Objective:
Physical exam skills are decline as graduate trainees spend less time in direct contact with patients. Few studies have assessed the ability of internal medicine residents to perform a pulmonary physical examination using real patients.

Methods:
First-year internal medicine interns from two large academic medical centers in Maryland examined the same patient with interstitial lung disease as part of the Assessment of Physical Examination and Communication Skills (APECS). Interns were evaluated on five clinical domains: physical exam technique, identifying physical signs, generating a differential diagnosis, clinical judgment, and maintaining patient welfare. Spearman’s correlation test was used to calculate associations between clinical domains. Preceptor comments were examined to identify common errors in physical exam technique and identifying physical signs.

Results:
One-hundred and fifty-four interns examined the same patient with interstitial lung disease across 33 APECS sessions. 111 interns (72.1%) correctly identified the presence of crackles, and 96 interns (62.3%) included interstitial lung disease on their differential diagnosis. There was a significant and positive correlation between physical exam technique and identification of correct physical findings (r=0.50192, p<0.0001). Physical exam technique (r=0.241, p<0.002) and identifying signs (r=0.45383, p<0.0001) were significantly associated with generating an appropriate differential diagnosis, which was significantly associated with clinical management (r=0.50214, p<0.0001). Common errors included failure to percuss the chest, incorrect percussion technique, auscultating over the examination gown and failure to auscultate the entire lung field.

Conclusions:
Internal medicine interns had variable skills in performing and interpreting the pulmonary physical exam. Common errors in exam technique can inform innovations in how the pulmonary examination is taught and assessed. Improving pulmonary exam skills would likely lead to increased identification of relevant pulmonary findings, inform clinical decision making and improve overall patient care.

Keywords: Clinical skills, bedside medicine.