CCCF Academy

Background: Cardiac examination of critically ill patients is considered challenging for both medical trainees and practitioners, as it requires integration of the physiology and anatomy of the heart, as well as inspection, palpation and auditory skills to discern normal and abnormal heart sounds. Cardiac examination skills do not significantly improve after undergraduate training and may decline after years of clinical practice [1], which may be a major factor hindering diagnostic abilities, future clinical practice, and patient safety. Although we have made advances in our diagnostic tools and technologies, Bedside diagnosis, including but not limited to the physical examination, is a cornerstone of patient evaluation in setting of critical illness and is a core competency in both medical school and at the postgraduate level. One of the biggest challenges is acquiring adequate exposure to patients with good physical exam findings during training, and lack of experienced instructors who provide comprehensive teaching at bedside. Many students and residents rely on currently available audiovisual 'eLearning' materials; however, evidence-based, concise and easily accessible resources are not readily available. 
 
Aim:  Our aim in this study is to establish a baseline level of cardiac examination knowledge among medical trainees, and their current use of audiovisual material. 
 
 Methods: A survey consisting of multiple-choice structured questions were developed by expert clinicians using current evidence-based information. The survey was distributed in electronic and paper based formats between medical students and Internal medicine residents with the goal of collecting 150 responses. The questionnaire included an initial consent form indicating anonymous response collection. Data were analyzed using Microsoft Excel in three main categories; 1) Basic cardiac physiology knowledge, 2) Evidence-based physical examination knowledge, 3) Audiovisual material usage, its significance in learning, and its accessibility. 
 
Results: Preliminary results had a 45% (N:61) response rate. On average, trainees answered only 47% of physiology-based questions correctly. In each main category of questions, we calculated the correct response rate for individual respondents, and took the mean and standard deviation of these results. Incomplete responses were counted as incorrect.  In comparison, 55% of evidence-based physical examination questions were answered correctly. Approximately 81% of trainees have tried web-based resources but less than 50% of those trainees found them useful. A majority of participants believed that trustful, concise, easily accessible, interactive and practical multimedia resources are lacking.
 
We compared the correct response rate of trainees based on their frequency of web-based resource usage. Participants were grouped as using these resources often (rating of 1-2), occasionally (rating of 3), or seldom (rating of 4-5). For each group, mean correct response rate for all questions was calculated and compared by single factor ANOVA.
There was no statistically significant difference in correct responses between trainees that used web-based resources often, occasionally, and seldom (P=0.074). Participants were also grouped based on their level of training: pre-clerkship (undergraduate years 1 and 2), clerkship (undergraduate years 3 and 4), junior residents (postgraduate years 1 and 2), senior residents (postgraduate years 3+), and staff physicians. Mean correct response rate for each group was compared by single factor ANOVA. There was no statistically significant difference in correct response rates between different levels of medical training (P=0.155).
 
Conclusion: There is a considerable lack of knowledge among trainees in performing cardiac physical exams, which could compromise patient's safety specially in urgent situations requiring rapid diagnosis and management . This could be a result of deficiencies in understanding and integrating basic cardiac physiology and clinical skills. A large proportion of the Medical trainees rely on online multimedia for study, yet suffer from lack of trustworthy sources that combine teaching clinical skills and basic physiology. Our preliminary analysis suggests that current web-based resources do not significantly improve the user's knowledge. There is a need for developing a well structured, concise, and evidence-based web resource that is readily available to trainees.