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Error Patterns of 3rd-Year Medical Students on the Cardiovascular Physical Examination

Background: Recent research documents widespread deficits in the physical examination skills of practicing physicians. Purpose: This study explored physical examination skills of 3rd-year medical students after completion of a course in physical diagnosis. Methods: Standardized patient physical examination checklist data were analyzed for a cohort of 2,038 medical students for a patient presenting with classic signs and symptoms of an acute myocardial infarction. A follow-up paper case and survey explored reasons underlying omissions. Results: Students systematically omitted 3 of 10 component maneuvers critical to the evaluation of a patient with shortness of breath and chest pain. The same pattern of omissions was observed across 8 medical schools and over 2 successive years. The paper case follow-up study ruled out time constraints and performance anxiety as the cause. Survey data revealed that students may omit a maneuver due to inability to recall pertinence (blood pressure in both arms) or difficulty discriminating findings (heart sounds at different locations), or because of inadequate technical mastery (percussion of the lungs). Conclusions: These data suggest fundamental inadequacies in the current paradigm for teaching physical examination skills. Standardized patient checklist data can provide an informative window into the efficacy of teaching practices.