A survey of commonly misunderstood vascular medicine physical exam findings among medical trainees

The field of vascular medicine unifies every organ system and several medical specialties. Medical students and house staff have limited exposure to vascular internists, and didactic training in the United States beyond the confines of a formal vascular medicine fellowship training program is lacking.¹

Untreated vascular disorders contribute to painful swollen limbs, poor wound healing, and limb loss.² According to one report of 25 million people in the United States, patients with under-treated chronic venous insufficiency (CVI) account for 10-fold more visits to primary care physicians and emergency departments. The financial impact on society includes $3 billion USD annual expenditures on wound care, and lost workforce productivity.³ Identifying and rectifying gaps in the clinical acumen of trainees may improve patient care.

We hypothesized that common physical exam findings are misunderstood by trainees and could be enhanced utilizing a lecture aimed at identifying gaps in medical knowledge of the vascular physical exam on patients with common lymphatic, arterial, and venous pathology. Prelecture questions were administered to assess the baseline knowledge of the vascular physical exam (see the online supplemental material):

1. What physical exam finding is most helpful in distinguishing lymphedema from other causes of swelling? Correct answer: A thickened skin fold at the base of the second toe (Stemmer sign).⁴

2. Which constellation of patient symptoms make a diagnosis of chronic venous insufficiency more likely than other etiologies? Correct answer: Leg heaviness, itching, recurrent edema, pain at rest.⁵

3. Which physical exam findings are most concerning for arterial inflow disease in an affected lower extremity? Correct answer: A femoral bruit, elevation pallor, and faint posterior tibial and dorsal pedal pulses.⁶

Participants utilized the audience response system (n = 531 medial students) or paper format (n = 53 internal medicine residents and n = 42 cardiology fellows). Results were tabulated over 3 years (2016–2018) in a study granted exemption status by the University of Rochester, which was the site of data collection (Study #00004335). The lecture contained real-life examples using the patient history and physical exam, complete with photographs. Lecture attendees were unaware that a post-lecture quiz would be administered. In a post-lecture quiz, the questions and order of possible responses were altered. Categorical data were displayed graphically as the correct number of responses and statistical significance was assessed by chi-squared and Fischer’s exact tests.

As a group for all questions, over 3 years of evaluation, medical students, internal medical residents, and cardiology fellows scored significantly better on the post-lecture quiz compared to the pre-lecture quiz as an entire cohort (91% vs 31.2%, respectively, p < 0.001). Each group’s performance is presented in Figure 1A. Internal medicine residents answered fewer pre-lecture questions correctly compared with medical students and cardiology fellows, which did not reach statistical significance (22.6% vs 30.9%, p = 0.21 and 22.6% vs 45.2%, p = 0.055, respectively). Internal medicine residents and cardiology fellows scored significantly worse on pre-lecture questions for arterial, venous, and lymphatic disorders compared to post-lecture questions (25.7% vs 27.2% vs 39.6%, respectively, p < 0.001). Cardiology fellows scored highest in the post-lecture quiz with 100% correct responses (Figure 1B).

Figure 1A.

Correct responses to all pre- and post-lecture questions.

Exam questions were administered to second-year medical students (n = 531), internal medicine residents (n = 53), and cardiology fellows (n = 42).

p <0.001 between pre- and post-lecture test for each of the three groups by Fischer’s exact test.

Figure 1B.

Correct responses to pre- and post-lecture questions based on vascular pathology.

Exam questions were administered to second-year medical students, internal medicine residents, and cardiology fellows.

These data demonstrate that common vascular pathology is poorly understood by trainees, regardless of their stage of training, as evident by the poor pre-test scores, which confirms our suspicion of limited exposure to the discipline of vascular medicine during training. Post-lecture, the number of correct responses to questions increased significantly. This is most likely secondary to enhanced understanding of vascular pathology but could also indicate increased familiarity of lecture material. The curious observation that internal medicine residents scored lower than medical students in all aspects of the vascular exam may be explained by the frequent formal assessment of medical students in the second-year curriculum, where they are tested more frequently, and in greater detail than postgraduate trainees. Test-taking skills during practical postgraduate training may regress or motivation toward engaging in multiple-choice questions may be lower. Internal medicine residents also practice more broadly than cardiology fellows, whose certification exam contains 18% of challenge questions in the area of non-coronary vascular disease.⁷ The higher baseline pre-lecture, as well as post-lecture, scores by cardiology fellows may also reflect a trainee selection bias since standardized exams are heavily used as a fellowship selection tool.

There are several limitations to these data. The primary intent was neither to perform a research study nor to validate a method of assessing a vascular medicine fund of knowledge, but to make trainees aware of gaps in their knowledge. The utility of the questions as a teaching tool would require independent validation following this training set, which is not within the scope of this report. While medical students had never been exposed to the lecturer, senior internal medicine residents and cardiology fellows had seen the lecture at least one time previously, and therefore should have been familiar with the subject matter. Cardiology fellows were continuously exposed to the lecturer in the hospital, which could have introduced bias into our evaluation of their acumen.

Overall, these are encouraging results showing that medical students and physicians in training are quite teachable in the area of commonly misunderstood areas of the vascular medicine examination. Catillon et al. similarly showed that an educational intervention for medical students in how to diagnose peripheral artery disease using the ankle–brachial index was effective.⁸ Our data emphasize the importance of introducing vascular medicine lectures into both the medical school and the postgraduate training curricula.