Context and setting Although standardised patients (SPs) can be trained to provide intricate medical histories or complex communication challenges, the potential for simulation of abnormal physical findings is more limited. Programmes have addressed this limitation by supplementing the SP encounter with computer- or manikin-based simulation. A key limitation of this technique is that the presence of a simulator cues the learner to anticipate an abnormality. Why the idea was necessary We were interested in determining whether students would correctly identify actual abnormal findings during an SP encounter. We therefore developed cases specifically for SPs with known physical abnormalities for our senior medical student clinical skills examination. What was done Cases were developed for 2 experienced SPs with stable cardiovascular abnormalities. The presenting problem for each case was neurological, but the case history was constructed to ensure that a cardiovascular examination would be warranted as part of the focused physical examination. Case 1 was portrayed by an SP with a mechanical aortic valve. Physical findings included a loud metallic valvular click and a grade II−III/VI systolic murmur. Case 2 was portrayed by an SP with chronic renal failure. His physical findings included a grade II−III/VI systolic murmur. Students were allowed 15 minutes with the patient, followed by 10 minutes to document pertinent interview and physical examination findings. All student−SP encounters were videotaped. Evaluation of results and impact A total of 53 students encountered these cases. Notes were reviewed for written documentation of the abnormal cardiac findings. Correct documentation for each SP were: case 1 (n = 27) valvular click 6 (22%), murmur 6 (22%); case 2 (n = 26) murmur 10 (38%). None of the students who described the click in case 1 also correctly described the murmur. Across both cases, 5 additional students documented the presence of a murmur, but described it incorrectly. A total of 23 students (43%) specifically wrote ‘no murmur, rub or gallop’ for cardiac auscultation. Video review showed that all 23 of these students performed a technically sufficient examination to detect the murmur. Documentation of any cardiovascular examination was missing from 9 notes. The limited correct documentation of the abnormal cardiac findings we observed is quite concerning. We initially thought that students might have missed the abnormalities due to inadequate examinations; however, videotape review suggested otherwise. Deliberate disregard of findings in the SP is a possible explanation, although students are instructed to accept all information obtained from SPs. Careless documentation may explain the lack of inclusion of findings, but the specific recording of ‘no murmur, rub or gallop’ in a substantial percentage of notes suggests that the students simply did not identify the auscultatory abnormalities. Students must both master the technical skills of the physical examination and learn to differentiate between normal and abnormal findings. Assessments using SPs are typically used to observe how well students select and perform specific, focused examinations. By using SPs with stable physical findings, student skill in detecting abnormalities can also be determined. We are continuing to develop cases for SPs with actual physical findings to enrich the assessment of our students.
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Szauter et al. (2006) studied this question.