Objective: Few studies have assessed the ability of internal medicine residents to perform a cardiovascular physical examination using real patients.
Methods: First year internal medicine interns from two large academic medical centers in Maryland examined the same patient with aortic insufficiency as part of the Assessment of Physical Examination and Communication Skills (APECS). Interns were assessed on five clinical domains: physical exam technique, identifying physical signs, generating a differential diagnosis, clinical judgement, and maintaining patient welfare. Spearman's correlation test was used to describe associations between clinical domains. Preceptor comments were examined to identify common errors in physical exam technique and identifying physical signs.
Results: One-hundred and nine interns examined the same patient with aortic insufficiency across 14 APECS sessions. Only 58 interns (53.2%) correctly identified the presence of a diastolic murmur, and only 52 interns (47.7%) included aortic insufficiency on their differential diagnosis. There was a significant and positive correlation between physical exam technique and identification of the correct physical findings (r=0.42, p<0.001). Both technique (r=0.34, p=0.003) and identifying findings (r=0.42, p<0.001) were significantly associated with generating an appropriate differential diagnosis. Common errors in technique included auscultating over the gown, timing the cardiac cycle with the radial pulse, and failing to palpate for the apical impulse.
Conclusions: Internal medicine interns had variable skills in performing and interpreting the cardiovascular physical exam. Improving cardiovascular exam skills would likely lead to increased identification of relevant cardiovascular findings, inform clinical decision making and improve overall patient care.
Keywords: bedside medicine; cardiovascular exam skills; graduate medical education; physical exam.
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