Performance of pulmonary physical exam skills by internal medicine interns

To assess the pulmonary physical examination (PE) skills of internal medicine residents using real patients to inform pulmonary PE educational initiatives.

First year medicine residents (interns) from two large academic medical centers in Maryland examined the same patient with interstitial lung disease (ILD) as part of the Assessment of Physical Examination and Communication Skills (APECS). Interns were evaluated on five clinical domains: PE technique, identifying physical signs, generating a differential diagnosis, clinical judgment, and maintaining patient welfare. Spearman's correlation test described associations between clinical domains. Preceptor comments were examined to identify errors in PE technique and identifying physical signs.

One-hundred and fifty-five interns examined the same patient with ILD across 33 APECS sessions. 111 interns (71.6 %) correctly identified the presence of crackles; 96 interns (61.9 %) included ILD on their differential diagnosis. There was a significant and positive correlation between PE technique and identification of PE findings (r=0.48, p<0.0001). PE technique (r=0.19, p=0.016) and identifying signs (r=0.42, p<0.0001) were both significantly associated with generating an appropriate differential diagnosis, which in turn was significantly associated with appropriate clinical management (r=0.46, p<0.0001). Common errors were not auscultating the entire lung (55 interns, 35.5 %), auscultating through the gown (20 interns, 12.9 %), not percussing the chest (15 interns, 9.7 %), and using incorrect technique for percussion (37 interns, 23.9 %).

Medicine interns had variable skills in performing the pulmonary PE. Improving PE skills would lead to increased identification of relevant pulmonary findings, inform clinical decision making, and improve overall patient care.