Home Learning abnormal physical examination signs: an introductory course
Article Open Access

Learning abnormal physical examination signs: an introductory course

  • Albert Sabirov EMAIL logo , Melodie Chludzinski , Emin Eminof , Alexis Eddy , John Gallagher and Ichabod Jung
Published/Copyright: March 31, 2023
Download Article (PDF)
Journal of Osteopathic Medicine
From the journal Journal of Osteopathic Medicine Volume 123 Issue 6

Abstract

Context

The acquisition of clinical skills is an essential part of the osteopathic medical school curriculum. Preclinical medical students, especially at osteopathic medical schools, have limited exposure to abnormal physical examination (PE) findings that are not typically seen in a student’s peers or in a standardized patient (SP). The early exposure of first-year medical students (MS1s) to normal and abnormal findings in the simulation settings better equips them to identify abnormalities when they encounter them in a clinical setting.

Objectives

The aim of this project was to develop and implement the introductory course on learning abnormal PE signs and pathophysiology of abnormal clinical findings to address the educational needs of MS1s.

Methods

The didactic part of the course consisted of PowerPoint presentations and lecture on the topics related to the simulation. The practical skill session was 60 min, during which time students first practiced PE signs and then were assessed on their ability to accurately identify abnormal PE signs on a high-fidelity (HF) mannequin. Faculty instructors guided students through clinical cases and challenged them with probing questions in clinically relevant content. Before- and after-simulation evaluations were created to assess students’ skills and confidence. Student satisfaction levels after the training course were also assessed.

Results

This study demonstrated significant improvements in five PE skills (p<0.0001) after the introductory course of abnormal PE clinical signs. The average score for five clinical skills increased from 63.1 to 88.74% (before to after simulation). The confidence of students in performing clinical skills and their understanding of the pathophysiology of abnormal clinical findings also increased significantly (p<0.0001) after simulation activity and educational instruction. The average confidence score increased from 3.3 to 4.5% (before to after simulation) on a 5-point Likert scale. Survey results demonstrated high satisfaction with the course among learners with mean satisfaction score 4.7 ± 0.4 on 5-point Likert scale. The introductory course was well received by MS1s and they left positive feedback.

Conclusions

This introductory course offered MS1s with novice PE skills the ability to learn a variety of abnormal PE signs, including heart murmurs and rhythms, lung sounds, measurement of blood pressure (BP), and palpation of the femoral pulse. This course also allowed abnormal PE findings to be taught in a time-efficient and faculty-resource–efficient manner.

Keywords: abnormal findings; clinical skills; medical students; physical exam; simulation

The acquisition of clinical skills is an essential part of the osteopathic medical school curriculum. As part of our integrated, comprehensive History and Physical (H&P) examination course, utilization of a simulation environment expands upon students understanding of abnormal physical examination (PE) findings that we do not typically see in a student population or in a standardized patient (SP). High-fidelity (HF) simulation provides students with the opportunity to learn abnormal clinical findings through hands-on practice in an environment similar to actual patient care. By exposing our students to normal and abnormal findings in the simulation settings, they are better equipped to identify abnormalities as they encounter them in a clinical setting [1].

Clinical-year students and residents often have low confidence in identifying abnormal clinical findings due to lack of exposure to abnormality in training, which results in poor cardiac and respiratory auscultatory skills [2], [3], [4], [5], [6]. Exposure to clinical work during clinical rotations and residency training may not be sufficient to acquire adequate competence in basic PE skills [7, 8]. These findings emphasized the need for students to learn abnormal PE findings at the beginning of their medical education.

In various studies, teaching of abnormal heart and lung sounds with the use of HF simulation was timed to follow cardiovascular or respiratory systems courses [9], [10], [11], [12], [13], [14], [15], [16]. This is in line with the concept that the learning of clinical skills should build on existing core knowledge of the basic sciences, which is usually acquired during the second year of medical school [17], [18], [19]. To our knowledge, limited data exist regarding teaching abnormal clinical findings to first-year medical students (MS1s) [13, 20]. In this report, the investigators presented the introductory course for MS1s to learn and practice the recognition of various abnormal clinical signs, including heart murmurs and rhythms, lung sounds, measurement of blood pressure (BP), and palpation of the femoral pulse. The investigators hypothesized that MS1s can learn basic PE skills regardless of their limited knowledge of the cardiovascular and respiratory systems, and that the instruction-based simulation is a suitable instrument to achieve this goal.

Methods

Curriculum context

The Institutional Review Board of Lake Erie College of Osteopathic Medicine (LECOM) approved this study as exempt (Protocol 26–135). The simulation course has been in existence in the medical school curriculum since 2018, and participation was required for all students. There was no compensation or informed consent for this study. At LECOM, the size of each medical school class is approximately 275 students. During the spring semester of the first year, students start learning and practicing PE skills on peers or SPs. In the current version of the course, the first year of the course covers teaching normal and abnormal PE findings, while the second year of the course focuses on clinical reasoning and patient management.

A total of 264 first-year LECOM students participated in the course. The simulation course was conducted in the simulation laboratory equipped with two HF mannequins by a group of clinical faculty from various specialties, including emergency medicine, urology, radiology, otolaryngology, and family medicine. The entire course consisted of 96 1 h sessions equally distributed over 12 consecutive weeks during the spring semester. It was identified that the optimal group size was three students per group. Larger groups would not allow for equal student engagement, whereas smaller groups would fail to provide adequate peer-to-peer support to the learners. The introductory course on learning abnormal PE signs contained preparatory materials and practical skill sessions.

Didactic part

The didactic part of the course consisted of two PowerPoint presentations placed on the school’s portal to explain how to perform a PE on the SimMan mannequin (Appendix A). Also, the students were oriented about the learning objectives and expected outcomes of the course (Appendix B). The simulated heart and lung sounds in Appendix B were utilized from the AURiS program, which is available on the App Store for iPhone and iPad (iSimulate Pry Ltd, Hamburg, Germany). Completion of didactic courses on the anatomy and physiology of the cardiovascular and respiratory systems, as well as a H&P course, have been made prerequisites for the simulation module. One month prior to the simulation, students had a lecture on the topics related to the simulation, so reading assignments were optional rather than required.

Practical skill sessions

Course developers assessed students’ basic PE skills (Five-item skills checklist; Appendix C) and confidence in performing clinical skills and their understanding of the pathophysiology of abnormal clinical findings before and after the simulation (5-point Likert scale; Appendix D). After completion of the training course, the students were asked to complete a satisfaction survey (5-point Likert scale; Appendix E) and voluntary anonymous feedback (Appendix F).

The total time allotted for the practical skill session is 60 min and included the following:

  1. Before Simulation Assessment (five-item skills checklist and confidence surveys): 15 min

  2. Training with an Instructor (Appendix G): 20 min

Under the instructor’s supervision, students performed a series of PE on the HF mannequin starting with normal, uncomplicated clinical scenarios and progressing to more complex conditions with abnormal physical findings. During the encounter, instructors prompted students about their knowledge of the factors that might affect certain physical findings (i.e., measurement of BP). Learners were also asked about the mechanisms of development of the heart and lung sounds and murmurs, as well as how other components of the PE can help with assessing the patient’s stability. Similarly, students demonstrated their knowledge of cardiac impulse generation and propagation and how different parts of the cardiac electrical activity are reflected on the electrocardiogram (ECG) and assessed via physical assessment maneuvers, such as palpating for pulses.

  1. After Simulation Assessment (five-item skills checklist, confidence and satisfaction surveys): 15 min

As an outcome measure, learners were required to demonstrate their competency in patient assessment and PE by performing a standardized Objective Structured Clinical Examination (OSCE)-type test with the use of the HF mannequin and standardized case-specific performance checklists. The accurate completion of all five checklist items was required to pass the module. The students who failed to demonstrate competency in patient assessment and PE were remediated after the debriefing. Remediation included repeating the training of the given skill under closer supervision with immediate feedback. Duration of remediation differed for each case, and it continued until the students demonstrated proficiency of the skill.

  1. Debriefing and Formative Feedback: 10 min

Before and after simulation test scores and confidence levels were compared utilizing a t-test. A p value less than 0.01was considered significant.

Results

This study demonstrated significant improvements of five PE skills (p<0.0001) after the introductory course of abnormal PE clinical signs (Table 1). The average score for five clinical skills increased from 63.1 to 88.74% (before to after simulation). We found that by engaging the students in an interactive simulation setting, the students demonstrated more thorough understanding of the material that was presented. For example, we found that asking students to reproduce auscultation findings by clapping enhanced their ability to understand, memorize, and clearly explain various heart murmurs and sounds. Twenty-eight out of 264 students (10.6%) required remediation. On average, it took approximately 15 min to remediate an underperforming learner. The confidence of students in performing clinical skills and their understanding of the pathophysiology of abnormal clinical findings also increased significantly (p<0.0001) after simulation activity and educational instruction (Table 2). The average confidence score increased from 3.3 to 4.5% (before to after simulation) on a 5-point Likert scale. A 13-item satisfaction survey (Table 3) measured Kirkpatrick level 1 (Reaction). Survey results demonstrated high satisfaction with the course among learners. The mean satisfaction score was 4.7 ± 0.4, and the satisfaction level range for survey items was 4.4–4.9 on a 5-point Likert scale. Nearly all responders to the satisfaction survey agreed or strongly agreed that it was a valuable learning experience (99.2%), and the goals and objectives were met as outlined for this educational session (99.6%). In terms of educational content, most students agreed or strongly agreed that the portal material was helpful in preparing for this simulation session (91.7%) and that the session provided them with information appropriate to their level of education (98.8%).

Table 1:

Students’ basic PE skills before and after simulation (n=264).

Before simulation, mean, SD After simulation, mean, SDa
Skills
 Blood pressure 73.6 (44.1) 94.2 (23.2)
 Heart murmurs 53.4 (49.9) 76.3 (42.5)
 Lung sounds 53.8 (49.9) 91.2 (28.3)
 Central pulse 71.7 (45.1) 89.3 (30.9)
 Heart rhythm 63.3 (48.2) 92.7 (25.9)

  1. aStatistically significant (t test, p<0.0001) compared with the scores achieved before simulation. PE, physical examination; SD, standard deviation of the mean.

Table 2:

Confidence levels before and after simulation (n=264).

Before simulation, mean, SD After simulation, mean, SDa
Statement
 I developed a better understanding of the pathophysiology of heart murmurs, rhythms, and lung sounds. 3.4 (0.9) 4.5 (0.6)
 I am confident in my skill of taking blood pressure. 4.1 (0.8) 4.6 (0.6)
 I am confident that I can distinguish systolic and diastolic heart murmurs. 2.7 (1.1) 4.2 (0.8)
 I am confident that I can distinguish various lung sounds. 2.9 (1) 4.5 (0.6)
 I am confident that I can evaluate arterial pulse for strength. 3.6 (1) 4.6 (0.6)
 I am more confident that I can distinguish different heart rhythms. 3.2 (1.7) 4.6 (0.6)

  1. a Statistically significant (t test, p<0.0001) compared with the scores achieved before simulation. Based on a 5-point scale (1=strongly disagree, 5=strongly agree). SD, standard deviation of the mean.

Table 3:

Satisfaction survey (n=264).

Statement Meana
The portal material was helpful in preparing for this simulation session. 4.4
The simulation session was helpful in reviewing common examination techniques for typical patient presentations and complaints. 4.6
The initial discussion section was informative regarding my clinical skills and preparation for the “quiz” section. 4.6
The SimMan Mannequins are valuable tools in reviewing and practicing my clinical skills and preparing me for any high stakes examination. 4.7
The faculty managed the workshop in an effective and organized manner. 4.8
The faculty presented their topics with enthusiasm. 4.8
The faculty were knowledgeable regarding their topics. 4.9
The faculty established a comfortable learning environment. 4.9
The goals and objectives were met as outlined for this educational session. 4.8
The duration of the session was adequate. 4.7
The room was conductive to learning the material during the sessions. 4.7
Overall, this was a valuable learning experience. 4.8
The session provided me with information appropriate to my level of education. 4.8

  1. aBased on a 5-point scale (1=strongly disagree, 5=strongly agree).

Based on students’ feedback, a combination of media-enhanced didactic teaching prior to the activity and utilizing HF simulators was an effective teaching instrument to teach normal and abnormal physical findings. A total of 264 students (100%) provided narrative comments about the introductory course, for which examples can be found on Table 4.

Table 4:

Examples of narrative comments provided by students about the introductory course.

  1. “I enjoyed this exercise very much as I find only learning on normal patients will not prepare me for clinicals.”

  1. “The clinical pearls thrown in by the faculty helped to contextualize the information.”

  1. “I enjoyed listening to the lung sounds and knowing their clinical correlations.”

  1. “I liked how realistic the SimMan models were for the tasks we performed. It was valuable to be able to hear pathologic sounds in a simulated clinical setting. When we practice H&P evaluation on each other, we typically only hear normal sounds.”

  1. “I liked that we walked through each of the different heart sounds, lung sounds, pulses, and blood pressures and the instructors gave good, well-rounded explanations behind them.”

  1. “I enjoyed the hands-on style of learning. I believe this will greatly improve my retention of concepts.”

  1. “Faculty were helpful in not only recognizing the different sounds and rhythms but also why they are that way and different tips and tricks, especially because we did not have cardio yet. I also liked the small group atmosphere.”

  1. “I learn better by performing actions, so by being able to perform these techniques in real-time was more beneficial than just learning about it in front of a lecture.”

  1. “I enjoyed the opportunity to hear abnormal vitals. This is something we cannot get in the H&P lab or in standardized patients.”

  1. “I liked learning clinically relevant things. Learning some of the abnormalities was very helpful.”

  1. “I liked the ability to appreciate different cases and listening to a variety of different sounds for the heart and lungs.”

Discussion

The simulation lab experience has become a vital portion of our integrated, comprehensive H&P course. This experience helps us to prepare our students to become excellent diagnosticians as they progress through their education and become osteopathic physicians. Integrating this hands-on approach to supplement learning in the H&P course follows our osteopathic teaching philosophy. In LECOM’s curriculum, HF simulation is utilized to teach clinical skills from a basic to increasingly advanced level in the first two years of medical school. As the students are exposed to systems-based instruction throughout their second year, having a strong base of normal vs abnormal findings enhances their ability to put data together as part of a holistic approach to the patient.

The traditional system-based curriculum suggests teaching abnormal cardiopulmonary PE findings starting in the second year of medical school. We proposed a more robust curriculum to teach basic clinical skills to MS1s by utilizing HF simulation. This study described an introductory course consisting of media-enhanced didactics and teaching abnormal PE signs in clinically relevant content.

There are two conclusions from our study. First, we believe that we have found an effective way to teach basic clinical skills to novice students provided they have basic clinical knowledge prior to simulation. Second, guiding MS1s through clinical cases and challenging them with probing questions in clinically relevant content helps them apply their knowledge on a simulated patient and acquire new knowledge of the pathophysiology of abnormal clinical findings.

Many students advocated for the implementation of more simulation sessions throughout the preclinical medical school curriculum. Although simulation could be utilized as standalone training for acquiring PE skills, it is more advisable to have more sessions over time to help students maintain retention and progress toward clinical reasoning.

Importantly, this course was capable of teaching students basic clinical skills in a time-efficient and faculty-resource–efficient fashion. This is especially important for LECOM, where we educate a large number of students with limited faculty availability.

During this course, the authors learned that the time required to master a skill depends on the complexity of the skill as well as the learner’s baseline knowledge. These variables can vary widely among learners, and it is highly recommended that course prerequisites are well defined ahead of simulation. The didactic teaching should be tailored to the learning objectives of the course, and the students’ assessment should be utilized to ensure students’ proficiency within the theoretical part of the simulation course.

The limitation of this study was utilizing a subjective self-evaluation as the method of assessment of students’ knowledge of the pathophysiology of the abnormal clinical findings. In order to improve this project, we will add an objective knowledge assessment in future studies. In addition, further evaluation is necessary to determine whether the skills acquired in the simulated environment translate to patient care.

Conclusions

The introductory course in the present study provides a framework for how to teach MS1s with novice PE skills a variety of abnormal PE findings in an interactive simulation setting. This training requires only basic understanding of the cardiovascular and respiratory systems and could progress throughout the second year of osteopathic school. This course could be useful for teaching in osteopathic schools where the time and faculty availability is an issue. Further investigation is needed to determine whether the results of this introductory course can be reproduced at other osteopathic schools.

Corresponding author: Albert Sabirov, MD, PhD, Department of Basic Science, Lake Erie College of Osteopathic Medicine, 1858 West Grandview Blvd., Erie, PA 16509-1025, USA, E-mail:

Acknowledgements

The authors would like to thank Dr Valeriy Kozmenko, MD, CHSE-A, Director of Parry Center for Clinical Skills & Simulation at Sanford School of Medicine (Sioux Falls, SD), for his advice on the study design, and all participating faculty and students of LECOM.

  1. Research funding: None reported.

  2. Author contributions: All authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; all authors drafted the article or revised it critically for important intellectual content; all authors contributed to the analysis and interpretation of data; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  3. Conflicts of interests: None reported.

References

1. Issenberg, SB, McGaghie, WC, Petrusa, ER, Gordon, DL, Scalese, RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach 2005;27:10–28. https://doi.org/10.1080/01421590500046924.Search in Google Scholar PubMed

2. O’Brien, B, Cooke, M, Irby, DM. Perceptions and attributions of third-year student struggles in clerkships: do students and clerkship directors agree? Acad Med 2007;82:970–8. https://doi.org/10.1097/ACM.0b013e31814a4fd5.Search in Google Scholar PubMed

3. Surmon, L, Bialocerkowski, A, Hu, W. Perceptions of preparedness for the first medical clerkship: a systematic review and synthesis. BMC Med Educ 2016;16:89. https://doi.org/10.1186/s12909-016-0615-3.Search in Google Scholar PubMed PubMed Central

4. Vukanovic-Criley, JM, Criley, S, Warde, CM, Boker, JR, Guevara-Matheus, L, Churchill, WH, et al.. Competency in cardiac examination skills in medical students, trainees, physicians, and faculty: a multicenter study. Arch Intern Med 2006;166:610–06. https://doi.org/10.1001/archinte.166.6.610.Search in Google Scholar PubMed

5. Mangione, S, Nieman, LZ. Cardiac auscultatory skills of internal medicine and family practice trainees. A comparison of diagnostic proficiency. JAMA 1997;278:717–22. https://doi.org/10.1001/jama.1997.03550090041030.Search in Google Scholar

6. Mangione, S, Nieman, LZ. Pulmonary auscultatory skills during training in internal medicine and family practice. Am J Respir Crit Care Med 1999;159:1119–24. https://doi.org/10.1164/ajrccm.159.4.9806083.Search in Google Scholar PubMed

7. Mangione, S, Nieman, LZ, Gracely, E, Kaye, D. The teaching and practice of cardiac auscultation during internal medicine and cardiology training. A nationwide survey. Ann Intern Med 1993;119:47–54. https://doi.org/10.7326/0003-4819-119-1-199307010-00009.Search in Google Scholar PubMed

8. Remmen, R. Unsatisfactory basic skills performance by students in traditional medical curricula. Med Teach 2009;20:579–82. https://doi.org/10.1080/01421599880328.Search in Google Scholar

9. Fraser, K, Peets, A, Walker, I, Tworek, J, Paget, M, Wright, B, et al.. The effect of simulator training on clinical skills acquisition, retention and transfer. Med Educ 2009;43:784–879. https://doi.org/10.1111/j.1365-2923.2009.03412.x.Search in Google Scholar PubMed

10. Quinn, A, Kaminsky, J, Adler, A, Eisner, S, Ovitsh, R. Cardiac auscultation lab using a heart sounds auscultation simulation manikin. MedEdPORTAL 2019;15:10839. https://doi.org/10.15766/mep_2374-8265.10839.Search in Google Scholar PubMed PubMed Central

11. Jackson, JM, Stacey, RB, Korczyk, SS, Williams, DM. The simulated cardiology clinic: a standardized patient exercise supporting medical students’ biomedical knowledge and clinical skills integration. MedEdPORTAL 2020;16:10957. https://doi.org/10.15766/mep_2374-8265.11008.Search in Google Scholar PubMed PubMed Central

12. Power, JE, Toft, LE, Barrett, M. The murmur online learning experience (MOLE) curriculum improves medical students’ ability to correctly identify cardiac murmurs. MedEdPORTAL 2020;16:10904. https://doi.org/10.15766/mep_2374-8265.10904.Search in Google Scholar PubMed PubMed Central

13. Wald, D, Heckman, J, Cripe, J. Basic science-clinical correlation exercise using a high fidelity simulator. MedEdPORTAL 2010;6:7786. https://doi.org/10.15766/mep_2374-8265.7786.Search in Google Scholar

14. Eyck, RT, Markus, M, Janz, T, Heitz, C, Schloneger, M, Ritucci, N. A multiple-case simulation module to support a second-year medical student respiratory curriculum. MedEdPORTAL 2010;6:7947. https://doi.org/10.15766/mep_2374-8265.7947.Search in Google Scholar

15. Mangrulkar, R, Judge, R, Chapman, C. Professional skill builder: mastering cardiac auscultation in under 4 hours. MedEdPORTAL 2017;13:10577. https://doi.org/10.15766/mep_2374-8265.10577.Search in Google Scholar PubMed PubMed Central

16. Jevtic, J, Torre, D, Sebastian, J. Cardiopulmonary cases – a clinical exam skills e-learning module. MedEdPORTAL 2007;3:454. https://doi.org/10.15766/mep_2374-8265.454.Search in Google Scholar

17. Ramani, S. Twelve tips for excellent physical examination teaching. Med Teach 2008;30:851–6. https://doi.org/10.1080/01421590802206747.Search in Google Scholar PubMed

18. Swamy, M, Bloomfield, TC, Thomas, RH, Singh, H, Searle, RF. Role of SimMan in teaching clinical skills to preclinical medical students. BMC Med Educ 2013;13:20. https://doi.org/10.1186/1472-6920-13-20.Search in Google Scholar PubMed PubMed Central

19. Goldstein, EA, Maclaren, CF, Smith, S, Mengert, TJ, Maestas, RR, Foy, HM, et al.. Promoting fundamental clinical skills: a competency-based college approach at the University of Washington. Acad Med 2005;80:423–33. https://doi.org/10.1097/00001888-200505000-00003.Search in Google Scholar PubMed

20. Gauthier, N, Johnson, C, Stadnick, E, Keenan, M, Wood, T, Sostok, M, et al.. Does cardiac physical exam teaching using a cardiac simulator improve medical students’ diagnostic skills? Cureus 2019;11:e4610. https://doi.org/10.7759/cureus.4610.Search in Google Scholar PubMed PubMed Central

Supplementary Material

This article contains supplementary material (https://doi.org/10.1515/jom-2022-0163).

Received: 2022-08-10
Accepted: 2023-03-07
Published Online: 2023-03-31

© 2023 the author(s), published by De Gruyter, Berlin/Boston

This work is licensed under the Creative Commons Attribution 4.0 International License.

Articles in the same Issue

  1. Frontmatter
  2. Cardiopulmonary Medicine
  3. Original Article
  4. Effects of the Strong Hearts program after a major cardiovascular event in patients with cardiovascular disease
  5. Medical Education
  6. Original Articles
  7. The relationship between required physician letters of recommendation and decreasing diversity in osteopathic medical school admissions
  8. Learning abnormal physical examination signs: an introductory course
  9. Musculoskeletal Medicine and Pain
  10. Original Article
  11. Evaluating the underreporting of patient-reported outcomes in carpal tunnel syndrome randomized controlled trials
  12. Neuromusculoskeletal Medicine (OMT)
  13. Original Article
  14. Utilization and reimbursement trends of osteopathic manipulative treatment for Medicare patients: 2000–2019
  15. Public Health and Primary Care
  16. Original Article
  17. Trends of colorectal cancer screening methods: an analysis of Behavioral Risk Factor Surveillance System data from 2018–2020
  18. Clinical Image
  19. Rosacea with pustules and papules
  20. Letters to the Editor
  21. The first step to strengthening graduate level osteopathic education: a national review
  22. Ensuring adequate power: the importance of statistically significant results in osteopathic research
https://doi.org/10.1515/jom-2022-0163
Keywords for this article
abnormal findings; clinical skills; medical students; physical exam; simulation
Creative Commons
BY 4.0

Articles in the same Issue

  1. Frontmatter
  2. Cardiopulmonary Medicine
  3. Original Article
  4. Effects of the Strong Hearts program after a major cardiovascular event in patients with cardiovascular disease
  5. Medical Education
  6. Original Articles
  7. The relationship between required physician letters of recommendation and decreasing diversity in osteopathic medical school admissions
  8. Learning abnormal physical examination signs: an introductory course
  9. Musculoskeletal Medicine and Pain
  10. Original Article
  11. Evaluating the underreporting of patient-reported outcomes in carpal tunnel syndrome randomized controlled trials
  12. Neuromusculoskeletal Medicine (OMT)
  13. Original Article
  14. Utilization and reimbursement trends of osteopathic manipulative treatment for Medicare patients: 2000–2019
  15. Public Health and Primary Care
  16. Original Article
  17. Trends of colorectal cancer screening methods: an analysis of Behavioral Risk Factor Surveillance System data from 2018–2020
  18. Clinical Image
  19. Rosacea with pustules and papules
  20. Letters to the Editor
  21. The first step to strengthening graduate level osteopathic education: a national review
  22. Ensuring adequate power: the importance of statistically significant results in osteopathic research
Sign up now to receive a 20% welcome discount
Institutional Access
How does access work?
Have an idea on how to improve our website?
Please write us.
© 2025 De Gruyter Brill
Downloaded on 24.9.2025 from https://www.degruyterbrill.com/document/doi/10.1515/jom-2022-0163/html
Scroll to top button