Teaching and testing physical examination skills without the use of patients

To design a cardiopulmonary physical exam curriculum that does not involve the use of patients. Bedside teaching is becoming a lost art, and the use of alternative methods of instruction such as simulation has become increasingly important. Simulators have been shown to enhance physical examination skills of students and physicians in training.(1)

In 1995, a program was started to improve cardiopulmonary physical diagnosis and the teaching of auscultation at the University of Texas Medical Branch at Galveston (UTMB). The teaching manikin "Harvey" played a vital role in the development of the new curriculum. In 1997, UTMB adopted an organ-based approach to the basic science curriculum. The cardiopulmonary module in the basic science curriculum was a ten-week course taught in the second year of medical school. The physical diagnosis section of that course involved six instructional hours; four of the six hours were dedicated to cardiac auscultation and two hours to pulmonary auscultation. Only simulators and CD-ROMs were used for instruction. The 184 second-year medical students at UTMB were formed into small groups for instruction and practice. Although "Harvey" was an effective teaching tool, other simulators had to be developed for testing students' skills after instruction. It would be very difficult to administer a skills OSCE for 184 students without the development of several smaller transportable simulators. A commercially available blood pressure simulator from the Medical Plastics Laboratory, Inc., Gatesville, TX, was used to test the accuracy of students' blood pressure readings. Small auscultation transducers combined with a palpable pulse simulator, developed by one of the authors (WT) in collaboration with Andries Acoustics, Spicewood, TX, were used to efficiently test students' proficiency in cardiopulmonary auscultation. Digital simulated cardiopulmonary sounds were recorded onto a standard CD-ROM mini-disc and transmitted to the small transducers. Students used their own stethoscopes for auscultation. The targeted skills were efficiently tested in one hour of testing time per student.

This cardiopulmonary instructional module was well received by the second-year medical students. In the skills OSCE, 80% of the students accurately measured systolic and diastolic blood pressure to within 5 mm Hg. Cardiopulmonary auscultation proficiency results showed average recognition of 60% for cardiac abnormalities and 88% for pulmonary sounds. Developing auscultation transducers with pulse simulation capability ensured that students could identify systole. Therefore, heart murmurs and sounds could be timed with the cardiac cycle. We found the results from the skills OSCE encouraging. Most students demonstrated reasonable competency in the skills taught, and the new transportable simulators performed well. The six-hour instructional module was meant to prepare students for their bedside teaching during the third year of medical school. The significant cost of the "Harvey" simulator may be a barrier to its widespread use for teaching. Therefore, continued development of smaller transportable simulators for teaching and testing purposes is important.