Ross Scalese

Objective outcome measures for use with simulator-based assessments of cardiac physical examination competence are lacking. The current study describes the development and validation of an approach to scoring performance using a cardiac findings checklist. A cardiac findings checklist was developed and implemented for use with a simulator-based assessment of cardiac physical examination competence at a Canadian national specialty examination in internal medicine. Candidate performance as measured using the checklist was compared with global ratings of clinical performance on the cardiac patient simulator and with overall examination performance. Interrater reliability for scoring the checklist ranged from 0.95 for scoring correct findings to 0.72 for scoring incorrect findings. A summary checklist score had a Pearson correlation of 0.60 with overall candidate performance on the simulator-based station. Use of a cardiac findings checklist provides one objective measure of cardiac physical examination competence that may be used with simulator-based assessments.

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High-stakes assessments of doctors' physical examination skills often employ standardised patients (SPs) who lack physical abnormalities. Simulation technology provides additional opportunities to assess these skills by mimicking physical abnormalities. The current study examined the relationship between internists' cardiac physical examination competence as assessed with simulation technology compared with that assessed with real patients (RPs). The cardiac physical examination skills and bedside diagnostic accuracy of 28 internists were assessed during an objective structured clinical examination (OSCE). The OSCE included 3 modalities of cardiac patients: RPs with cardiac abnormalities; SPs combined with computer-based, audio-video simulations of auscultatory abnormalities, and a cardiac patient simulator (CPS) manikin. Four cardiac diagnoses and their associated cardiac findings were matched across modalities. At each station, 2 examiners independently rated a participant's physical examination technique and global clinical competence. Two investigators separately scored diagnostic accuracy. Inter-rater reliability between examiners for global ratings (GRs) ranged from 0.75-0.78 for the different modalities. Although there was no significant difference between participants' mean GRs for each modality, the correlations between participants' performances on each modality were low to modest: RP versus SP, r = 0.19; RP versus CPS, r = 0.22; SP versus CPS, r = 0.57 (P < 0.01). Methodological limitations included variability between modalities in the components contributing to examiners' GRs, a paucity of objective outcome measures and restricted case sampling. No modality provided a clear 'gold standard' for the assessment of cardiac physical examination competence. These limitations need to be addressed before determining the optimal patient modality for high-stakes assessment purposes.

Many standardized patient (SP) encounters employ SPs without physical findings and, thus, assess physical examination technique. The relationship between technique, accurate bedside diagnosis, and global competence in physical examination remains unclear. Twenty-eight internists undertook a cardiac physical examination objective structured clinical examination, using three modalities: real cardiac patients (RP), "normal" SPs combined with related cardiac audio-video simulations, and a cardiology patient simulator (CPS). Two examiners assessed physical examination technique and global bedside competence. Accuracy of cardiac diagnosis was scored separately. The correlation coefficients between participants' physical examination technique and diagnostic accuracy were 0.39 for RP (P < .05), 0.29 for SP, and 0.30 for CPS. Patient modality impacted the relative weighting of technique and diagnostic accuracy in the determination of global competence. Assessments of physical examination competence should evaluate both technique and diagnostic accuracy. Patient modality affects the relative contributions of each outcome towards a global rating.