Our study demonstrates that, in one academic medical center, there are clearly differences in self-confidence regarding overall and individual physical examination skills from the perspective of medical students, Internal Medicine residents, and faculty Internists. It is reassuring that all groups reported greatest self-confidence in measuring blood pressure, as this is a frequently performed key vital sign measurement. It is worrisome that some skills, such as the nondilated fundoscopic exam to assess retinal vasculature, detecting a thyroid nodule, and interpreting a diastolic murmur, had the lowest self-confidence scores through all groups. This raises concern that there is little improvement in self-confidence in particular physical examination skills despite continued training and experience.
We expected that M3 students would have less self-confidence in most individual skills compared to other levels. However, we found that M3 students had less confidence than PGY-1 residents in only one skill, and a lack of significant difference in overall self-confidence in physical examination skills between these 2 groups. Overall self-confidence was generally higher at advanced training levels, but M4 students had more self-confidence than did PGY-1 residents. One explanation may be that M4 students have an artificially inflated self-confidence because, having completed the third year of medical school, they possess a new sense of accomplishment and mastery, whereas PGY-1 residents, confronted with newfound responsibility for patient care, realize their deficiencies in skill, thereby casting lower perceptions of their abilities. Alternatively, PGY-1 residents’ lower self-confidence may be attributed to their having learned the physical exam at various different medical schools with different curricular experiences, whereas M3 and M4 students were from one institution, and PGY-2–4 residents had spent at least 1 year training in the same institution. A recent study of students in an inpatient medicine clerkship showed that students spent more time with interns than residents, and seemed more satisfied with physical examination instruction by interns compared to residents.20
However, our study implies that, during a critical time in their education, medical students in clerkships may not be learning the physical examination from the most optimal teachers. Interestingly, a recent study by McMahon et al. showed that upper-level Internal Medicine residents rated their overall physical examination skills lower than those of medical students and PGY-1 residents.21
In our study, we found that M3 students had lower self-confidence, and PGY-1 residents had similar self-confidence, when compared to upper-level residents.
Our results also show that even the faculty Internists, although having relatively higher confidence in their physical examination skills, nonetheless still have areas where they rate their skills as only slightly above “Neutral.” It has been shown that faculty attending physicians’ observations of housestaff physical examination skills can reveal a high incidence of errors.22
However, our study raises the question of how faculty can be the “gold standard” of physical examination skills if their self-confidence is not much different than that of housestaff.
Our study demonstrates that there are also differences across levels of training in perceived utility regarding overall and individual physical examination skills, as we saw with self-confidence. It was reassuring that all groups reported greatest perceived utility in measuring blood pressure and reported perceived utility above “Neutral” for all skills. However, 2 commonly taught skills, detecting clubbing and determining vertical liver span, consistently had the lowest perceived utilities, raising concern that the clinical context of these skills may not be fully appreciated. Furthermore, our finding that housestaff have an overall decreased perceived utility of the physical examination compared to medical students is troublesome because this attitude could potentially negatively affect the students’ perspective on clinical skills.
Overall, the physical examination skills with the largest numerical differences between self-confidence and perceived utility included distinguishing between a mole and melanoma, detecting a thyroid nodule, interpreting a diastolic murmur, detecting a breast mass in a female patient, and the nondilated fundoscopic examination using an ophthalmoscope to assess retinal vasculature. Although these numerical differences have no measurable units, they indicate, nonetheless, areas in which instruction and practice in these physical examination skills need improvement at all training levels.
Regarding specific physical examination skills, a previous study of Internal Medicine and family medicine residents found high importance attributed to cardiac auscultation and relatively lower self-confidence in this skill, but without comparison to other skills.5
Although we have shown that, compared to other skills, interpretations of systolic and diastolic murmurs have a lower perceived utility, there still exists a gap between self-confidence and perceived utility, particularly with interpretation of a diastolic murmur. These findings combined demonstrate a continued need to improve the teaching of cardiac auscultation skills and emphasize the utility of these skills.
Interestingly, although having a relatively lower self-confidence score, the nondilated fundoscopic examination using an ophthalmoscope to assess retinal vasculature also had a relatively lower perceived utility score. In fact, among the faculty Internists, this skill had the lowest perceived utility score. Was this because it is a difficult exam to master, and so medical students and physicians are prone to de-emphasize its importance? Would our results have been different had we specified using the new technology of the PanOptic ophthalmoscope? It is also possible that respondents felt that this exam is better done by an ophthalmologist and could be accomplished by emergent consultation if necessary. This area could be further studied to see if there is a change in attitude toward this skill using this new technology.
Our study had several limitations. The study investigated a limited set of physical examination skills and was conducted at only one institution. The study was done during an academic training year, thereby including variation in skill level because of differing educational and training experiences within each medical student and resident class. The students were from one medical school, whereas the residents and faculty graduated from many different schools. The residents are also all former students who chose Internal Medicine, whereas the students may not necessarily be entering Internal Medicine. Our questions regarding self-confidence and perceived utility were inherently subjective. Furthermore, there was no objective assessment of participants’ physical exam skills to validate the self-ratings. It is well-known that physicians’ self-assessment do not correlate with actual skill when examined with external assessment, as recently summarized in a systematic review by Davis et al.23
In addition, our use of a 5-point Likert-type scale in assessing self-confidence and perceived utility, even with “3 = Neutral,” does not provide a clear minimum acceptable standard with which to compare respondents’ ratings. Finally, it is unclear what the implication of confidence in and perceived utility of physical examination skills has on patient care and outcomes.
However, our study had strengths that should be noted. To the best of our knowledge, no study has been done investigating the attitudes toward a wide variety of physical examination skills over the spectrum of educational and training levels from medical student to faculty Internist at one institution. Furthermore, no other studies have shown a comparison of the relative perceived utilities of specific components of the physical examination. Those who view specific skills as having less utility may be less likely to be motivated to improve their competence in these skills, even if they have less self-confidence.
Knowledge and performance of the physical examination is essential to a physician. For most medical students, however, the learning of the physical examination during medical school is best described as variable. It has long been known that teaching of clinical skills requires time and patience, yet the most qualified physicians for this instruction are often unavailable because of other commitments, thereby leaving medical housestaff recruited to teach the physical examination to medical students.24
Yet, few residency programs provide additional instruction in physical examination skills. Housestaff, when in doubt of a finding, typically turn to attending physicians for guidance, and it is assumed that they, given their experience, are more proficient in the physical exam. However, as we have shown, even if faculty Internists may potentially be competent in their skills, they do not have complete confidence, and this may contribute to the decline in teaching at the bedside, although they acknowledge that this will lead to decreased skills in medical students and residents.25
With easier access to and widespread use of technology, such as the echocardiogram, magnetic resonance imaging, and computed tomography, physicians may find themselves hesitant to rely on their own physical findings in diagnosing disease; rather, technologic diagnosis is viewed as the means to diagnostic confidence.2
Still, being able to perform a physical examination confidently and competently may perhaps decrease the inappropriate use of more expensive diagnostic confirmatory tests. Indeed, it has been shown that physical examination, in conjunction with patient history, leads to the correct diagnosis much of the time.26
A doctor’s physical examination skills remain as critical tools in patient care, as well as in teaching students and residents about patient care. Faculty teaching physicians must continue to emphasize and exhibit confidence in the physical examination and undertake improvement in their skills to teach properly future generations of physicians.