The Teaching of Clinical Skills and the Applicability of a Simplified Guide to Physical Examination in Undergraduate Medical Training

Kahwage, Salomão Georges; Braga, Tiago Kiyoshi Kitabayashi; Portella, Márcia Bitar; Andriolo, Régis Bruni

doi:10.1590/1981-52712015v41n4RB20160110

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Original Article • Rev. bras. educ. med. 41 (4) • Oct-Dec 2017 • https://doi.org/10.1590/1981-52712015v41n4RB20160110 copy

The Teaching of Clinical Skills and the Applicability of a Simplified Guide to Physical Examination in Undergraduate Medical Training

O Ensino de Habilidades Clínicas e a Aplicabilidade de um Guia Simplificado de Exame Físico na Graduação de Medicina

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Introduction:

Despite technological advances, anamnesis and physical examination remain the most important and effective diagnostic tools in a clinical case. However, many students complete their medical degree lacking these essential skills. The unstandardized character of the physical examination is considered one of the major hurdles in the teaching-learning of this practice.

Objective:

To evaluate the clinical skills of medical students and the applicability of a simplified physical examination guide for the improvement of these skills.

Methods:

This was an analytical and quantitative-approach study, which compared before-and-after information among general medicine student interns from January to February 2014. The students were trained with the simplified guide for a 3-week period. The students had their clinical examination evaluated in 13 items: vital signs, oral cavity examination, ophthalmoscopy, otoscopy, thyroid examination, cardiovascular, pulmonary, abdominal examination, lymph nodes, anthropometric measurements, ankle-brachial index (ABI), neurological examination, examination of the breast (female patients) or testicles (male patients). The result of each part of the examination was classified into three categories: complete assessment, partial assessment and absent assessment.

Results:

A total of 31 students participated. Significant improvement was found in almost all items in relation to the complete evaluation after training with the guide: cardiovascular system (3.23% versus 74.19%, before and after training, respectively, p < 0.01), pulmonary system (22.58% versus 90.32%, p < 0.01), abdomen (22.58% versus 74.19%, p = 0.01), vital signs (16.13% versus 100%, p < 0.01), palpation of lymph nodes (6.45% versus 77.42%, p < 0.01), neurological examination (0% versus 22.58%, p = 0.02), thyroid palpation (0% versus 61.29%, p < 0.01), examination of oral cavity (6.45% versus 67.74%, p < 0.01), anthropometric measurements (0% versus 45.16%, p < 0.01), breast examination (0% versus 36.84%, p = 0.02), ophthalmoscopy (0% versus 32.26%, p < 0.01), otoscopy (0% versus 64.52%, p < 0.01); evaluation of the ankle-brachial index (0% versus 83.87%, p < 0.01), examination of the testicles (0% versus 8.33%, p = 1.0). A 280.7% increase was also observed in the students’ median score after training (1.92 versus 7.31 points, P < 0.001). There was no significant correlation between student performance and time on the medical course (R2 = 0.1242; P = 0.0515).

Conclusions:

There is a large deficit in teaching clinical skills during undergraduate medical courses. As an effective solution, a simplified sequential clinical examination guide can serve as training for medical students.

KEYWORDS
Physical Examination; Medical Education; Guide; Undergraduate Medical Education

Semiologic domain	Before (N = 31) %	After (N = 31) %
Cardiovascular system	100	100
Pulmonary system	100	100
Abdomen	100	100
Vital signs	83.87	100
Palpation of lymph nodes	35,48	100
Neurological	25,81	93,55
Thyroid palpation	16,13	67,74
Oral cavity examination	12,90	96,77
Anthropometric measurements	9,68	70,97
Breast examination^* * N = 19.	5,26	68,42
Ophthalmoscopy	0	35,48
Otoscopy	0	74,19
Testicular examination^ N = 12.	0	25
Ankle-brachial index	0	90,32

Domains evaluated	Quality	% Before (N = 31)	% After (N = 31)	RR	P
Vital signs	Complete	16.13	100.00	6.20	< 0.01
	Partial	67.74	0.00	42.00	< 0.01
	Absent	16.13	0.00	10.00	0.06
Palpation of lymph nodes	Complete	6.45	77.42	12.00	< 0.01
	Partial	29.03	22.58	0.78	0.79
	Absent	64.52	0.00	40.00	< 0.01
Thyroid palpation	Complete	0.00	61.29	not estimable	< 0.01
	Partial	16.13	6.45	0.40	0.45
	Absent	83.87	32.26	0.38	< 0.01
Cardiovascular system	Complete	3.23	74.19	23.00	< 0.01
	Partial	96.77	25.81	0.27	< 0.01
	Absent	0.00	0.00	not estimable	1.00
Pulmonary system	Complete	22.58	90.32	4.00	< 0.01
	Partial	77.42	9.68	0.13	< 0.01
	Absent	0.00	0.00	not estimable	1.00
Abdomen	Complete	22.58	74.19	3.29	0.01
	Partial	77.42	25.81	0.33	< 0.01
	Absent	0.00	0.00	not estimable	1.00
Neurologic	Complete	0.00	22.58	not estimable	0.02
	Partial	25.81	70.97	2.75	< 0.01
	Absent	74.19	6.45	0.09	< 0.01
Neurological Oral cavity examination	Complete	6.45	67.74	10.50	< 0.01

	Partial	6.45	29.03	4.50	0.07
	Absent	87.10	3.23	0.04	< 0.01
Ophthalmoscopy	Complete	0.00	32.26	not estimable	<0.01
	Partial	0.00	3.23	not estimable	1.00
	Absent	100.00	64.52	0.65	< 0.01
Otoscopy	Complete	0.00	64.52	not estimable	< 0.01
	Partial	0.00	9.68	not estimable	0.25
	Absent	100.00	25.81^* ***** Of the cases of "absent assessment", one was considered absent due to the unavailability of information in the evaluation form. P values obtained by means of the McNemar statistical test. RR: Relative risk.	0.26	< 0.01
Breast^* * N = 19.	Complete	0.00	36.84	not estimable	0.02
	Partial	5.26	31.58	6.00	0.13
	Absent	94.74	31.58^* ***** Of the cases of "absent assessment", one was considered absent due to the unavailability of information in the evaluation form. P values obtained by means of the McNemar statistical test. RR: Relative risk.	0.33	< 0.01
Testicles^ N = 12.	Complete	0.00	8.33	not estimable	1.00
	Partial	0.00	16.67	not estimable	0.50
	Absent	100.00	75.00	0.75	0.25
Anthropometric measurements	Complete	0.00	45.16	not estimable	< 0.01
	Partial	9.68	25.81	2.67	0.22
	Absent	90.32	29.03^* ***** Of the cases of "absent assessment", one was considered absent due to the unavailability of information in the evaluation form. P values obtained by means of the McNemar statistical test. RR: Relative risk.	0.32	< 0.01
Ankle-brachial index	Complete	0.00	83.87	not estimable	< 0.01
	Partial	0.00	6.45	not estimable	0.50
	Absent	100.00	9.68	0.10	< 0.01

Overall score before (min. and max. median) N = 31	Overall score after (min. and max. median) N = 31	Difference between medians	P
1.92 (1.15–5.38)	7.31 (4.23–10.0)	5.38	< 0.01

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