A Single-Blinded, Direct Observational Study of PGY-1 and PGY-2 Residents in Evaluating their History-Taking and Physical Examination Skills

Background: Medical interns and PGY-2 residents are often the first contact for newly admitted patients in a teaching hospital. The proper evaluation, diagnosis and treatment may depend on this initial encounter.

Methods: An independent medical observer uses a yes/no checklist with 61 variables, in a single-blinded observational study. Frequency tables were generated and results were based on descriptive statistics. 25 newly admitted patient encounters using 15 different medical interns and 2nd year residents.

Results: The results were worse than anticipated. In 5 of the 7 categories specifically aimed at chart review for accuracy, it was found that the majority of interns and 2nd year residents lied about findings recorded in the patient's chart, when in fact, during their patient encounter, the questions were never asked nor the procedures done. In 64% of the 25 encounters, the time spent on history-taking was less than 7 minutes. In 68% of the 25 patient encounters, the time spent for the physical examination was less than 5 minutes. Regarding history-taking, in 72% of the encounters, patients were not asked about family medical history. No patients were asked about level of salt intake, despite encountering patients with history of hypertension. No patients were asked about recent weight loss or weight gain. None of the interns or PGY-2 residents took their own measurements of the patient's blood pressure. There were no examinations of the fundus, no examinations for accommodation, 76% of encounters were not examined for pupillary light reflex. In 96% of the encounters, there were no eye movement tests done. In 92% of the encounters, there were no pulses measured using a watch. The carotids were not examined in any of the patients. The thyroid was not examined in any of the patients. In only 16% of the encounters, the intern or 2nd year resident looked in the patient's throat. In 88% of the encounters, reflexes were not tested. Muscle strength was not tested in 80% of the 25 patients. Sensory was not tested in 96% of the encounters. Gait was not tested in 92% of the encounters. Pedal edema was not checked in 68% of the patient encounters.

Conclusions: The single-blinded nature of this study exposed the poor overall performance of our interns/residents in the quality of their history-taking and physical examination skills on newly admitted patients. Surprisingly, the percentage of interns and residents lying when recording information in the patient's chart was high.