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Junior Doctor Skill in the Art of Physical Examination: a Retrospective Study of the Medical Admission Note Over Four Decades

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Junior Doctor Skill in the Art of Physical Examination: a Retrospective Study of the Medical Admission Note Over Four Decades 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 physical examination: 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 patients 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, heart rate, 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 patient 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 medical record 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, abdominal pain, 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
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