Relationship of Physical Examination Technique to Associated Clinical Skills: Results from a Direct Observation Assessment

Published:December 30, 2021DOI:



      : The purpose of this research was to use direct observation of the physical examination to elucidate the role physical examination technique plays in diagnostic accuracy. Physical examination is important for quality clinical care and requires multiple interrelated skills. The relationship of physical examination technique to related skills is poorly understood. Current methods of teaching and assessing physical examination skills provide few opportunities to evaluate physical examination technique and accuracy.


      : The authors developed a clinical examination assessment using volunteer patients and direct observation. Trained faculty preceptors rated resident performance in 7 domains: 1) physical examination technique, 2) identification of physical signs, 3) clinical communication, 4) differential diagnosis, 5) clinical judgment, 6) managing patient concerns, and 7) maintaining patient welfare. The Pearson correlation coefficient was used to determine relationships between performance in each of these domains. Data on residents’ self-assessed competency in the physical examination and perceptions of feedback received during the assessment were collected.


      : From December 2018 to February 2020, 113 interns from 2 internal medicine residency programs participated in the assessment. Physical examination technique was significantly correlated with accurate identification of physical signs, differential diagnosis and clinical judgment. Time spent in graduate medical education was negatively correlated with performance. Interns more highly rated the feedback received from this assessment than traditional clinical skills feedback.


      : Our findings emphasize the necessity of multi-dimensional physical examination assessment. Observed deterioration of physical examination skill during internship may reflect contemporary practice patterns, which deprioritize the physical examination. Future research on physical examination education should focus on the interface between physical examination technique and related clinical skills.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Reilly BM.
        Physical examination in the care of medical inpatients: an observational study.
        Lancet. 2003; 362: 1100-1105
        • Gandhi TK
        • Kachalia A
        • Thomas EJ
        • et al.
        Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims.
        Ann Intern Med. 2006; 145: 488-496
        • Schiff GD
        • Hasan O
        • Kim S
        • et al.
        Diagnostic error in medicine: analysis of 583 physician-reported errors.
        Arch Intern Med. 2009; 169: 1881-1887
        • Elder A
        • Chi J
        • Ozdalga E
        • Kugler J
        • Verghese A.
        The road back to the bedside.
        JAMA. 2020; 323: 1672-1673
        • Verghese A.
        Culture shock–patient as icon, icon as patient.
        N Engl J Med. 2008; 359: 2748-2751
        • Myers SS
        • Phillips RS
        • Davis RB
        • et al.
        Patient expectations as predictors of outcome in patients with acute low back pain.
        J Gen Intern Med. 2008; 23: 148-153
        • de Wit M
        • Delemarre-van de Waal HA
        • Bokma JA
        • et al.
        Monitoring and discussing health-related quality of life in adolescents with type 1 diabetes improve psychosocial well-being: a randomized controlled trial.
        Diabetes Care. 2008; 31: 1521-1526
        • Wray NP
        • Friedland JA.
        Detection and correction of house staff error in physical diagnosis.
        JAMA. 1983; 249: 1035-1037
        • Leblanc VR
        • Brooks LR
        • Norman GR.
        Believing is seeing: the influence of a diagnostic hypothesis on the interpretation of clinical features.
        Acad Med. 2002; 77: S67-S79
        • Verghese A
        • Charlton B
        • Kassirer JP
        • Ramsey M
        • Ioannidis JP.
        Inadequacies of physical examination as a cause of medical errors and adverse events: a collection of vignettes.
        Am J Med. 2015; 128 (1322-4.e3)
        • Vukanovic-Criley JM
        • Criley S
        • Warde CM
        • et al.
        Competency in cardiac examination skills in medical students, trainees, physicians, and faculty: a multicenter study.
        Arch Intern Med. 2006; 166: 610-616
        • Vukanovic-Criley JM
        • Hovanesyan A
        • Criley SR
        • et al.
        Confidential testing of cardiac examination competency in cardiology and noncardiology faculty and trainees: a multicenter study.
        Clin Cardiol. 2010; 33: 738-745
        • Ortiz-Neu C
        • Walters CA
        • Tenenbaum J
        • Colliver JA
        • Schmidt HJ.
        Error patterns of 3rd-year medical students on the cardiovascular physical examination.
        Teach Learn Med. 2001; 13: 161-166
        • Li JT.
        Assessment of basic physical examination skills of internal medicine residents.
        Acad Med. 1994; 69: 296-299
        • Epstein RM.
        Assessment in medical education.
        N Engl J Med. 2007; 356: 387-396
        • Holmboe ES.
        Faculty and the observation of trainees' clinical skills: problems and opportunities.
        Acad Med. 2004; 79: 16-22
        • Haber RJ
        • Avins AL.
        Do ratings on the American Board of Internal Medicine Resident Evaluation Form detect differences in clinical competence?.
        J Gen Intern Med. 1994; 9: 140-145
        • Shields HM
        • Fernandez-Becker NQ
        • Flier SN
        • et al.
        Volunteer patients and small groups contribute to abdominal examination's success.
        Adv Med Educ Pract. 2017; 8: 721-729
        • Garibaldi BT
        • Niessen T
        • Gelber AC
        • et al.
        A novel bedside cardiopulmonary physical diagnosis curriculum for internal medicine postgraduate training.
        BMC Med Educ. 2017; 17: 182
        • Clark BW
        • Lee YZJ
        • Niessen T
        • Desai SV
        • Garibaldi BT.
        Assessing physical examination skills using direct observation and volunteer patients.
        Diagnosis (Berl). 2021; 8: 101-110
        • Elder A
        • McManus C
        • McAlpine L
        • Dacre J.
        What skills are tested in the new PACES examination?.
        Ann Acad Med Singap. 2011; 40: 119-125
      1. L Edgar, S McLean, SO Hogan, S Hamstra, ES Holmboe. The Milestones Guidebook. American College of Graduate Medical Education (ACGME). Available at: Accessed May 20, 2021 at

        • Leppink J
        • van den Heuvel A.
        The evolution of cognitive load theory and its application to medical education.
        Perspect Med Educ. 2015; 4: 119-127
        • Garibaldi BT
        • Olson APJ.
        The hypothesis-driven physical examination.
        Med Clin North Am. 2018; 102: 433-442
        • McGee S.
        Evidence-Based Physical Diagnosis.
        3rd ed. Saunders, Philadelphia, PA2012
        • Garibaldi BT
        • Kugler J
        • Goyal A
        • et al.
        The physical examination, including point of care technology, is an important part of the diagnostic process and should be included in educational interventions to improve clinical reasoning.
        Diagnosis (Berl). 2019; 6: 299-300
        • Allenbaugh J
        • Corbelli J
        • Rack L
        • Rubio D
        • Spagnoletti C.
        A brief communication curriculum improves resident and nurse communication skills and patient satisfaction.
        J Gen Intern Med. 2019; 34: 1167-1173
        • Lorié Á
        • Reinero DA
        • Phillips M
        • Zhang L
        • Riess H.
        Culture and nonverbal expressions of empathy in clinical settings: a systematic review.
        Patient Educ Couns. 2017; 100: 411-424
        • Papageorgiou A
        • Loke YK
        • Fromage M.
        Communication skills training for mental health professionals working with people with severe mental illness.
        Cochrane Database Syst Rev. 2017; 6 (06)CD010006
        • Verghese A
        • Brady E
        • Kapur CC
        • Horwitz RI.
        The bedside evaluation: ritual and reason.
        Ann Intern Med. 2011; 155: 550-553
        • Lu DW
        • Dresden SM
        • Mark Courtney D
        • Salzman DH
        An investigation of the relationship between emergency medicine trainee burnout and clinical performance in a high-fidelity simulation environment.
        AEM Educ Train. 2017; 1: 55-59
        • Crumlish CM
        • Yialamas MA
        • McMahon GT.
        Quantification of bedside teaching by an academic hospitalist group.
        J Hosp Med. 2009; 4: 304-307
        • Block L
        • Habicht R
        • Wu AW
        • et al.
        In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time?.
        J Gen Intern Med. 2013; 28: 1042-1047
        • Mamykina L
        • Vawdrey DK
        • Hripcsak G.
        How do residents spend their shift time? A time and motion study with a particular focus on the use of computers.
        Acad Med. 2016; 91: 827-832
        • Garibaldi BT
        • Russell SW.
        Strategies to improve bedside clinical skills teaching.
        Chest. 2021.;
        • Norcini JJ
        • Blank LL
        • Duffy FD
        • Fortna GS.
        The mini-CEX: a method for assessing clinical skills.
        Ann Intern Med. 2003; 138: 476-481