gms | German Medical Science

The practical skills associated with recording case history and physical examination are of fundamental importance to the practice of medicine. Up to 70% of suspected diagnoses can be made correctly using anamnesis and physical examination [8]. The central role of bedside teaching during medical education as a method for imparting these skills is frequently emphasized [5], [3], [1]. If structured training in these basic medical skills is absent, students experience difficulty, at the latest during the final year of medical education, in examining patients in a structured and targeted manner. In many cases, the main problem lies in the absence of a systematic approach and standardization concerning physical examination.

At a total of three medical clinics of the Technical University Munich, the Medical Clinics I and II at the Klinik rechts der Isar and the Klinik für Herz- und Kreislauferkrankungen at the Deutsches Herzzentrum München, a clinical examination course is offered during the first year of clinical study to learn practical skills involving anamnesis and physical examination. Since 2007 regular student evaluations of this examination course have taken place. The results indicate the need for improvement of the examination course sessions. In particular, the absence of structure regarding the course sessions, the missing articulation of a learning objective, the insufficient provision of additional learning materials, and the lack of preparation of the instructors have been criticized.

In addition, the often young course instructors display a lack of confidence regarding curricular content and its implementation.

The aim of this study is to examine if and to what extent targeted measures for improvement to the curricular content and teaching method of the clinical examination course lead to a higher degree of satisfaction among students and to better self-assessment regarding the acquired examination techniques.

During the 2010 summer semester, a total of 49 students in their first year of clinical study attended a clinical examination course held in a total of six wards at the Klinik für Herz- und Gefäßerkrankungen housed at the Deutsches Herzzentrum München and at the Medical Clinics I and II at the Klinikum rechts der Isar (teaching hospitals of the Technical University Munich). These course sessions covered the following four subject areas: cardiovascular system, thorax, arterial and venous systems, abdomen and lymphatic system. This study adheres to the principles of the Declaration of Helsinki.

Evaluations using preprinted surveys (see Figure 1 [Fig. 1]) were conducted after completion of a course session prior to and after structural changes were implemented (see Table 1 [Tab. 1]). The students were not informed of the improvements that were undertaken.

The aspects evaluated encompassed the preparation and punctuality of the instructors, the organization of the particular course sessions and the use of additional materials, such as handouts (see Figure 2 [Fig. 2]). Furthermore, information was asked for regarding online teaching materials and the students’ self-assessment. The evaluation used the German scholastic grading scale (grades 1 to 6), with 1 being the highest rating and 6 the lowest.

To achieve an improvement of the clinical examination course, the curricular content was not only revised, but global as well as specific learning objectives were also laid down. Moreover, students were given opportunity to prepare for a particular course session in advance and to process the material afterwards using specific course scripts on the various topics. These scripts also served as a tool to prepare the instructors for the particular examination course sessions. Within the scope of the course sessions in addition to distributing the handouts, the instructors were urged to inform students about Internet links containing further preparatory material, such as films and texts on examination techniques. Furthermore, the instructors were regularly reminded in advance of the examination course sessions, and the revised learning objectives for the clinical examination course were communicated using the scripts.

Since the questionnaires were filled out anonymously before and after the improvements, the results could not be analyzed in direct comparison. Therefore, an exploratory statistical analysis was undertaken of the evaluative part with a T test for independent random samples with normally distributed parameters, as well as with a non-parametric test for independent random samples with abnormally distributed parameters (Mann-Whitney U test). All tests were performed at a significance level of 5% (SPSS 17, SPSS Inc. Chicago, IL, USA). Adjustment for multiple testing was not undertaken.

The evaluations of two examination course sessions – one before structural improvements and one after – covering the topics cardiovascular system, thorax, arterial and venous systems, and abdomen and lymphatic system were compiled and averaged. 47 of a total of 49 students (96%) completed the evaluation survey prior to the changes and 34 students (69%) filled it out after measures for improvement had been implemented.

Table 2 [Tab. 2] depicts the evaluation results according to specific aspects of the course.

The measures listed above led to significant improvement in the evaluative ratings of the clinical examination course in the areas of mentoring by instructors, structure of the course, and self-assessed confidence in conducting an examination when compared to the results prior to the changes. A significant improvement of the ratings was seen in the following areas: short introduction to the topic of each clinical examination course (from 2.4±1.2 to 1.7±1.0; p=0.002) and to hygienic measures (from 3.8±1.9 to 2.5±1.8; p=0.004), structured demonstration of each examination step (from 2.9±1.5 to 1.8±1.0; p=0.001), practice of clinical examination steps (from 3.1±1.8 to 2.2±1.4; p=0.030), structured feedback on examination techniques (from 3.0±1.4 to 2.3±1.0; p=0.007), use of handouts (from 5.2±1.4 to 1.8±1.4; p<0.001), tips regarding additional learning material (from 5.0±1.4 to 3.4±2.0; p<0.001), general learning experience (from 2.4±0.9 to 1.9±0.8; p=0.017), and students’ self-assessment regarding confidence in performing physical examinations (from 3.5±1.3 to 2.5±1.1; p<0.001).

Improvement concerning punctuality on the part of instructors could not be achieved with the measures implemented here (before 1.7±1.2; and after 2.4±2.0; 0.198).

In open-ended responses, students actively took advantage of the possibility to voice their expectations regarding the examination course and make suggestions for improvement. In respect to this, students primarily wrote down their interest in smaller examination groups (38 of a total of 83 open-ended responses, 46%) and the desire for more time to practice examination techniques on patients (25 of a total of 83 open-ended responses, 30%). In addition, students expressed the wish for more pathological findings corresponding to the particular examination course topics (21 of a total of 83 open-ended responses, 25%). A further relevant expectation of the examination course involved the instructors showing up on time (10 of a total of 83 open-ended responses, 12%).

Using a clinical examination course as an example, the value of structural improvements to teaching method and curricular content was analyzed.

By means of the basic structural measures described, significant improvement in the student evaluations of a clinical examination course could be achieved in the areas of mentoring by instructors, structure of the course, and self-assessed confidence in conducting an examination when compared to the results prior to the implementation of changes.

Other studies have also achieved an optimization of practical courses based on bedside teaching through various measures [2], [6], [7], [10]. In this study, the structural changes in the preparation of the clinical examination course session through specific handouts for the instructors led to a substantially better evaluation of the instructors by the students. The punctuality of the instructors, however, could not be influenced by this measure. Most likely, freeing instructors to a greater extent from simultaneous clinical duties would be a more effective way to remedy this problem.

The wish for more pathological findings matching the particular course topic was evident primarily in the open-ended answers included in the evaluation surveys (25%). This demonstrated another shortcoming of the present examination course which has not yet been taken into account regarding optimization. The evaluation results have led to continued structural improvements, even after completion of this study. As a result, students in the examination courses now rotate among the various wards with their typical clinical pictures to ensure exposure to the different pathological findings.

Limitation of the study: external assessment of the students, for instance through a standardized clinical test, would have been a good way to objectify the structural improvements. Practical testing in the form of objective structured clinical examinations (OSCEs) also comes into question as a recognized method of assessing practical skills [4], [7], [9]. Questionnaires, however, also pose a recognized and frequently used manner of evaluation [2].

The basic structural changes to facilitate preparation of the instructors and optimize the curricular content of the clinical examination course significantly improved the evaluations of the clinical examination course and led to substantially higher levels of student satisfaction and self-confidence.

The successful improvement seen here rests directly on the regular reminders and briefings of the instructors prior to each day on which the course took place and on the use of handouts that not only facilitated instructor preparation alongside the daily hospital routine, but also served as take-home messages for the students.

In future, practical tests, the objective structured clinical examinations (OSCEs), are also to be applied as objective assessment of the acquired practical skills. The resonance among instructors was not examined in this study. Further studies are necessary to analyze the influence on motivation levels among instructors, who are often doubly burdened. This should be taken into consideration in future studies.

The authors declare that they have no competing interests.