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Research Article

Family physicians’ ability to detect a physical sign (hepatomegaly) from an unannounced standardized patient (incognito SP)

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Pages 95-102 | Received 14 Jun 2010, Accepted 08 Dec 2010, Published online: 12 Jan 2011
 

Abstract

Background: Little is known about the quality of the physical examination and its effectiveness in daily practice. Objective: To determine if family physicians (FPs) were able to detect an important physical sign (hepatomegaly) and to relate this result with other measures of quality. Methods: 57 of 104 invited FPs from the National Health Service of the Southern Barcelona Area agreed to schedule an unannounced Standardized Patient (SP) randomly into their daily practice. The SP presented with hepatomegaly and mild abdominal pain. After the visit clinical notes, medical orders, an audiotape of the visit and a checklist completed by the SP detailing items in the physical examination (PE) were analysed. The attainment of a number of quality standards was assessed. Results: The three major findings that resulted from this study were: (a) only 4 of the 57 FPs who examined the patient detected the hepatomegaly; (b) FPs performed better at history taking (84.24%) than at PE (26.35%); no correlation was found between the two; (c) diagnostic accuracy was associated with older age, years of experience, history taking skills and better performance at requesting diagnostic tests. Most FPs (88%) requested the appropriate tests. FPs who scored better on requesting diagnostic tests spent an average of four minutes more with the patient. None of the participants detected the SP.

Conclusions: Clinical hepatomegaly is difficult to detect, even by well trained FPs. Senior doctors scored better on physical examination.

Acknowledgments

The authors should like to thank the members of the nominal expert groups conducted by Professor Rafael Azagra (MD), Jordi Cebrià Andreu (MD) and Josep Maria Bosch Fontcuberta (MD). The authors are grateful to Dr José María Martínez Carretero from the Catalan Institute of Health Studies (IES) and Dr Ronald M. Epstein (Rochester University), who provided important methodological support, and to the Health Centre directors, Dr X. Bayona and Dr C. Pujol, as well as Professor Randol Barker (MD), Dr Elena Barquero and Dr Leonore Novotny (MD), who helped with the editing, Fermín Quesada and Pablo Bonal participated in writing the script of the Standardized Patient. The authors also thank the 61 doctors who volunteered to participate in the study, with no other compensation than to improve our knowledge on clinical practice. The authors are grateful to the IDIAP Jordi Gol for funding the translation of the study into English.

This research was supported by FISS grant number.02/10054, 18 December 2002 (Prados JA Principal Investigator), and a 2003 REAP grant, Carlos III Health Institute, ‘Assessment of Health Technology’ (number REAP-22/2002).

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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