A comprehensive and accurate history and physical examination is essential for clinical reasoning and forms the cornerstone of the doctor-patient relationship. Incomplete or inaccurate history taking and physical examination skills may lead to excessive reliance on laboratory and imaging tests, delayed diagnoses, and potentially harmful consequences for patients. Despite the importance, the teaching of physical exam techniques has become considerably less frequent over the past several decades.
As leaders of an international Internal Medicine physician training program in the United Arab Emirates, we must meet regulations of the Arab Board of Medical Specialties and the United States-based Accreditation Council for Graduate Medical Education- International (ACGME-I). Arab Board graduation and licensure requirements mandate that our senior trainees pass a high stakes Objective Structured Clinical Examination (OSCE) that focuses primarily on physical exam skills. Over the past five years, our program’s pass rates have been low. Prior to the April 2019 OSCE, we developed a six-week physical examination review course as a pilot program. In this paper, we share lessons learned from this experience with the hope of helping others avoid similar disappointing outcomes.
The pilot program consisted of late afternoon teaching sessions, lasting 45 to 60 minutes each, which were scheduled twice weekly. Each session focused on a single organ system, and trainees practiced their clinical skills and detection of physical signs. Patient volunteers were recruited from the inpatient medical unit based on underlying disease pathology and clinical findings. In small groups of three to four, trainees performed a focused physical examination on an inpatient volunteer under the supervision of a senior clinician, who provided immediate feedback and demonstrated techniques as needed. We were encouraged by studies demonstrating feasibility and success from similar educational programs.
We were surprised by difficulties faced both in the process and in the outcome of the review course. We had anticipated reluctance from our busy clinicians to take on additional teaching responsibility, albeit temporary, and did, in fact, sometimes find it difficult to ensure senior clinician involvement. When questioned about their hesitation, most faculty reported excessive clinical workload, while some complained about unfamiliarity with OSCE formats and the lack of checklists to guide the sessions. Irrespective of faculty issues, trainee engagement was high and verbal feedback was positive. Since the sessions were optional, we were initially concerned that trainee participation in an after-hours activity would below. However, we were pleased that trainee turn out was consistently high, and they were eager to perform and receive feedback on their clinical skills. During debriefing sessions, the trainees perceived great benefit from the extra teaching and felt that their clinical skills had improved significantly. Yet, a survey of trainees on the morning of the licensing OSCE revealed that there were no significant differences in confidence levels or anxiety between trainees who participated in the pilot course and those who did not. Further, much to our surprise, despite the extensive time and resource investment, pass rates remained low and were not significantly higher for the course participants.
The poor OSCE performance was disheartening for both the trainees and teaching faculty. As program leaders, we were particularly discouraged by the outcome. Several lessons were learned during this process. First, we needed to acknowledge that clinical training in today’s busy academic medical centers does not naturally lend itself to teaching physical examination techniques. Rapid throughput of patients through the hospital and excessive administrative burdens have significantly interfered with patient care time, with one study revealing that US hospitalists can spend as little as 18% of their shift with patients.
In conclusion, the deterioration of physical examination skills is a serious concern. Today’s faculty likely trained and practiced in an era where physical examinations were not emphasized and may lack confidence in their own clinical exam skills, contributing to a downward spiral. Faculty development is essential so that daily ward rounds can again become an essential venue for clinician educators to role model and teach proper physical examination techniques during their everyday work.
The author declares that there are no conflicts of interest.