706 - Improving Medical Student Physical Diagnosis and Diagnostic Reasoning Skills in a Pre-Clinical Doctoring Course

Publication Number: 2689.706

Simranjeet S. Sran, Children's National Hospital, Washington, DC, United States; Sarah Boutwell, George Washington University, School of Medical and Health Sciences, Washington, DC, United States; benjamin Jim. Blatt, George Washington University School of Medicine & Health Sciences, kensington, MD, United States; Natasha N. Powell, George Washington University School of Medicine and Health Sciences, Washington, DC, United States

Background: Practice of Medicine (POM) is a 3-semester pre-clinical doctoring course at the School of Medicine and Health Sciences at The George Washington University. Based on feedback obtained through systematic course evaluations and a school Physical Diagnosis (PDX) Task Force highlighting perceived deficiencies in student physical exam and diagnostic reasoning skills, the Course Directors implemented a series of coordinated interventions to improve these metrics as measured on Performance Based Exams (PBEs).

Objective: Improve student performance in a pre-clinical doctoring course in the areas of physical diagnosis and diagnostic reasoning through a series of coordinated, targeted interventions.

Design/Methods: Two interventions were implemented in the first semester of POM: 1. Orientation via asynchronous threaded online discussions was replaced with a required, non-recorded in-person orientation with the Course Directors for each PBE emphasizing need for active practice of history and physical skills. 2. 15 minutes was added to the two Formative Objective Structured Clinical Experiences (FOSCEs) for the purposes of self-directed PDX deliberate practice and review of diagnostic reasoning. Two PBEs occur in the first semester of POM (mid-semester and end-of-semester). PBE performance within the PDX domain and on NBME Diagnostic Exercises was compared for pre- and post-intervention cohorts.

Results: There was significant improvement in performance in the PDX domain on the first PBE representing the Core (head-to-toe) physical exam (Figure 1) after the in-person orientation intervention (MD +1.9, 95% CI 1.0 to 2.8, p = 0.0001). Improvement in the PDX domain persisted (Figure 2) after introduction of deliberate practice in FOSCEs (MD +4.4, 95% CI 1.7 to 7.1, p = 0.0012). Scores on NBME Diagnostic Reasoning Exercises (Figure 3) increased (MD +4.2, 95% CI 2.5 to 5.9, p < 0.0001).

Conclusion(s): Refocusing students' preparation through active rehearsal for PBEs via in-person orientation was associated with improved PDX performance. Addition of physical exam deliberate practice in FOSCEs was associated with continued improved performance in the PDX domain and improved performance on NBME Diagnostic Reasoning Exercises. Further follow up is needed to assess the long-term efficacy of our interventions and transfer of skills to performance on clinical rotations. Future interventions that will span all three semesters of POM include provision of proto-Illness Scripts for all organ blocks of the pre-clinical curriculum in support of improved diagnostic reasoning and interactive AI-powered case-based modules.

Figure 1
Performance on core (head-to-toe) physical exam SP checklist of mid-semester PBE comparing pre- (2023) to post-orientation intervention (2024) cohorts

Figure 2
Performance on focused physical diagnosis SP checklist items on end-of-semester PBE comparing pre- (2023) to post-FOSCE intervention (2024) cohorts

Figure 3
Performance on NBME Diagnostic Exercises on end-of-semester PBE comparing pre- (2023) to post-FOSCE intervention (2024) cohorts