Open Access Research BMJ Open: first published as 10.1136/bmjopen-2012-002257 on 3 April 2013. Downloaded from Junior doctor skill in the art of : a retrospective study of the medical admission note over four decades

Charlotte M Oliver,1 Selena A Hunter,2 Takayoshi Ikeda,3 Duncan C Galletly2

To cite: Oliver CM, ABSTRACT et al ARTICLE SUMMARY Hunter SA, Ikeda T, . Objectives: To investigate the hypothesis that junior Junior doctor skill in the art doctors’ examination skills are deteriorating by assessing of physical examination: a Article focus the medical admission note examination record. retrospective study ▪ There is well-documented international evidence of the medical admission Design: Retrospective study of the admission record. supporting a declining standard in junior note over four decades. BMJ Setting: Tertiary care hospital. doctors’ physical examination skills in recent Open 2013;3:e002257. Methods: The admission records of 266 years. doi:10.1136/bmjopen-2012- admitted to Wellington hospital between 1975 and 2011 ▪ This study was conducted to address the 002257 were analysed, according to the total number of physical research question that this deterioration has examination observations (PEOtot), examination of the occurred locally in Wellington, New Zealand. ▸ Prepublication history for relevant system pertaining to the presenting complaint this paper are available (RelSystem) and the number of body systems examined Key messages ▪ There has been a decline in the quantity and online. To view these files (Nsystems). Subgroup analysis proceeded according to quality of the medical admission note examin- please visit the journal online admission year, level of experience of the admitting (http://dx.doi.org/10.1136/ ation records in this tertiary care centre between doctor (registrar, house surgeon (HS) and trainee intern bmjopen-2012-002257). 1975 and 2011, which implies a decline in the (TI)) and medical versus surgical admission notes. examination skills of local junior doctors. Further analysis investigated the trend over time in http://bmjopen.bmj.com/ Received 24 October 2012 ▪ The total number of physical examination obser- documentation with respect to cardiac murmurs, Revised 1 February 2013 vations and number of body systems examined Accepted 4 February 2013 palpable liver, palpable spleen, carotid bruit, , declined over the study period, and fewer exami- funduscopy and apex beat location and character. nations were performed for palpable liver, palp- This final article is available Results: PEOtot declined by 34% from 1975 to 2011. able spleen, cardiac murmur and apex beat for use under the terms of Surgical admission notes had 21% fewer observations location and character. the Creative Commons than medical notes. RelSystem occurred in 94% of Attribution Non-Commercial ▪ Measures to address this decay in clinical ability admissions, with no decline over time. Medical notes 2.0 Licence; see include improved undergraduate curriculum, http://bmjopen.bmj.com documented this more frequently than surgical notes greater supervision of junior doctors, greater on September 29, 2021 by guest. Protected copyright. (98% and 86%, respectively). There were no involvement of junior doctors in the admission differences between registrars and HS, except for the process and increased staffing levels. 2010s subgroup (97% and 65%, respectively). Nsystems declined over the study period. Medical Strengths and limitations of this study 1School of Medicine and admission notes documented more body systems ▪ This is a significant study involving large Health Sciences, University of than surgical notes. There were no differences numbers of admission records over a Otago Wellington, Wellington, between registrars, HSs and TIs. Fewer examinations substantial period of time (358 patient records New Zealand were performed for palpable liver, palpable spleen, over four decades) with a multitude of statistic- 2 Department of Surgery and cardiac murmur and apex beat location and character ally robust outcome measures analysed. Anaesthesia, University of over the study period. There was no temporal change ▪ Our study is limited due to its retrospective Otago, Wellington, in the positive findings of these observations or heart nature, single-centre study, the use of the ‘surro- New Zealand rate rounding. gate’ marker of the written to 3Dean’s Department, There has been a decline in the University of Otago, Conclusions: reflect clinical examination skills, and the confus- Wellington, New Zealand admission record at Wellington hospital between 1975 ing admission process, whereby doctors will see and 2011, implying a deterioration in local doctors’ a patient but not necessarily “admit” them. In Correspondence to physical examination skills. Measures to counter this addition, the data were extracted by only one Dr Selena A Hunter; trend are discussed. researcher. [email protected]

Oliver CM, Hunter SA, Ikeda T, et al. BMJ Open 2013;3:e002257. doi:10.1136/bmjopen-2012-002257 1 Junior doctors’ examination skills evidenced by admission note documentation BMJ Open: first published as 10.1136/bmjopen-2012-002257 on 3 April 2013. Downloaded from

INTRODUCTION METHODS Thoughtful history taking and physical examination are This retrospective study looked at admission records recognised as fundamental to the practice of medicine.1 from patients admitted to Capital and Coast District Moreover, physicians rate physical examination as their Health Board (Wellington and Kenepuru Hospitals) most valuable skill.2 It has also been shown that despite between 1975 and 2010. The records were randomly the current technology, physical examination remains selected by National Health Index (NHI) number if the important due to its diagnostic contribution,3 positive patient had been admitted during this time with certain effect on patient care4 and cost reduction.5 medical diagnoses, as reflected by the ‘coding diagnosis’ There has been a well-recognised international which enables clerical staff to enter the correct com- decline in the physical examination skills of doctors. puter information about each admission. The year 1998 Potential reasons for this deterioration include busy clin- was the earliest year for which we could get a random ical workloads and lack of clinical teaching.67However, NHI list generated. In this way we obtained 300 sets of it is generally recognised that the most important influ- patient admission records, 100 from 1998, 100 from ence has been the increased availability of specialised 2000 and 100 from 2010, from the medical records diagnostic equipment.89Imaging technology such as department at Wellington Hospital. Out of each set of ultrasound, CT and MRI have overshadowed the use of 100 records there were 50 general medical and 50 surgi- physical examination for diagnostic information.89 cal admissions. The medical coding diagnoses were Although adding enormously to the cost of healthcare, pneumonia, congestive heart failure, shortness of breath these investigations are seen to be more accurate and or chest pain. The surgical coding diagnoses were less liable to litigation, than the more subjective art of inguinal hernia, appendicitis, , fractured physical examination.89It has been argued that the neck of femur or bowel obstruction. Many of these overuse of this technology has also helped to erode the medical files included records from previous admissions teaching and skill in physical diagnosis810and that it to hospital. We included these older admission notes if may be undermining the value of these skills.4 This is they had been coded with the aforementioned diagno- further impacted by the shift away from bedside teach- ses, and if there was at least 10 years temporal separation ing and supervision of physical examination skills during from the randomly selected admission and we used only undergraduate years and early years of practice.61011In one older admission per patient. Strict patient and staff the USA bedside teaching has fallen from 75% of clin- confidentiality was maintained at all times. ical teaching in the 1960s10 to 8–19% of clinical teach- The admission note from each record was examined ing in 2008.12 Thus there are significant changes and the relevant data were extracted by one researcher, required from both the medical school and hospital the primary author, with verification and close supervi- http://bmjopen.bmj.com/ culture regarding physical examination skill acquisition, sion by two other researchers (the corresponding and improvement and retention. final authors). This data were entered into a predeve- The medical record is a tool for communication loped spreadsheet. If there was no admission note, we between multiple health professionals, facilitating con- examined the last documented examination in the tinuity of care and good patient management.13 There emergency department before ward admission. This was have been a number of studies referencing the import- generally performed by the registrar of the admitting – ance of the quality of the medical record.14 19 The ward. The data from this examination were then entered medical record is also a legal document and as such as stated previously. on September 29, 2021 by guest. Protected copyright. deserves the appropriate time and attention to ensure it We recorded the total number of physical examination is ‘comprehensive and accurate’.13 Some studies observations (PEOtot) that were documented per admis- have looked into ways to improve documentation such sion. We also documented the number of major body as introducing a clinical note header section,20 educa- systems that had been examined (Nsystems). These were tion and instruction21 22 and structured encounter defined as the cardiovascular, gastrointestinal, respira- forms23 with positive results. There are currently no tory and central nervous systems. We then noted evidence-based standards for best practice concerning whether the relevant system pertaining to the presenting adequacy of documentation of physical examination complaint had been examined (RelSystem). We then findings for Wellington Hospital, neither are there any analysed the data in terms of year groups, in order to clinical guidelines derived from expert opinion. Thus it look for temporal change. is difficult to ascertain the expected minimum level of We subsequently analysed the data according to documentation. In order to retrospectively investigate whether it was a medical or surgical admission note, and examination practice over time we are reliant on this the level of experience of the admitting doctor (regis- medical record for our information. The current study is trars, house surgeons (HS) or trainee interns (TI)) with inevitably an investigation into both the skills of doctors respect to PEOtot, Nsystems and RelSystem. We also per- and their documentation practices, although our formed year group analysis on these subgroups. primary hypothesis is that there has been a decline in We also investigated whether there was documentation the standards of junior doctors’ physical examination of particular examination observations, positive or nega- skills. tive. These were palpable liver, palpable spleen, carotid

2 Oliver CM, Hunter SA, Ikeda T, et al. BMJ Open 2013;3:e002257. doi:10.1136/bmjopen-2012-002257 Junior doctors’ examination skills evidenced by admission note documentation BMJ Open: first published as 10.1136/bmjopen-2012-002257 on 3 April 2013. Downloaded from bruit, cardiac murmur, apex beat location and character variable and the ‘admission ward’ and ‘doctor level of and funduscopy. We analysed whether the frequency of experience’ as categorical variables. these documented observations changed over time. Of With respect to the examination of the RelSystem, we the admission notes documenting the performance of have found that this occurred in 94% of all admission these examinations, we then examined the frequency of notes (95% CI) and there was no statistically significant positive findings and any change over time. change over time (p<0.1). There was, however, a signifi- Finally we investigated the documentation of heart cant difference according to specialty, with surgical rate. Of those admission notes with a heart rate value, doctors less likely to have examined RelSystem com- we analysed the frequency with which the heart rate was pared with their medical counterparts (86% vs 98%, given as a value perfectly divisible by five, suggesting a respectively, p<0.001). Further subanalysis of specialty tendency of the admitting doctor towards rounding the and RelSystem with respect to year group showed no actual value and thus potential inaccuracy. We then statistically significant differences except for the 2010s, examined for a change in this trend over time. in which 25% of surgical admissions did not record examination of the relevant system compared with 3% of medical admissions (p<0.05); (pre 1990s (p>0.05), RESULTS 1990s (p<0.1) 2000s (p<0.1)). We examined 358 patient admission records, from 266 There was no statistically significant difference overall patients admitted to Capital and Coast District Health between examination of the relevant system pertaining Board (Wellington and Kenepuru Hospitals) between to their presenting complaint (RelSystem) with respect 1975 and 2010. For administrative reasons we were to level of experience of admitting doctor (registrar, HS unable to obtain 34 of the ordered sets of notes. There and TI; p<0.01). Further analysis by year groups shows a was no statistically significant difference in the patients’ difference only for the 2010s, in which registrars docu- age between the year groups, after Kruskal-Wallis ana- mented RelSystem in 97% of admissions compared with lysis. A biostatistician performed all analyses. 65% of HSs (p<0.005). As evidenced by the documentation in the hospital The total number of body systems examined record admission notes, there has been a statistically sig- (Nsystems) significantly declined over the study period, nificant decrease (34%) in the PEOtot per admission with a change of 1.184 mean body systems (p<0.001; from 1975 to 2011 (p<0.001; figure 1). figure 2). There were significantly fewer (21%) total observa- The most commonly omitted body system was the tions in surgical admission notes, compared with central , across all the year groups. medical admission notes (p<0.001). Registrars recorded There was a significant difference according to spe- http://bmjopen.bmj.com/ 12% fewer total observations compared with HSs cialty between medical and surgical admissions, with sur- (p<0.001). Statistical significance with respect to admis- gical doctors examining less Nsystems than physicians sion year group, specialty and level of experience of the (p<0.01). There were no significant differences between admitting doctor in terms of predicting PEOtot was specialty within each of the year groups (p<0.1). With achieved by using the Wald χ² test. PEOtot was analysed respect to the level of experience of the admitting as a negative binomial regression model (overdispersed doctor, there were no significant differences in Nsystems data) by rendering the ‘admission year’ as a continuous (p>0.5) or within year groups (p<0.1). on September 29, 2021 by guest. Protected copyright.

Figure 1 Total number of physical examinations Figure 2 Mean number of body systems examined per year observations per admission versus time. group.

Oliver CM, Hunter SA, Ikeda T, et al. BMJ Open 2013;3:e002257. doi:10.1136/bmjopen-2012-002257 3 Junior doctors’ examination skills evidenced by admission note documentation BMJ Open: first published as 10.1136/bmjopen-2012-002257 on 3 April 2013. Downloaded from

There was a significant decline over the study period 1.7, 0.2 and 0.5 respectively, df=1, p>0.5 for the rest). in the percentage of admission notes with recorded This is probably due to the low frequency of positive examinations for palpable liver, palpable spleen, cardiac findings within each of the year groups. Statistical ana- murmur and apex beat location and character (χ²=51.3, lysis was performed by Cochran-Armitage testing, and 47.8, 32.0 and 57.9, respectively, df=1, p<0.001). 95% CIs were used (figure 3B). Statistical analysis was performed by Cochran-Armitage We found that the vast majority of admission notes testing, and 95% CIs were used. There was no significant documented heart rate, with approximately 50% in each change in the frequency of recorded examinations for year group documenting a heart rate divisible by five carotid bruits (χ²=0.4, df=1, p>0.5). There was no year and no change over time with respect to the latter group analysis performed for funduscopy, as this was (χ²=0.8, df=1, p>0.5). Statistical analysis was provided by only documented in the pre 90-year group (figure 3A). Cochran-Armitage testing, and 95% CIs were used. There were no changes over time with respect to posi- tive cardiac murmur, palpable liver, palpable spleen, carotid bruit and apex beat location and character DISCUSSION (χ²=0.01, df=1, p>0.5 for cardiac murmur; χ²=1.5, 1.8, Our results imply that there has been deterioration in the physical examination skills of junior doctors in Wellington Hospital from 1975 to 2010, after detailed analysis of the medical admission record notes. This is evident from the observed decline in the recorded PEOtot, total number of body systems examined and the number of recorded observations for palpable liver, palpable spleen, cardiac murmur and apex beat location and character. In the author’s opinion, this temporal deterioration could be due to the increased use and availability of complex diag- nostic technology89as well as the concurrent loss of confi- dence in physical examination skills. Busy workloads may necessitate substandard physical examinations and the resulting documentation. Low examination skill profi- ciency after initial training, and little opportunity to improve these skills67and the resultant effect on student and teacher confidence further contribute to the demise http://bmjopen.bmj.com/ of clinical examination. Recent anecdotal comments from undergraduate students attached to surgical wards at Wellington Hospital suggest that junior staff transmit a negative view towards the value of physical examination skills, thus creating a ‘cyclic’ phenomenom of further medical deskilling with each year of medical graduates. Interestingly there has been no general decline in the examination of the RelSystem. It could be argued that on September 29, 2021 by guest. Protected copyright. the latter constitutes the ‘bare minimum’, and hence has suffered less than the other parts of the medical admission record. We found that registrars recorded 12% fewer total observations than HSs. In the authors’ opinion, this could be a reflection of the local admission process, for both medical and surgical patients. For many years, it has been the convention in Wellington that registrars assess and diagnose the patient before instigating appro- priate initial therapy. Then the team HS is called to complete the ‘clerking’ process—that is, complete the history and examination of the admission, chart the patients’ and fluids, etc. This is also the Figure 3 (A) Percentage of admission notes with recorded examinations for palpable liver, palpable spleen, carotid bruit, case for elective patients undergoing the preassesment murmur, apex location, apex character and funduscopy versus process before their scheduled surgery, where the initial ’ year group. (B) Percentage of admission notes with positive documentation of the patient s medical problems is per- findings for palpable liver, palpable spleen, carotid bruit, formed by an anaesthetist before the HS interviews the murmur, apex location, apex character and funduscopy versus patient. This may not reflect practice in all New Zealand year group. or international hospitals.

4 Oliver CM, Hunter SA, Ikeda T, et al. BMJ Open 2013;3:e002257. doi:10.1136/bmjopen-2012-002257 Junior doctors’ examination skills evidenced by admission note documentation BMJ Open: first published as 10.1136/bmjopen-2012-002257 on 3 April 2013. Downloaded from

It remains unclear why surgical admission notes obtain some earlier admission notes, when these were contain less total observations and number of body co-filed with more contemporary records, although these systems than their medical counterparts. In the authors’ were not randomly selected. However, these earlier notes opinion, physicians may arguably take a more holistic were at least 10 years apart from the other records, there approach to their patients, and are hence more likely to was only one older file per patient, and statistical analysis examine more body systems and document a greater showed no difference in patient age across the year number of examination findings. The differential diagno- groups. This was single-centre study hence further ses of medical complaints may be broader than surgical research is warranted at other national and international complaints, warranting such a detailed assessment. hospitals. Finally, our data were extracted by only one Junior surgical staff are frequently time pressured as they researcher, the first author, however, this was closely super- are often on call for acute assessments, as well as being vised and verified by two other researchers. expected to be in the operating theatre. Surgical house This is the second study from Wellington Hospital that officers are the only staff available to deal with the often has identified the declining quality of the hospital admis- complex medical issues in the surgical ward. If this time sion note with regard to physical examination. A previous pressure is indeed a true factor in the declining standards Wellington study concluded that there has been a decline of the surgical admission note, greater surgical staffing in the quality of the surgical HS admission note resources could ameliorate this situation. Other measures (SHSurgAdN) when comparing 2005 and 2009 (Morgan that may help reduce the workload include the involve- TG, Dennet ER. Quality of House Surgeon Acute ment of senior medical staff early in the admission Surgical Admissions, 2005 vs 2009 (personal communica- process in managing complex medical problems. This is tion)). The authors found that the SHSurgAdN was com- already occurring in some wards, with Consultant paratively deficient in the documentation of the relevant Geriatricians seeing elderly orthopaedic patients with hip system examination and the cardiorespiratory examin- fractures soon after admission. Certainly there is consen- ation, and that this deficiency had worsened over the sus regarding the benefits resulting from the routine intervening 4 years. This study faced similar limitations as involvement of an elderly care physician in such circum- the current study, that is, it was single-centred, retrospect- stances.24 Many studies have shown shorter hospital stays, ive, the admission note was used as a surrogate for the reduced mortality, improved placement on discharge assessment of the junior doctors’ physical examination although there is conflicting evidence regarding cost- skills, and the admission process is complicated. However, savings.24 While this approach may indeed benefit hospi- it was well designed and had good power, with 100 admis- tals and orthogeriatric patients, it may result in further sion notes audited in total. This study differed from the clinical deskilling of junior doctors. current study in that it incorporated a HS questionnaire, http://bmjopen.bmj.com/ Surgical admission notes contained less examination of with questions on history taking as well as clinical examin- the relevant system pertaining to the presenting complaint ation. The current study involves the investigation of an compared with medical admission notes. This was espe- even greater number of admissions over a longer time cially true in the 2010-year group. In the authors’ opinion, period, with more extracted data. this could be again due to the surgical admission process, There are potential solutions to halt this decline in whereby the surgical registrar assesses the patient (and physical examination skills. Some local barriers to clin- presumably examines the relevant system) but does not ical competence have been identified and ways to actually complete a full admission note, which is then com- improve this deficit have been suggested.7 In the on September 29, 2021 by guest. Protected copyright. pleted by the surgical house officer. Anecdotal experience authors’ opinion, these could include increased senior shows that in recent years, junior staff, completing the supervision of the admitting process including formative admission note. often do not feel it is necessary to repeat feedback and reflection, as well as a local cultural the examination of the relevant system, especially as change enabling HSs to initially assess patients while further examination of a tender abdomen or fractured senior staff provide supervision and guidance. This limb can cause discomfort. This is borne out by the sub- would require increased junior staffing or work-based group analysis finding showing that in the 2010-year group changes to address workload issues, as well as commit- the registrars documented RelSystem in 97% of admis- ment from senior colleagues to ensure that there is no sions, compared with 65% of HSs. compromise to patient safety. Finally, international evi- There were several limitations to our study. These dence suggests that improved undergraduate curriculum include its retrospective nature, the use of the ‘surrogate’ especially bedside teaching and enhanced supervision of marker of the medical record to reflect clinical examin- new doctors could redirect the current downward trend ation skills, and the confusing admission process, whereby in physical examination.6 8 10 11 doctors will see a patient but not necessarily ‘admit’ them. During the audit process in this study, there was also In addition, database restrictions in the medical records significant variation in the history component of the department meant we were only able to request medical admission note. History is a vital part of the admission admission files from 1998 onwards. The study could have process, and is crucial to diagnostic success.25 26 Further had greater statistical impact if we were able to access large research is warranted regarding the adequacy of history numbers of records from much earlier. We were able to taking as evidenced by the admission record.

Oliver CM, Hunter SA, Ikeda T, et al. BMJ Open 2013;3:e002257. doi:10.1136/bmjopen-2012-002257 5 Junior doctors’ examination skills evidenced by admission note documentation BMJ Open: first published as 10.1136/bmjopen-2012-002257 on 3 April 2013. Downloaded from

Acknowledgements The authors would like to thank Professor Michael 11. Crumlish CM, Yialamas MA, McMahon GT. Quantification of bedside Harrison for his advice and help in revision of the paper. teaching by an academic hospitalist group. J Hosp Med 2009;4:304–7. Contributors The authors listed have made significant contributions to this 12. Williams KN, Ramani S, Fraser B, et al. Improving bedside teaching: paper. CMO was involved in the extraction and processing of the data, data findings from a focus group of study learners. Acad Med 2008;83:257. ’ analysis and interpretation, literature search, discussion points and initial draft 13. Cole s Medical Practice in New Zealand. Wellington Medical Council of New Zealand. 2011. formation. SAH was not only involved in an administrative and 14. Baker MD, Schoenfeld PS. Documentation in the pediatric communication capacity but has contributed significantly with respect to emergency department: a review of resuscitation cases. Ann Emerg study design, data extraction and analysis, interpretation and statistical Med 1991;20:641–3. analysis, literature search and final paper revisions. TI was responsible for the 15. Cox JL, Zitner D, Courtney KD, et al. Undocumented patient statistical analysis and figures. DCG designed the study and was involved in information: an impediment to quality of care. Am J Med – the extraction of the data, interpretation of the data and critical review of the 2003;114:211 16. 16. Dunlay SMMD, Alexander KPMD, Melloni CMD, et al. Medical publication. All authors read and approved the final manuscript. records and quality of care in acute coronary syndromes: results – Funding The original project was funded by the Research Office in the from CRUSADE. Arch Inter Med 2008;168:1692 8. 17. Hicks TA, Gentleman CA. Improving physician documentation through University of Otago Wellington. a clinical documentation management program. Nurs Adm Q Competing interests None. 2003;27:285. 18. Liesenfeld B, Heekeren H, Schade G, et al. Quality of Provenance and peer review Not commissioned; externally peer reviewed. documentation in medical reports of diabetic patients. Int J Qual Health Care 1996;8:537–42. Data sharing statement No additional data are available. 19. Miller JM, Velanovich V. The natural language of the surgeon’s clinical note in outcomes assessment: a qualitative analysis of the medical record. Am J Surg 2010;199:817–22. 20. Denny JC, Miller RA, Johnson KB, et al. Development and evaluation of a clinical note section header terminology [Evaluation REFERENCES Studies Research Support, U.S. Gov’t, P.H.S.]. AMIA Annu Symp 1. Li J. Clinical skills in the 21st century. Arch Intern Med 1994;154:22. Proc 2008:156–60. 2. Kern DC, Parrinog TA, Korst DR. The lasting value of clinical skills. 21. Tinsley JA. An educational intervention to improve residents’ J Am Med Assoc 1985;254:70. inpatient charting. Acad Psychiatry 2004;28:136–9. 3. Lembo NJ, Dell’Italia LJ, Crawford MH, et al. Bedside diagnosis of 22. Smith JJ, Bland SA, Mullett S. Temperature—the forgotten vital sign systolic murmurs. N Engl J Med 1988;318:1572–8. [Evaluation studies]. Accid Emerg Nurs 2005;13:247–50. 4. Reilly B. Physical examination in the care of medical inpatients: an 23. Kanegaye JT, Cheng JC, McCaslin RI, et al. Improved observational study. Lancet 2003;362:1100–5. documentation of wound care with a structured encounter form in 5. Shaver JA. Cardiac : a cost-effective diagnostic skill. the pediatric emergency department [Evaluation Studies]. Ambul Curr Probl Cardiol 1995;20:441. Pediatr 2005;5:253–7. 6. Chan-Yan C, Gillies JH, Ruedy J, et al. Clinical skills of medical 24. Khan R, Fernandez C, Kashig F, et al. Combined orthogeriatric care residents: a review of physical examination. CMAJ 1988;139:629. in the management of hip fractures: a prospective study. Ann R Coll 7. Sheehan D, Wilkinson TJ, Billett S. Interns’ participation and Surg Engl 2002;84:122–4. learning in clinical environments in a New Zealand hospital. Acad 25. Peterson MC, Holbrook JH, Hales D. Contributions of the history, Med 2005;80:302–8. physical examination and laboratory investigation in making medical 8. Mangione S, Peitzman S. Physical diagnosis in the 1990s. Art or diagnoses. Br Med J 1992;156:163–5.

artifact? J Gen Intern Med 1996;11:490–3. 26. Hampton JR, Harrison MJG,, Mitchell JRA. Relative contributions of http://bmjopen.bmj.com/ 9. Tavel M. Cardiac auscultation: a glorious past—but does it have a history-taking, physical examination, and laboratory investigation to future? Circulation 1996;93:1250–3. diagnosis and management of medical outpatients. BMJ 10. LaCombe MA. On bedside teaching. Ann Int Med 1997;126:217. 1975;2:486–9. on September 29, 2021 by guest. Protected copyright.

6 Oliver CM, Hunter SA, Ikeda T, et al. BMJ Open 2013;3:e002257. doi:10.1136/bmjopen-2012-002257