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

Figures & data

Table I. Information collected at the end of each encounter.

1.	Report of physical examination (SP)
2.	Audio recording of the meeting (SP)
3.	Physician's personal data and clinical experience
4.	Years in his/her job (seniority)
5.	If prior training in a family medicine residency programme
6.	If the physician was accredited as teaching tutor
7.	If a student or resident were present at the encounter
8.	Duration of interview
9.	Clinical notes (medical record)
10.	Tests requested
11.	Treatment
12.	Total number of visits (and average length) made by doctor the same day he/she visited our SP

Note: Data for items 1, 2 and 7 were collected by the SP.

Table II. Quality standard and percentage of compliance.

	Score	n	%
History taking
1. Since when ... duration	1	54	94.7
2. How is the pain? Characteristics.	1	46	80.7
3. Radiating pain	1	15	26.3
4. Improves or worsens with...?	1	37	64.9
5. Where is the pain located?	1	57	100
6. High temperature?	1	29	50.9
7. Any previous disease or surgical procedure	0.5	42	73.7
8. Vomiting or diarrhoea	0.5	48	84.2
9. Allergies?	0.5	39	68.4
10. Medication she was taking	0.5	16	28.1
11. Impact on daily activities	0.5	18	31.6
12. Smoking or drinking	0.5	27	47.4
13. Changes in her urine colour	1	31	54.4
Physical examination
14. Superficial abdominal palpation of 4 quadrants	2	57	100
15. Deep abdominal palpation in inspiration + expiration (Murphy sign).	2	24	42.1
16. Rebound sign	1	12	21.1
17. Abdominal percussion (at least once)	1	10	17.5
18. Bilateral lung auscultation (at least one location)	1	11	19.3
19. Cardiac auscultation	1	8	14
20. Bilateral lumbar fist percussion	1	8	14
21. Abdominal auscultation (at least once with stethoscope)	0.5	12	21.1
22. Jugular engorgement	0.5	4	7
Final procedures (tests requested)
23. ALT and AST and GGT and bilirubin	3	27	47.4
24. ALT +/−bilirubin or any other combination with AST or GGT	2	10	17.5
25. Abdominal ultrasound	3	30	52.6
26. B and C Hepatitis serology	1	50	87.7
27. Full blood count	1	38	66.7
28. Creatinine	1	38	66.7
29. Glycaemia	1	38	66.7
Diagnostic orientation (only one option)
30. Pain in right hypochondrium with hepatomegaly	10	4	7
31. Hepatomegaly	7	0	0
32. Pain in right hypochondrium	5	46	80.7
33. No diagnostic orientation or misdiagnosis	0	7	12.3

Table III. Quality features: basic skills and diagnoses.

A. Basic skills

1. Sufficient history taking: equal or more than 5 points, but only if the ‘how’, ‘when’ and ‘where’ of abdominal discomfort were recorded.

2. Sufficient physical examination: equal or more than 5 points, but only if the abdomen was examined.

3. Sufficient diagnostic tests: at least either blood tests or ultrasonography requested.

B. Diagnostic impression

(a) no diagnosis

(b) abdominal pain and/or upper abdominal pain

(c) hepatomegaly

C. Diagnostic tests

(a) ‘appropriate’: when a blood test and an ultrasound were requested

(b) ‘in need of improvement’: when only either the blood test or the ultrasound were requested

(c) ‘inappropriate’: when neither were requested.

Table IV. Overall quality of the encounter.

	History taking	Physical examination	Final tests requested	n (%)
Correct encounter	> or = 5 points	> or = 5 points	Blood tests or ultrasound	17 (30)
Encounter in need of improvement	History taking or PE less than 5 points		Blood tests or ultrasound	28 (49)
Encounter showing unexpected success	< 5 points	< 5 points	Blood tests or ultrasound	5 (8.7)
Unacceptable	< or > 5 points		Neither blood tests or ultrasound	7 (12.2)

Table V. Characteristics of the physicians who participated in the study.

	Mean	SD
Physician's age	40.60	5.95
Experience in primary care (years)	13.60	5.70
Time in the workplace (years)	9.58	5.53
Interview duration (minutes)^a	9.28	5.56
Number of visits^b	34.58	9.80

^aThe average time spent with our SP.

^bNumber of visits on the day of the encounter.

Table VI. Assessment of clinical skills in 57 physicians.^a

	Mean	SD	Minimum	Maximum
History taking (maximum score: 10)	6.39	1.59	2	9.5
Physical examination (maximum score: 10)	3.84	1.40	2	8
Final tests score (maximum score: 10)	6.23	3.21	0	10
Diagnosis score (maximum score: 10)	4.74	2.20	0	10

^aA panel of experts weighted the diagnostic and therapeutic behaviour of physicians.

Figure 1. Main results.