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Physical Examination Education inGraduate Medical Education A Systematic Review of theLiterature Somnath Mookherjee MD.
Lara Pheatt MA Sumant R Ranji MD Calvin Chou MD PhD SDRME Summer Meeting 2012 Importance of PE skills .
Fletcher RH Fletcher SW Has medicine outgrownphysical diagnosis AnnIntern Med 1992 117 9 786 7 .
Flegel KM Does thephysical examinationhave a future CMAJ 1999 161 9 1117 8 Jauhar S The demise of.
the physical exam N EnglJ Med 2006 354 6 548 CXR from The Practioner 1904 Laennec examines a consumptive patient with a stethoscope in front of his students at the Necker Hospital Painting by Th obald Chartran Physical diagnosis a guide to methods of clinical investigation George Alexander Gibson William Russell D Appleton Co 1891 New York .
A pocket book of physical diagnosis for the student and physician Edward Tunis Bruen P Blakiston 1881 PhiladelphiaBackground Methods Results Comment Discussion Un importance of PE skills ACGME Internal Medicineprogram requirements.
Background Methods Results Comment Discussion Resurgence of PE Physical examination is still important Hypothesis based Evidence based.
Verghese A Culture shock patient as icon icon as patient N Engl J Med 2008 359 26 p 2748 51 Verghese A A touch of sense Health Aff Millwood 2009 28 4 p 1177 82 Yudkowsky R et al Residents anticipating eliciting and interpreting physical findings Med Educ 2006 40 11 p 1141 2 Yudkowsky R et al A hypothesis driven physical examination learning and assessment procedure for medical students initial validityevidence Med Educ 2009 43 8 p 729 40 .
McGee S Evidence Based Physical Diagnosis Second Edition ed2007 St Louis Saunders Elsevier David L Simel and D Rennie The Rational Clinical Examination Evidence Based Clinical Diagnosis 2009 New York McGraw HillProfessional Background Methods Results Comment Discussion But skills are inadequate.
Trainee Type of Exam ReferencesGaskin et al Pediatrics 2000Pediatrics Ausculation Dhuper et al Clinical Pediatrics 2007 Jones et al Academic Emergency Medicine 1997 .
Emergency medicine Cardiac examEmergency medicine General PE Mangione et al Academic Emergency Medicine 1995 Internal medicine General PE Li et al Academic Medicine 1994Johnson et al Archives of Internal Medicine 1986.
Ramani et al JGME 2010 Internal Medicine Rectal Wilt et al JGIM 1991 Internal medicine and Family medicine Cardiac Vukanovic Criley et al Archives of Internal Medicine 2006 Mangione et al JAMA 1997 Mangione et al AJM 2001 .
Vukanovic Criley et al Clinical Cardiology 2010 St Clair et al Annals of Internal Medicine 1992 Mangione et al American journal of respiratory and critical care medicine Internal medicine and Family medicine Pulmonary 1999 Meenan et al The Journal of rheumatology 1988 .
Internal medicine and Family medicine MSKInternal medicine and Family medicine Breast Exam Chalabian et al Annals of surgical oncology 1998 Internal medicine and OB GYN Pelvis and breast Dugoff et al American journal of obstetrics and gynecology 2003 Heiligman et al JAMA 1998 .
Family medicine Pelvic Lang et al F Family medicine 1990 Surgery Vascular Endean et al Journal of vascular surgery 1994 Background Methods Results Comment Discussion Why focus on GME Different than students.
Little protected time for didactics Constant time pressure Mainly experiential learning Skills needed for imminent practice New program requirements.
Background Methods Results Comment Discussion Developmental Milestones for InternalMedicine Training Patient CareGreen ML Aagaard EM Caverzagie KJ Chick DA Holmboe E Kane G et al Charting the road to competence developmentalmilestones for internal medicine residency training Journal of graduate medical education 2009 1 1 5 20 .
Background Methods Results Comment Discussion Research Questions What teaching methods are used What assessment methods are What teaching methods are.
effective GME Program Curricula Individual practices of teachersBackground Methods Results Comment Discussion Search strategy Search 1 physical examination MESH AND.
Education Medical MESH Search 2 physical examination AND Education Medical MESH Search 3 physical examination AND resident OR internOR graduate OR residents OR interns OR graduates AND.
teaching OR learning OR education OR teach OR learn Search 4 physical examination MESH AND residentOR intern OR graduate OR residents OR interns ORgraduates AND teaching OR learning OR education ORteach OR learn .
Personal filesBackground Methods Results Comment Discussion Eligibility1 English language2 Inclusion of a description of the study population .
number of participants and level of training3 Description of an educational intervention intention of improving PE skills4 Inclusion of assessment of efficacy5 Inclusion of a clear comparison group.
6 Report of data analysis descriptions of outcomeswithout statistical analysis were not included 7 Study subjects enrolled in GMEBackground Methods Results Comment Discussion Data Extraction.
Study Quality Medical Education Research Study Quality Instrument Based on Best Evidence Medical EducationCollaboration protocol Nation.
Type of physical examination Level and numbers of learners Summary of intervention Human examinees Deliberate practice.
Summary of outcomes Benefit to learner Assessment methodsBackground Methods Results Comment Discussion Deliberate Practice .
1 Repetitive performance Papers independently scored for theof skills by the learner presence of these elements 0 not reported2 Assessment of skills by 1 reportedthe teacher Global deliberate practice score.
3 Specific feedback to the 0 no use of deliberate practice orlearner by the teacher unable to determine4 Observation of 1 possible use of deliberateimproved performance practice 2 definite use of deliberate practice.
in a controlled setting Ericsson KA Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains Academic medicine journal of theAssociation of American Medical Colleges 2004 79 10 Suppl S70 81 McGaghie WC Issenberg SB Cohen ER Barsuk JH Wayne DB Medical education featuring mastery learning with deliberate practice can lead to better health forindividuals and populations Academic medicine journal of the Association of American Medical Colleges 2011 86 11 e8 9 .
McGaghie WC Issenberg SB Cohen ER Barsuk JH Wayne DB Does simulation based medical education with deliberate practice yield better results than traditionalclinical education A meta analytic comparative review of the evidence Academic medicine journal of the Association of American Medical Colleges 2011 86 6 706 Duvivier RJ van Dalen J Muijtjens AM Moulaert VR Van der Vleuten CP Scherpbier AJ The role of deliberate practice in the acquisition of clinical skills BMC medicaleducation 2011 11 1 101 Background Methods Results Comment Discussion.
Educational Outcomes Kirkpatrick Level Level 0 no assessment of impact Level 1 assessment of reaction to the intervention Level 2a assessment of attitudes or perceptions.
Level 2b assessment of knowledge or skills Level 3 assessment of changes in behavior Classification X not measured or not compared to a control group 0 not better than control group.
1 beneficial intervention group with significantly betteroutcome than control Background Methods Results Comment Discussion Statistics and Analysis Inter rater reliability.
Individual elements of the MERSQI scores Individual elements of deliberate practice Global deliberate practice score Study quality Average and median MERSQI scores with.
standard deviations using consensus scores Narrative synthesis Group review of tabulated summaries of studiesBackground Methods Results Comment Discussion Search and Selection of Articles.
7250 Articles Identified and Screened1543 physical examination MESH AND Education Medical MESH 1943 physical examination AND Education Medical MESH 2038 physical examination AND resident OR intern OR graduate OR residents OR interns OR graduates AND teaching OR learning OR education OR teach OR learn .
1695 physical examination MESH AND resident OR intern OR graduate OR residents OR interns ORgraduates AND teaching OR learning OR education OR teach OR learn 31 Hand search and expert review7095 Rejected Based on Initial Screening Criteria is the studyabout PE education in GME .
155 Citations Meeting Initial Screening Criteria141 Citations Removed109 Duplicates32 Not Meeting Full Inclusion Criteria14 Articles Included in Systematic Review.
Background Methods Results Comment Discussion Study characteristicsCharacteristic N 14 Characteristic Studies StudiesNation GME a .
USA 13 Pediatrics 3 Denmark 1 Internal Medicine 8Type of examination Family Medicine 2 Cardiac 6 Danish house officer 1 Thyroid 1 Outcomes assessed in.
Pelvic 3 comparison to controls a b Breast 1 Kirkpatrick level 1 3 General 1 Kirkpatrick level 2a 4 Musculoskeletal 2 Kirkpatrick level 2b 12Randomized 4 Kirkpatrick level 3 2.
a not mutually exclusive b comparison to control not applicable for level 1 outcomesBackground Methods Results Comment Discussion Study Quality MERSQI Score Perfect inter rater 15.
agreement kappa 1 0 14 95 CI 1 0 1 0 for all 12but two items 11o Sampling kappa 100 44 95 CI 0 16 .
o Content validity 6 kappa 0 95 CI 50 52 0 52 3Reed DA Cook DA Beckman TJ Levine RB Kern DE Wright SM 0 Association between funding and quality of.
published medical education research JAMA 2007 298 9 1002 1009 Background Methods Results Comment Discussion Interventions14 Studies No residentinteraction w human Criley 2008 Web based cardiac tutorial.
Horiszny 2001 Multimedia cardiacexaminee n 7 lecture Iversen 2006 Multimedia cardiac lecture Mangione 1994 PE elective lectures Keren 2005 Brief cardiac audio tutorial.
Resident interaction Oddone 1993 Cardiology simulatorw a human Smith 2005 MSK small group sessionexaminee n 7Interaction w patientsTeaching associates Patient volunteers.
in a clinical context Leder 2005 Pelvic exam Branch 1999 Arthritis patientduring clinical rotation educator Houck 2002 Thyroid exam on Smith 2006 Cardiac exam Herbers 2003 Pelvic exam volunteer patient in workshopbedside rounds patient educator.
Freund 1998 Breast exam breast care clinic Rabinovitz 1987 Pelvicexam adolescent medicinerotation Single session.
Background Methods Results Comment Discussion AssessmentsNo CrileyCriley 2008 2008 Computer.
Computer programprogram toMulti assess cardiac examinteraction media Horiszny 2002 Recorded heart sounds14 Studies Keren 2005 Recorded heart sounds.
examinee Freund 1998 Chart review forn 6 Chart frequency of breast exam Leder 2005 Chart review for genitalreview examResident interaction Rabinovitz 1987 Survey for pelvic exam.
w a human Survey confidenceexaminee n 8Objective StructuredTeaching associates Patient VolunteersClinical Examinations.
Houck 2002 Thyroid exam Branch 1999 MSK exam Oddone 1993 Cardiac examOSCE patient educators testing also used simulator Mangione 1994 Multiple PE Herbers 2003 Pelvic exam Iversen 2006 Cardiac examtype OSCEs patient educators testing patient volunteers Smith 2006 Cardiac exam.
Smith 2005 MSK exam OSCEPreviously published assessment toolBackground Methods Results Comment Discussion Outcomes What teaching methods are used .
What assessment methods are used What teaching methods are effective Effective Ineffectiveinterventions interventions Summary Summary.
Kirkpatrick LevelBackground Methods Results Comment Discussion Outcomes KL 3Effective interventions Ineffective interventionsFreund 1998 Breast Weekly session at Leder 2005 Pelvic Precepted exams in clinic No.
Outcomes Level 3 BehaviorBreast Health Center with observed difference in completeness of documentation inexamination of patients Improved chart review of suspected sexual abuse cases 4 Branch 1999: MSK exam, patient educators. Herbers 2003: Pelvic exam, patient educators. Objective Structured Clinical Examinations. Resident interaction w/ a human examinee, n = 8. No interaction w/ human examinee, n = 6. Houck 2002: Thyroid exam OSCE. Mangione 1994: Multiple PE type OSCEs. Smith 2006: Cardiac exam OSCE. Smith 2005: MSK exam ...

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