be taught during or after the clerkship.
Clerkship directors and clinical faculty agreed that this set of 39 commonly taught physical examination skills should be learned at some time in the four-year undergraduate medical curriculum. The large majority also agreed that most of these examination skills should be learned by the end of the clerkship year. However, we observed wider variability among respondents in the recommended timing for skill learning than we had expected. For example, only 50% (130) of respondents agreed on the timing for when this set of skills should be taught. Using a consensus level of 80%, agreement existed on only 18 of the 39 skills. These results compare with those of an earlier CDIM survey that found a similar level of agreement regarding the learning of basic procedural skills.10 Of 20 basic procedures listed, there was 80% agreement among respondents that students should learn nine of them during the third year of medical school. It is likely that this degree of variation in clinical educators’ opinions reflects significant differences in the content of the preclerkship and clerkship curricula from school to school. There is also the question of how much within-school variability might also exist among faculty on this issue. Our limited survey data suggest that there is no difference between clerkship directors and other clerkship faculty respondents on this issue. We are not aware of comparison data in other clerkship disciplines.
We noted that the more senior faculty had earlier expectations for the level of student skill learning than did younger faculty. This difference may be attributable to changes in the clinical environment over a longer period of time that influence the faculty expectation for students’ learning of physical examination skills. Recent deterioration in the quality of clinical skills teaching remains an issue of concern in the current literature.1,11–13 Our data are consistent with the idea of a generational effect—namely, that there may be diminishing expectations and, therefore, less teaching effort, by more junior faculty regarding the development of students’ physical examination skills.
The CDIM/SGIM core curriculum for undergraduate medical education is organized around a set of clinical problems. On the other hand, many preclerkship physical examination curricula are designed according to an organ-system approach. An important question is whether such curricular organization influences faculty expectations for when skills should best be learned. The data from this survey suggest that an organ-system approach does not account for obvious variability in CDIM members’ opinions about when examination skills learning should take place except for reproductive organ exam skills.
This study had a number of limitations. For one, this survey involved primarily internal medicine clerkship directors but comparatively fewer medicine clerkship faculty, so that conclusions regarding what faculty as a whole think and do in their teaching of students could have been different if more of the latter group had been respondents. This is also the first CDIM survey regarding physical examination skills. Thus, implications regarding actual changes in faculty opinion over time remain speculative. Also, although the respondents represent a large percentage of national clerkship directors in internal medicine (89; 72%), the number of faculty from any one school is very small, so that any conclusions regarding major differences between schools and among faculty within one institution are limited.
Also, these survey data are limited to just one discipline among many whose faculty are involved in teaching physical diagnosis skills to clerkship students. Many of these skills can also be learned in the rotations of other clerkship disciplines. It should also be kept in mind that this survey used a limited number of common yet informally selected physical examination skills that may not represent what others may consider most important in the physical diagnosis curriculum for medical students. These considerations may account for some of the variation in opinion about the timing of skill learning.
Finally, although this survey addressed the question of when a number of common examination skills should be learned in the curriculum, it did not ask about how well each skill should be performed at the various stages in students’ clinical development. The question of whether there exists a national consensus regarding standards for levels of performance proficiency throughout the medical school curriculum also remains an important subject for consideration. A major implication from this survey is that some enhancement in students’ education may result from achieving a greater level of consensus among teaching faculty as to what students should be able to do, and when and how well in the curriculum they should learn it.
An important function of a curriculum is to foster among teachers a standard approach to what should be taught and learned. Although similarity of expectation for students’ clinical education may likely exist within one institution, the results of this survey reveal areas of significant variability regarding expectations for a selected set of common physical examination skills that students should learn, across a sample of U.S. and Canadian clinical education leaders. In contrast to the fact that national standards and licensure requirements at graduation exist with respect to basic science and clinical knowledge acquisition, our findings suggest that there is comparatively greater variation in expectations for students’ learning of physical examination skills. This is likely related, at least in part, to the fact that clinical skill performance standards have remained traditionally implicit and unstandardized in undergraduate medical education.1,14 With a shift in emphasis to competency-based medical education in the undergraduate medical curriculum level, as recommended by a recent consensus of national clerkship directors,1 it will be important to achieve a greater degree of agreement among faculty about performance expectations, including when and how well students should become proficient in basic clinical skills. Such a consensus would be useful as a reference to those designing curricula and evaluating students on a local and national level.
In summary, the results of this survey suggest that although a large percentage of internal medicine clerkship directors and faculty agreed that a selected set of common physical examination skills should be learned in medical school, significant variability existed in the views about when in the curriculum these skills should be learned. To the extent that there is little national consensus to date on explicit standards for students’ clinical skill performance development in general, these survey findings may come as no surprise. Nevertheless, at a time when there are increasing expectations for clinical performance competency across the continuum of medical education and clinical practice, progress is needed regarding a common vision of what neophyte clinicians must learn to do and when they are expected to be able to do it.
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