Clinical skill involves many components that all have the common goal of understanding what's happening with a patient and how best to proceed.
“There’s also that connection that we make with our patients through the physical exam,” said Brian Garibaldi, MD, associate professor of medicine at Johns Hopkins Medicine and director of its biocontainment unit. He also is founder and past president of the Society of Bedside Medicine.
Emerging evidence suggests that doing a physical exam well promotes health and wellness in patients, and doing it poorly can have negative consequences, said Dr. Garibaldi. He joined the AMA’s vice president of graduate medical education (GME) innovations, John Andrews, MD, for a webinar on improving resident burnout and clinical skill.
The webinar was part of the AMA GME Insight Network, a component of the AMA GME Resource Program that provides resources to help GME leaders more effectively meet accreditation requirements, enhance education delivery and improve well-being for their learners and faculty.
The COVID-19 pandemic has hampered the clinical skills of medical trainees, as medical student teaching was halted during the pandemic and traditional bedside rounds were conducted in the hallway or by teleconferencing, said Dr. Garibaldi.
“It's now an incredibly urgent problem to figure out how we can bolster those clinical skills and continue to make the argument that those skills matter—not just for the clinical care that we provide, but for our own well-being and for the relationships we develop with patients,” he added.
Dr. Garibaldi has been involved in the Graduate Medical Education Laboratory, one of 11 projects to get grant support from the AMA Reimagining Residency initiative. The effort is a collaboration of four internal medicine residency programs—Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center, Stanford University and the University of Alabama at Birmingham—dedicated to understanding the factors in the training environment that affect clinical skills and professional fulfillment.
Dr. Garibaldi and his colleagues are measuring potentially modifiable factors in the training environment—for example, time spent in patient rooms, EHR-use patterns, resident schedules, the number of patients seen during a given time period—and looking for associations between those factors and objective measures of resident clinical skills and longitudinal surveys on resilience, burnout and fulfillment.
This data on resident behavior, clinical skills and fulfillment will be used to drive innovations in the training environment designed to improve the resident experience and enhance the clinical encounter for both residents and patients alike.
Real-time tracking at the bedside
During the webinar, Dr. Garibaldi discussed what Johns Hopkins is doing to improve the bedside manner of residents and help them reconnect with patients. One of those endeavors is the Assessment of Physical Exam and Communication Skills (APECS), a formative assessment that's modeled after a high-stakes summative one used in the U.K.
As part of the assessment, residents examine a volunteer patient with real clinical issues. Faculty members observe the residents and provide them with instant feedback. That's the critical piece, said Dr. Garibaldi.
“We watch and see what they do and then in real time—we help them to understand how they can get better. If they miss a finding, we can correct their technique” so the residents can apply that finding to the next patient they see, he noted.
Residents work at various “stations” to experience different types of clinical scenarios. One offers a case on integrated telemedicine, something the COVID-19 pandemic revealed as an untaught and necessary skill. Residents do a focused history and physical exam on a patient and then report their findings.
A physical exam station offers no history at all, just that the patient has abdominal discomfort. Residents get six minutes to conduct a focused exam, report their findings and get feedback.
A standardized patient case is all about shared decision-making and counseling.
There’s also a cardiac exam case, in which the residents report out their findings and get a tutorial from faculty on using an ultrasound machine. “If you want to get good at ultrasound, you have to go into the room, you have to talk to the patient,” said Dr. Garibaldi.
So far, APECS performance data shows a clear and statistically significant correlation between good physical exam technique and getting the right finding. There is a also a statistically significant correlation between appreciating the right finding and getting the correct diagnosis.
“Technique matters, and findings matter, and this is something that we can teach in real time,” said Dr. Garibaldi.
Tracking progress
Through the Graduate Medical Training Laboratory, Dr. Garibaldi and his colleagues have tracked more than 100 first-year medical residents at Johns Hopkins using a real-time locating system. So far it’s amassed nearly 300,000 hours of tracking data. The data shows that residents spend only about 13% of their time in patient rooms, with the majority of their time spent in physician workrooms or the hallway.
There was a huge disconnect between perceived versus actual time spent at the bedside. However, significant correlations existed between certain clinical skills and perceived time at the bedside.
“For example, people who think they spend more time at the bedside scored higher on one of the clinical skills domains, which is managing patient concerns,” he said.
