title: A hypothesis-driven physical examination learning and assessment procedure for medical students: initial validity evidence.
abstract: BACKGROUND
  Diagnostic accuracy is maximised by having clinical signs and diagnostic hypotheses in mind during the physical examination (PE). This diagnostic reasoning approach contrasts with the rote, hypothesis-free screening PE learned by many medical students. A hypothesis-driven PE (HDPE) learning and assessment procedure was developed to provide targeted practice and assessment in anticipating, eliciting and interpreting critical aspects of the PE in the context of diagnostic challenges.
  
  
  OBJECTIVE
  This study was designed to obtain initial content validity evidence, performance and reliability estimates, and impact data for the HDPE procedure.
  
  
  METHODS
  Nineteen clinical scenarios were developed, covering 160 PE manoeuvres. A total of 66 Year 3 medical students prepared for and encountered three clinical scenarios during required formative assessments. For each case, students listed anticipated positive PE findings for two plausible diagnoses before examining the patient; examined a standardised patient (SP) simulating one of the diagnoses; received immediate feedback from the SP, and documented their findings and working diagnosis. The same students later encountered some of the scenarios during their Year 4 clinical skills examination.
  
  
  RESULTS
  On average, Year 3 students anticipated 65% of the positive findings, correctly performed 88% of the PE manoeuvres and documented 61% of the findings. Year 4 students anticipated and elicited fewer findings overall, but achieved proportionally more discriminating findings, thereby more efficiently achieving a diagnostic accuracy equivalent to that of students in Year 3. Year 4 students performed better on cases on which they had received feedback as Year 3 students. Twelve cases would provide a reliability of 0.80, based on discriminating checklist items only.
  
  
  CONCLUSIONS
  The HDPE provided medical students with a thoughtful, deliberate approach to learning and assessing PE skills in a valid and reliable manner.
authors: Department of Medical Education, College of Medicine, University of Illinois at Chicago, Chicago, Illinois 50612, USA. rachely@uic.edu
authors: Rachel
authors: R
authors: Yudkowsky
authors: Junji
authors: J
authors: Otaki
authors: Tali
authors: T
authors: Lowenstein
authors: Janet
authors: J
authors: Riddle
authors: Hiroshi
authors: H
authors: Nishigori
authors: Georges
authors: G
authors: Bordage
mesh_terms: D002983:Clinical Competence / Q000592:standards*; D003162:Competency-Based Education / Q000379:methods*; D003937:Diagnosis, Differential; D004504:Education, Medical, Undergraduate / Q000379:methods*; D004521:Educational Measurement / Q000379:methods; D005069:Evaluation Studies as Topic; D005246:Feedback; D006801:Humans; D010808:Physical Examination / Q000379:methods / Q000592:standards*