A core physical examination in internal medicine: What should students do and how about their supervisors?

Figures & data

Table

Practice points

Performing a focused physical examination after the phase of history taking in a new patient encounter is a very complex task for novice learners. Expectations regarding physical examination by medical students are related to the personal habits of their supervisors. A consensus on what physical examination medical students should perform while examining a new patient will reduce cognitive load and might enhance their learning. The results of a survey amongst physicians who supervise medical students during their clerkship internal medicine provides such a consensus.

Table 1.  Characteristics of the respondents

Gender	n = 92
Male	52 (56.5%)
Female	40 (43.5%)
Work environment
University centre	47 (51.1%)
Affiliated hospital	45 (48.9%)
Specialization
General internal medicine	32 (34.8%)
Nephrology	17 (18.5%)
Oncology	11 (12.0%)
Gastroenterology	9 (9.8%)
Endocrinology	5 (5.4%)
Pulmonology	5 (5.4%)
Rheumatology	4 (4.3%)
Infectiology	3 (3.3%)
Vascular medicine	3 (3.3%)
Hematology	3 (3.3%)
Year of finishing specialization
<1980	7 (13.1%)
1980–1989	29 (31.5%)
1990–1999	34 (37.0%)
≥2000	20 (21.7%)
Unknown	2 (2.2%)

Table 2.  Results of the questionnaire regarding the general physical examination in internal medicine

	Question 1*: Should be done by the medical student	Question 2†: Reported frequency of use by physicians who supervise medical students			Correlation questions 1 and 2
Examination	Yes (%)	Always (%)	Never (%)	Average (1–5)‡	R
Assessment of skin turgor	81	22	3	2.5	0.39§
Counting pulse rate	100	78	0	1.3	0.36§
Measuring Blood pressure	100	83	3	1.3	NS
Measuring blood pressure on both arms	48	11	11	3.1	0.30§
Measuring blood pressure standing	52	15	8	2.8	0.45§
Counting breathing frequency	80	17	6	2.7	0.35§
Measuring height	96	75	4	1.5	NS
Measuring weight	99	90	0	1.2	NS
Measuring jugular venous pressure	74	25	13	2.6	0.52§
Assessment of sinus tenderness	52	7	11	3.2	0.40§
Assessment of nasal patency	35	2	32	3.8	0.42§
Inspection of the nasal cavity	14	2	51	4.2	0.42§
Inspection of the conjunctiva	91	36	4	2.2	0.36§
Inspection of the oral cavity and pharynx	93	44	3	2.0	0.35§
Examination of the thyroid gland	98	52	5	1.8	0.28§
Inspection of the chest	100	79	3	1.4	NS
Percussion of the lungfields	100	73	2	1.5	NS
Assessment of the level of diaphragmatic dullness	95	51	9	2.0	0.41§
Auscultation of the lungfields	100	90	2	1.1	NS
Evaluation of the tactile fremitus	33	2	33	3.8	0.27§
Auscultation of the heart	100	89	0	1.3	NS
Percussion of the heart	51	26	31	3.1	0.48§
Assessment of cardiac movements	78	26	19	2.8	0.44§
Inspection of the breasts	86	35	7	2.2	NS
Palpation of the breasts	82	30	8	2.4	0.18§
Inspection of the abdomen	100	90	0	1.1	NS
Auscultation of the abdomen	100	90	1	1.1	NS
Percussion of the liver	99	75	1	1.4	0.27§
Percussion of the spleen	91	67	4	1.7	0,37§
Percussion of the abdomen	97	84	1	1.3	0.29§
Palpation of the liver	100	91	1	1.1	NS
Palpation of the spleen	97	80	2	1.4	0.25§
Light and deep palpation of the abdomen	99	79	0	1.3	0.20||
Assessment of kidney tenderness	76	36	7	2.4	0.51§
Palpation of the kidneys	36	14	32	3.5	0.45§
Percussion of the bladder	74	33	5	2.4	0.20||
Inspection of the penis	35	6	19	3.4	0.51§
Inspection and palpation of the scrotum	35	7	15	3.3	0.40§
Rectal examination	46	6	4	2.8	0.23§
Inspection of the external female genitalia	20	4	23	3.7	0.27§
Pelvic examination	11	1	46	4.1	0.20||
Palpation of the temporal artery	46	7	15	3.3	0.21||
Auscultation of the carotid artery	91	43	8	2.3	0.33§
Palpation of the carotid artery	87	42	8	2.4	0.27§
Palpation of the abdominal aorta	84	38	3	2.3	0.54§
Auscultation of the femoral artery	90	47	8	2.2	0.43§
Palpation of the femoral artery	98	52	7	2.0	0.25§
Palpation of the popliteal artery	61	18	20	3.2	0.32§
Palpation of the dorsalis pedis artery	98	50	9	2.1	0.31§
Palpation of the posterior tibial artery	96	48	9	2.1	0.31§
Palpation of the lymph nodes of the head and neck	99	79	0	1.3	0.21||
Palpation of the axillary lymph nodes	96	56	0	1.7	0.37§
Palpation of the inguinal lymph nodes	98	60	2	1.7	0.31§
Global inspection of the extremities	98	77	6	1.5	0.31§
Examination of the shoulder	19	3	32	3.9	0.36§
Examination of the elbows	16	3	36	4.0	0.31§
Examination of the wrists	19	3	31	3.9	0.25§
Examination of the hand joints	20	4	30	3.8	0.38§
Examination of the hips	19	3	30	3.9	0.33§
Examination of the knees	20	3	29	3.9	0.33§
Examination of the ankles	21	4	30	3.9	0.34§
Examination of the toe joints	16	4	35	3.9	0.30§
Examination of peripheral edema	96	79	3	1.4	0.56§
Bringing vertical pressure to the spine	55	22	19	3.0	0.42§
Percussion of the spine	75	36	9	2.5	0.35§
Assessment of the curvature and mobility of the spine	75	19	19	3.1	0.40§
Examination of the sacroiliac joint	24	7	31	3.7	NS
Total inspection of the skin	92	53	3	1.8	0.49§
Assessment of visual acuity	30	1	41	4.1	NS
Assessment of visual fields	30	2	32	3.8	NS
Testing pupillary light reflex	74	17	17	3.1	0.29§
Testing the near reflex	48	8	32	3.8	0.31§
Assessment of ocular motility	57	10	26	3.5	0.33§
Ophtalmoscopic examination	3	2	76	4.6	NS
Assessment of auditory acuity	11	3	70	4.5	NS
Tuning fork tests (Weber and Rinne test)	12	1	67	4.5	NS
Assessment of the remaining cranial nerves	18	7	47	4.1	NS
Testing strength of the lower extremities	53	7	16	3.3	0.42§
Testing strength of the upper extremities	52	7	15	3.3	0.47§
Assessment of sensibility	58	9	15	3.0	0.36§
Testing reflexes of the upper extremities	64	14	19	3.2	0.28§
Testing reflexes of the lower extremities	80	20	15	2.9	0.38§
Assessment of balance	18	4	50	4.2	NS
Assessment of the gait	34	7	38	3.9	0.28§
Assessment of coordination	20	2	40	4.0	NS
Barre test	14	2	63	4.5	NS

Parts of the physical examination highlighted in bold will be included in the standard physical examination for medical students in the clerkship internal medicine.

Question 1: Which parts of a general physical examination should a student perform during the clerkship of internal medicine when examining a new patient?

Question 2: Which parts of a general physical examination do you perform yourself, when you examine a new patient and at which frequency?

*Answers to Question 1: n ranges from 85 to91 (missing survey items were not included in the analysis).

†Answers to Question 2: n ranges from 87 to 91 (missing survey items were not included in the analysis).

‡For generating an average score, frequency of use was used as a continuous variable (always = 1, regularly = 2, sometimes = 3, seldom = 4, never = 5).

§p = < 0.01

||p = <0.05

Table 3.  Significant differences in mean scores for Question 1 for academic versus non-academic supervisors of the clerkship internal medicine

	Question 1 Mean score (0–1)*
Examination	Academic	Non-academic	p
Measuring blood pressure standing	0.64	0.39	0.018
Assessment of sinus tenderness	0.65	0.40	0.016
Assessment of nasal patency	0.48	0.22	0.010
Inspection conjunctiva	0.98	0.84	0.027
Assessment of cardiac movements	0.89	0.68	0.020
Inspection of the breasts	0.78	0.93	0.043
Palpation of the kidney	0.47	0.26	0.042
Rectal examination	0.30	0.64	0.002
Inspection of the external female genitalia	0.11	0.29	0.036
Pelvic examination	0.04	0.18	0.041
Assessment of the curvature and mobility of the spine	0.85	0.64	0.026
Testing the near reflex	0.59	0.37	0.043
Assessment of ocular motility	0.70	0.44	0.016

Question 1: Which parts of a general physical examination should a student perform during the clerkship of internal medicine when examining a new patient? Italic indicates higher frequency among non-academic supervisors

*For generating a mean score, answers were used as a continuous variable: No = 0, Yes = 1.

Figure 1. Expectations from supervisors towards student versus reported performance. For each physical examination item, the frequency with which supervisors expect their students to perform it in a new patient encounter is compared to the frequency in which the supervisors report to standard perform the physical examination item. In general, supervisors report to perform physical examination items less frequent than they expect from their students.