Teaching and learning physical examination in the clinical setting: Authentic assessment of multi-domain competencies for independent professional practice

Abstract

Introduction: Physical examination (PE) is a unit of professional practice. Competency in performing PE is more than just picking up abnormal clinical signs; it also requires clinical reasoning and professional conduct. Performing PE is an Entrustable Professional Activity (EPA) encompassing medical knowledge, skill and attitude which are best evaluated in the authentic workplace. Method: A point-of-care EPA assessment framework was implemented in final year medical students undergoing paediatrics residency. Students determined the approach of examination with respect to the clinical situation. Performance was evaluated by a set of competency domains, including 1) targeting PE to systems relevant to the clinical situation; 2) performing PE maneuvers correctly and in an organized manner; 3) responding to patient’s verbal and non-verbal cues; 4) using tools / positioning appropriately; 5) presenting findings logically; 6) identifying and interpreting findings correclty; 7) integrating findings with history to prioritize differential diagnoses and 8) professional conduct e.g. good rapport, privacy and comfort, and age-appropriate instructions. Each of these domains is graded as ‘developing’, ‘competent’ or ‘proficient’. Findings: Majority of students were able to target PE to relevant systems and present PE findings logically with correct interpretation. However, exercising flexibility in the sequence of PE by responding to the child's verbal and non-verbal cues often required prompting by the teacher. At the bedside, immediate feedback could be provided to improve PE maneuvers, positioning, appropriate use of tools, and ways to give age-appropriate instructions. With the use of a tablet device, the teacher provides real-time entries of grading and comments. Conclusion: Execution of the defined task by the student, observation by the teacher, debriefing, reflections and documentations are integral components of EPA assessment. The competency domains assessed in this learning activity correlate with professional attributes expected from a medical graduate in the real-world context, and are aligned with learning outcome of independent professional practice.