Using Web-Based Video to Enhance Physical Examination Skills in Medical Students

Vol. 40, No. 7 471 Medical Student Education

Using Web-based Video to Enhance Physical Examination Skills in Medical Students

Eugene Orientale, Jr, MD; Lynn Kosowicz, MD; Anton Alerte, MD; Carol Pfeiffer, PhD; Karen Harrington, MSW, LCSW; Jane Palley, MSW; Stacey Brown, PhD; Teresa Sapieha-Yanchak

Background and Objectives: Physical examination (PE) skills among US medical students have been shown to be deficient. This study examines the effect of a Web-based physical examination curriculum on first-year medical student PE skills. Methods: Web-based video clips, consisting of instruction in 77 elements of the physical examination, were created using Microsoft Windows Moviemaker software. Medical students’ PE skills were evaluated by standardized patients before and after implementation of the Internet-based video. Results: Following implementation of this curriculum, there was a higher level of competency (from 87% in 2002–2003 to 91% in 2004–2005), and poor performances on standardized patient PE exams substantially diminished (from a 14%–22% failure rate in 2002–2003, to 4% in 2004–2005. Conclusions: A significant improvement in first-year medical student performance on the adult PE occurred after implementing Web-based instructional video.

(Fam Med 2008;40(7):471-6.)

Physical examination skills among US medical students the physical examination. For the purpose of medical have been shown to be deficient.1-5 It appears that tradi- student education and evaluation, we believed that it tional methods for teaching physical examination skills was important to provide a consistent, uniform, and (eg, lecture, demonstration, peer-to-peer practice, and standardized approach to physical examination content practice with both standardized and actual patients) are and technique. not producing competency.6 To improve the consistency and quality of instruction Several innovative education interventions have been on physical examination skills, we developed a Web- undertaken by medical schools in the United States to based curriculum consisting of 77 video vignettes that strengthen students’ physical examination skills.7-10 For supported teaching of the physical exam during our example, several schools have introduced Web-based Principles of Clinical Medicine (PCM) course. We hy- “encounters” and compared them to the use of standard- pothesized that this curricular enhancement would have ized patients to teach clinical diagnosis skills,9, 12 with a positive effect on our students’ physical examination positive results. skills when assessed at end of the first year of medical At our institution, we were faced with significant school. This study’s purpose was to measure changes challenges in teaching physical examination skills. in first-year students’ performance of physical exami- While some consider the diversity of the faculty to nations on standardized patients after implementation be a major strength of our institution, it also pres- of this Web-based curriculum. ents a significant challenge. Including community preceptors, nearly 300 faculty members are involved Methods in teaching basic physical examination skills to our Study Participants medical students. Predictably, this results in a wide All 319 medical students at the University of Con- range of teaching styles, with varying approaches to necticut School of Medicine entering their first year of training in 2002, 2003, 2004, and 2005 were participants in this study. Our Institutional Review Board From the Department of Family Medicine, University of Connecticut. granted the study an exemption from formal review. 472 July-August 2008 Family Medicine

Students were assigned to a class cohort correspond- is a 3-year curriculum that emphasizes ambulatory ing to their entering year. The first-year medical student care and early exposure to generalist approaches to classes entering training in 2002 and 2003 classes did medicine. Students spend 1 half day per week with not have the Web-based video vignettes to use as part physician preceptors who are primary care community of the curriculum. The 2004 and 2005 classes received physicians in the fields of internal medicine, pediatrics, the new curriculum that included the video vignettes. and family medicine. This community-based experi- The demographics of the two cohorts were similar ence provides students with an opportunity to put their to one another, with most students beginning medical physical examination skills to practice. school in their early 20s and all groups comprised of Given the size and heterogeneous nature of our fac- more than 60% women. The main criteria for medical ulty, we conceptualized a Web-based physical exami- school admission, which included university grades, nation curriculum that could be uniformly referenced performance on standardized exams, and a personal by all course participants (including faculty, medical interview, did not change during the study time frame students, and standardized patients). This online cur- (Table 1). Core faculty teaching the PCM course also riculum could be accessed in both a synchronous (dur- remained largely unchanged during the study time ing instruction) and asynchronous manner. frame; of 20 core faculty members teaching the course, turnover totaled no more than two (and sometimes The Video Vignettes. We created 77 short video fewer) faculty members each year. vignettes consisting of downloadable video files to match the 77 maneuvers on our physical examination Program Development checklist (Figure 1). Before videotaping began, we Background. The PCM course meets one afternoon reviewed the evidence-based literature on some of the per week in small-group seminars during the first 2 more controversial aspects of physical examination years of medical school. Each group is facilitated by techniques. Our multidisciplinary faculty leadership two faculty members, one of whom is a physician and agreed that while many acceptable variations exist for the other a nonphysician health professional. Through a particular organ system (eg, thyroid exam), we would a combination of lectures, small-group discussions, and try to eliminate some of the variations in technique practice sessions, students learn the basic components by suggesting only those that were most supported by of the history and physical examination. A new body evidence.15,16 Where supportive evidence did not exist, system is introduced each week and every 4 weeks is faculty consensus was used to make decisions about punctuated by a formative clinical skills assessment physical exam technique. (CSA) session. During CSA sessions, students received Filming sessions took place in CSA, in which a stan- formative feedback from trained standardized patients dardized patient served as the physical exam model. about their performance on physical exam techniques Course faculty members were used as instructors in taught to date. the video, while others served as moderators in reading Concomitant with the PCM course, students par- a prepared script. Approximately 16 hours of video- ticipate in Student Continuity Practice (SCP), which taped instruction was edited to identify the 77 unique maneuvers. Video was downloaded in .mpg format, and Microsoft Moviemaker was used for video editing. Editing consisted of truncating, combining, dub- Table 1 bing, and title overlays for each video segment. Clips range in length from 30 to 240 seconds, highlighting Student Demographics of Classes important aspects of physical exam maneuvers and Entering 2002–2005 fully demonstrating a particular exam technique in its entirety. In some cases, different viewing angles were 2002 2003 2004 2005 added to enhance clarity. Percent female 64 66 63 71 All together, the final vignettes comprise nearly 90 Average age (years) 24 24 24 24 minutes of video. Editing was conducted by one indi- MCAT 29.7 30.5 30.8 30.2 vidual and took approximately 50 hours of effort. Video Ethnicity clips were subsequently reviewed by course faculty, % URM 15 16 22 23 CSA faculty and trainers, standardized patients, and % Asian 17 16 5.2 14 selected medical students. Based on feedback, clips % White 68 68 72 63 were retaped or reedited for additional clarity and GPA undergraduate 3.60 3.66 3.66 3.66 emphasis.

MCAT—Medical College Admissions Test URM—underrepresented minorities GPA—grade-point average Medical Student Education Vol. 40, No. 7 473

Introducing the New Curriculum. The Web-based resource of video clips was then demonstrated to faculty Figure 1 and first-year medical students (class entering in 2004) in January 2005 at the outset of physical examination Maneuvers on Physical Examination Checklist instruction in the second semester of curriculum. Faculty members giving lectures or conducting small- NAME______group sessions were encouraged to reference the video PRECEPTOR______clips directly in their presentations. Medical students PATIENT INSTRUCTOR______were actively encouraged to access the Web page and DATE______download PE clips at any time. To further encourage use of the videos, students were informed that the S=Satisfactory, US=Unsatisfactory, ND=Not Done Web page format was precisely that of their summa- S US ND tive assessment in clinical skills. In fact, a Web page ______Inspect hands and arms was designed to mimic the CSA physical examination ______Inspect nails, capillary refill checklist, which also serves as the final summative ______Radial pulse rate/15 sec evaluation form. Clips were hyperlinked to the checklist ______Blood pressure—one arm sitting for ease of downloading. The Web page was main- ______Examine scalp tained on an institutional server for both Intranet and ______Visual fields (CN II) Internet access. This made access simple for all course ______Extraocular movement (CN III, IV, VI) participants and instructors and did not require use of the medical library. ______Inspect conjunctiva, sclera ______Pupillary reflexes (CN II, III) Program Evaluation ______Red reflex At the conclusion of the PCM course, a final sum- ______Fundoscopic exam—disc,vessels,macula mative CSA occurs; students are expected to perform a ______Hearing acuity (CN VIII) complete adult physical examination on a standardized ______Inspect Pinnae patient. This remained unchanged during the study ______Otoscopic ear exam time frame. ______Rinne Each student’s performance was assessed by stan- ______Weber dardized patients using two sets of measures: a percent ______Nasal exam correct score on the 77-item physical exam checklist ______Transillumination or percussion—sinuses (PE checklist) and a mean score on a four-item physical ______Inspect oral cavity exam process instrument (PE process) that used a Likert ______Palpate oral cavity scale, with 1 indicating poor and 5 indicating excellent. ______Neck ROM The PE process score was a sum score of four items: (1) ______Palpate neck nodes attention to patient comfort, (2) efficiency of exam, (3) ______Thyroid draping technique, and (4) overall skills level. ______Carotid arteries pulses—palpate ______Carotid arteries pulses—auscultate Data Analysis ______Palpate or percuss spine Student data were de-identified and presented in ______Percuss costo—vertebral angles aggregate. Data analysis included calculation of the ______Tactile fremitus—posterior—three sites/side mean percentage of correct items on the PE checklist ______Percuss lungs—posterior—three sites/side and mean value for the PE process items for each co- ______Percuss diaphragmatic excursion hort. T test analysis and repeated measures ANOVA ______Auscultate lungs—posterior—three sites/side were used to determine statistical significance of pre- ______Vocal fremitus or pectoriloquy implementation (2002–2003) and post-implementation ______Egophony (E-A change) (2004–2005) performance of medical students on the ______Auscultate lungs—laterally—each side adult physical examination of standardized patients. ______Percuss lungs—anterior—three sites/side Analyses were performed using SPSS 11.5, 2004 soft- ______Auscultate lungs—anterior—three sites/side ware (SPSS, Inc, Chicago). ______Auscultate heart sitting ______Palpate axillae Results ______Palpate breasts The mean score on the PE checklist showed a statis- ______Observe cervical veins—CVP estimate tically significant increase for students in the cohorts that had access to the Web-based curriculum (Table 2). ______Palpate precordium for PMI Mean PE checklist performance scores rose from 87% ______Auscultate four areas—supine, with diaphram (continued on next page) 474 July-August 2008 Family Medicine

in 2002–2003, to 91% in 2004–2005 (P<.05). There was Figure 1 (continued) also a decline in the standard deviation of those scores (Table 2) and a significant drop in the percentage of S US ND students scoring below 80%, which has been designated ______Auscultate two areas—supine, with bell as the minimum passing score (Figure 2). The repeated ______Auscultate at apex, LLD, with bell measures ANOVA indicated that the overall increase in ______Auscultate abdomen for bowel sounds PE checklist score was statistically significant P( <.01) ______Auscultate renal arteries—left and right between the years prior to and following implementa- ______Palpate abdomen for tenderness/masses tion of the new curriculum. The PE process scores did ______Percuss liver span and spleen not change during the study time frame. ______Palpate liver edge ______Palpate spleen Discussion ______Palpate abdominal aorta This study demonstrates a positive and statistically ______Palpate inguinal nodes significant benefit in first-year medical students’ -per ______Palpate femoral pulses formance after implementing our Web-based curricular ______Auscultate femoral bruits innovation. Although prior to the introduction of these ______Palpate leg pulses—DP, PT 77 video vignettes most students succeeded in passing ______Inspect lower extremities the threshold score of 80%, a sizeable number did not ______Joint inspection and joint ROM upper extremities (22% in 2002 and 14% in 2003). Following imple- ______Joint inspection and joint ROM lower extremities mentation of this curricular enhancement, there was a ______-CN V—motor and sensory—three branches/side substantial and consistent decrease in the percentage of ______-CN VII—forehead, frown/smile students who did not pass: 4% in both 2004 and 2005. ______-CN IX, X—(agh) Arguably, this is perhaps our most important result, ______-CN XI—shrug since our primary objective was to have all students ______-CN XII—tongue out and to sides perform at a higher competency level than before the ______Muscle strength—upper extremities curricular innovation. This diminution of the “tail” of ______Muscle strength—lower extremities marginal or substandard performance is an important ______Sensory—sharp touch step toward ensuring competency of all first year stu- ______Vibration—toes dents in these skills. ______Proprioception—toes We believe that introducing the reference video en- ______DTRs—biceps, triceps, knee, ankle hanced the uniformity of both instruction and learning. ______Babinski reflex Multidisciplinary instructors at all levels of the course ______Cerebellar—FTN or RAM were given a reference, or standard, from which to ______Cerebellar—heel-to-shin (HTS) teach. Standardized patients, who used the videos for ______Gait—normal, tandem, walk on heels and toes their own reference purposes, may have contributed ______Romberg to improved accuracy of their evaluative feedback to ______Pronator drift learners. Medical students, the primary recipients of ______Back mobility—six directions this instruction, had a reference and standard from ______Mental status—orientation which to learn. In effect, we believe that this teaching tool reduced the variance inherent in physical exam General Assessment instruction that is common in many medical school Attention to patient comfort: curricula. Excellent Poor Further, these standardized video demonstrations 5 4 3 2 1 served to eliminate much of the controversy regarding Efficiency of exam: students’ final summative evaluation. Students had a Excellent Poor clearer understanding of precisely how they would be 5 4 3 2 1 evaluated a priori and could prepare more efficiently for their performance-based adult physical exam at the Draping: course conclusion. Excellent Poor Given the complexity and scope of teaching physical 5 4 3 2 1 examination skills in our setting, we feel that our results likely can be generalized to other medical education Overall skills level: settings. Without a reference or standard for physical Excellent Poor examination instruction, many curricula create unnec- 5 4 3 2 1 essary “noise” and variance in instruction; even text- books do little to harmonize instruction in examination Washed Hands ___Y ___N Medical Student Education Vol. 40, No. 7 475

the curriculum has been used by nursing students, advanced- Table 2 practice nurses in training, and medical students at another Physical Exam (PE) Performance in Four Classes of Medical Students* state medical school.

Class Percent Scoring Below Percent Scoring Below Limitations (Entering Year) PE Checklist PE Process 80% on Checklist 3.5 on Process We acknowledge several 2002 87+8 4.0+0.6 22 17 n=81 limitations of our study. First, 2003 87+7 3.9+0.8 14 34 we initially did not anticipate n=80 studying the effectiveness of 2004 91+6 4.2+0.6 4 15 this innovative tool; as such, n=81 we did not directly measure or 2005 91+5 3.9+0.6 4 26 track actual utilization of the n=77 video clip Web site by students, * Pre-implementation performance in years 2002–2003, post–implementation performance in 2004–2005, teachers, or patient instructors. P<.05). This might easily have been facilitated by a Web page counter device, which we subsequently technique. Standardized Web-based video provides a added in 2006. However, we have no reason to doubt unique instructional framework for both teacher and the use of this Web-based video, given the favorable pupil that reduces variance and enhances competency. feedback from all users. By providing a classroom and outside-the-classroom Second, this tool was implemented at a single medi- reference that is available whenever desired, we have cal school. Because of the unique undergraduate cur- augmented the performance of the entire medical riculum that interfaces with this tool, the results may student class, as well as the performance of marginal have some limits in applicability to the curriculum of performers. some other medical schools. The availability of our online curricula has had far- Third, our study used a retrospective design that was reaching effects in our health care setting. Based on in- not blinded. All study participants in each study year formal discussion, multidisciplinary Clinical Medicine either did (2002, 2003) or did not (2004, 2005) receive Course faculty members have expressed appreciation the study intervention. In retrospect, it might have for a reference standard from which to teach. Standard- been useful to have each year of medical students ran- ized patients have described these videos as a valuable domized into groups using the curricular intervention resource, particularly for those with limited experience/ and those using only the conventional curriculum. A knowledge in medical education and those in primary prospective, randomized, placebo-control study design occupations other than health care. On a larger scale, would have more accurately revealed the effects of our curricular intervention. Lastly, we acknowledge that these improved performance results may not have Figure 2 a lasting effect on more senior medical students’ competence in physical exami- Percent of Students Scoring Below the Mean Physical nation skills. Future research may exam- Exam Checklist Score of 80% Before and After Implementation ine test results from these same medical of the Web-based Curriculum (P<.05) student classes to see if better performance in the first year of training is sustained throughout all years of undergraduate medical education.

Conclusions This study demonstrated a measur- able improvement in first-year medical Before After students’ physical examination skills following implementation of a Web-based curriculum consisting of 77 instructional video vignettes that provided students with a demonstration of acceptable physi- 476 July-August 2008 Family Medicine cal examination techniques. This curriculum may be 6. Dull P, Haines DJ. Methods for teaching physical examination skills to 17 medical students. Fam Med 2003;35(5):343-8. obtained by others via the Internet following free user 7. Fagan MJ, Griffith RA, Obbard L, O’Connor CJ. Improving the physi- registration. cal diagnosis skills of third-year medical students: a controlled trial of a literature-based curriculum. J Gen Intern Med 2003;18(8):652-5. Acknowledgments: We acknowledge Jeri Hepworth, PhD, professor of fam- 8. Schwind CJ, Boehler ML, Folse R, Dunnington G, Markwell SJ. Devel- ily medicine, vice-chair of family medicine, University of Connecticut, for opment of physical examination skills in a third-year surgical clerkship. final manuscript review. Am J Surg 2001;181(4):338-40. IRB approval: Exempt Research, Full Approval 07-116-1 (December 9. Triola M, Feldman H, Kalet AL, et al. A randomized trial of teaching 6, 2006). clinical skills using virtual and live standardized patients. J Gen Intern This study was presented as “Using�� Web-based Video to Enhance Teach- Med 2006;21(5):424-9. ing the Physical Examination in Medical Student Education” at the Society 10. Berg D, Sebastian J, Heudebert G. Development, implementation, and of Teachers of Family Medicine 2007 Predoctoral Education Conference evaluation of an advanced physical diagnosis course for senior medical in Memphis. students. Acad Med 1994;69(9):758-64. 11. Wilkerson L, Lee M. Assessing physical examination skills of senior Corresponding Author: Address correspondence to Dr Orientale, Asylum medical students: knowing how versus knowing when. Acad Med Hill Family Medicine Center, 99 Woodland Street, Hartford, CT 06105. 2003;78(10 Suppl):S30-S32. [email protected]. 12. Turner MK, Simon SR, Facemyer KC, Newhall LM, Veach TL. Web-based learning versus standardized patients for teaching clinical diagnosis: a randomized, controlled, crossover trial. Teach Learn Med Re f e r e n c e s 2006;18(3):208-14. 13. Losh DP, Mauksch LB, Arnold RW, et al. Teaching inpatient commu- 1. Ozuah PO, Curtis J, Dinkevich E. Physical examination skills of US nication skills to medical students: an innovative strategy. Acad Med and international medical graduates. JAMA 2001;286(9):1021. 2005;80(2):118-24. 2. Ortiz-Neu C, Walters CA, Tenenbaum J, Colliver JA, Schmidt HJ. Error 14. Koeppen B. University of Connecticut School of Medicine. Acad Med patterns of third-year medical students on the cardiovascular physical 2000;75(9 Suppl):S43-S49. examination. Teach Learn Med 2001;13(3):161-6. 15. McGee S. Evidence-based physical diagnosis. Philadelphia: Saunders, 3. Mangione S. Cardiac auscultatory skills of physicians-in-training: 2001. a comparison of three English-speaking countries. Am J Med 16. The rational clinical examination collection. JAMA 1992–2006. 2001;110(3):210-6. 17. http://fitsweb.uchc.edu/PCMLogin/login.asp. (Note: users must register 4. Anderson RC, Fagan MJ, Sebastian J. Teaching students the art and with a username, password, and working e-mail address for free ac- science of physical diagnosis. Am J Med 2001;110(5):419-23. cess). 5. Mangione S, Peitzman SJ. Physical diagnosis in the 1990s. Art of artifact? J Gen Intern Med 1996;11(8):490-3.