Will clinical signs become myth? Developing structured Signs Circuits to improve medical students' exposure to and confidence examining clinical signs.

BACKGROUND: Correctly eliciting and interpreting physical examination (PEx) signs contributes to successful diagnosis and is fundamental to patient care. A significant decline in the time spent acquiring these skills by medical students, and the decreased ability to elicit and recognise signs is widely acknowledged. However, organising teaching to counteract this in the busy clinical environment is challenging. We evaluated the prior exposure to clinical signs, and experience of examination teaching among a cohort of final-year medical students. Following this, we assessed the utility of a structured circuit-based approach (Signs Circuits) using hospital inpatients and junior doctors to provide high-yield PEx teaching and overcome these limitations. MATERIALS AND METHODS: Qualitative and quantitative survey feedback, including a standardised list of 62 clinical signs, was sought from final-year medical students during their rotations at a teaching hospital in London, UK, before and after the provision of Signs Circuits. RESULTS: Prior to the course the 63 students reported limited exposure to even the most common clinical signs. For example, the murmurs of mitral and tricuspid regurgitation and the sound of lung crackles eluded 43%, 87%, and 32%, respectively. From qualitative feedback, the reasons for this included that much of their prior PEx experience had focused on the performance of appropriate examination steps and techniques in patients without pathology. During the course, students were exposed to an average of 4.4 new signs, and left with increased confidence examining and eliciting signs, and a firmer belief in their importance to diagnosis. CONCLUSION: Medical students continue to have limited exposure to clinical signs in medical school. This signs-focused approach to PEx teaching is an effective and reproducible way to counter the deficiencies identified in signsexposure.

A diagnostic conundrum in the context of a pandemic of Coronavirus Disease 2019 (COVID-19).

A 52-year-old with lung cancer and brain metastases, on a 3-month weaning regime of dexamethasone, had a coincidental finding of bilateral, patchy ground-glass opacifications of both central and peripheral lung fields on computed tomography (CT). This was reported to be a sign of Coronavirus Disease 2019 (COVID-19). On Day 13, due to poor clinical progression and multiple negative reverse transcriptase-polymerase chain reaction tests for COVID-19, an alternative diagnosis was sought. Subsequently, this led to a diagnosis of Pneumocystis jirovecii pneumonia. This case demonstrates complicating factors in the diagnosis of COVID-19 and the presence of cognitive bias during a pandemic, which may lead clinicians to overlook a diagnosis, which may otherwise be addressed earlier.