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JAOA/AACOM Medical Education  |   March 2018
Physician-Mentored Patient Rounds to Observe and Assess Entrustable Professional Activities 1 and 2 in Preclinical Medical Students
Author Notes
  • From the Departments of Microbiology and Immunology (Dr Chamberlain), Family Medicine, Preventative Medicine, and Community Health (Dr Sexton), Internal Medicine (Dr Hardee), and Physiology (Dr Baer) at the A.T. Still University Kirksville College of Osteopathic Medicine (ATSU-KCOM) in Missouri. 
  • Financial Disclosures: None reported. 
  • Support: Funding for this project was provided by ATSU-KCOM. 
  •  *Address correspondence to Neal R. Chamberlain, PhD, Department of Microbiology and Immunology, ATSU-KCOM, 800 W Jefferson St, Kirksville, MO 63501-2486. Email: nchamberlain@atsu.edu
     
Article Information
Medical Education / Pulmonary Disorders
JAOA/AACOM Medical Education   |   March 2018
Physician-Mentored Patient Rounds to Observe and Assess Entrustable Professional Activities 1 and 2 in Preclinical Medical Students
The Journal of the American Osteopathic Association, March 2018, Vol. 118, 199-206. doi:https://doi.org/10.7556/jaoa.2018.039
The Journal of the American Osteopathic Association, March 2018, Vol. 118, 199-206. doi:https://doi.org/10.7556/jaoa.2018.039
Web of Science® Times Cited: 1
Abstract

Context: Thirteen entrustable professional activities (EPAs) for entering residency were created to aid medical educators as they prepare preclinical students for their residency and to assess student readiness for residency. The A.T. Still University Kirksville College of Osteopathic Medicine (ATSU-KCOM) developed a program called physician-mentored patient rounds (PMPR), which focuses on EPA 1 and EPA 2.

Objective: To determine whether PMPRs could be used to assess expected behaviors of EPA 1 (gather a history and perform a physical examination) and EPA 2 (prioritize a differential diagnosis after a clinical encounter).

Methods: The PMPR sessions at ATSU-KCOM take place over several weeks (30-minute sessions per week), during which students gather a patient's history (sessions 1 and 2), observe a physical examination by the physician mentor (session 2), analyze diagnostic test results (session 3), and formulate a treatment plan (session 4). The PMPRs in this study used a real patient with confirmed chronic obstructive pulmonary disease (COPD). This study did not include the session-4 treatment plan. Between sessions, students completed an assignment to further demonstrate their behaviors as expected in the EPAs. Student responses were analyzed and summarized for physician feedback in the subsequent PMPR session. Students’ diagnostic accuracy was measured at the conclusion of each session.

Results: A total of 516 students were included in the study. The PMPR weekly attendance was high (453-475). Although history gathering in the large-group setting was disorderly, diagnostic accuracy over the 3-session period improved. After history taking, 411 students (86.5%) included COPD in the differential diagnosis. A smaller number, 235 students (49.5%), listed COPD as the most likely diagnosis. After the physical examination, 439 included COPD in the differential diagnosis, and 385 listed COPD as the most likely diagnosis. After analysis of diagnostic test results, 468 students listed COPD as the most likely diagnosis.

Conclusion: Physician-mentored patient rounds seem to be an effective means to assess preclinical students’ expected behaviors as described in EPA 1 and EPA 2.

One goal of undergraduate medical education is to provide medical students with the medical knowledge, skills, values, and attitudes (competencies) they will need to enter residency.1,2 To provide quality patient care in their future residency programs, medical students must demonstrate proficiency in performing a large number of competencies.3 However, some students may become fixated on learning and taking assessments for these competencies and lose focus on the clinical thought process and interpersonal interactions with patients—aspects essential for quality patient care. Medical educators may also feel that they themselves lose this focus if they are overwhelmed by the requirements of guiding and assessing students with regard to competencies. 
To regain medical students’ and educators’ focus on quality patient care, the Association of American Medical Colleges (AAMC) commissioned a team in 2014 to develop preresidency entrustable professional activities (EPAs) that graduate medical students must be able to perform.2,4 The 13 preresidency EPAs combine competencies with the hope of making learning, teaching, and assessing students’ clinical behaviors less complex. For example, if a student could be entrusted to complete AAMC preresidency EPA 1 (gather a history and perform a physical examination), they should, in performing EPA 1, demonstrate proficiency in 7 competencies.4 
In that same year, the Board of Deans at the American Association of Colleges of Osteopathic Medicine (AACOM) charged the Society of Osteopathic Medical Educators to examine the AAMC's EPAs.5 The Society of Osteopathic Medical Educators committee integrated AACOM's osteopathic principles and practice competencies into the AAMC's preresidency EPAs. The Osteopathic Considerations for Core Entrustable Professional Activities (EPAs) for Entering Residency was then published by AACOM.5 The AAMC's EPA 1 and the AACOM's EPA 1 each have 7 competencies; however, both organizations list Interpersonal and Communication Skills 1, which means that osteopathic graduates have to be proficient in 13 competencies. 
To ensure that medical students have the knowledge, skills, values, and attitudes they need to enter residencies, medical educators have the opportunity to develop learning experiences and assessments to determine whether students can be entrusted to perform each of the preresidency EPAs. Many experiences for assessing students’ preresidency EPAs already exist (eg, clerkships, DxR Development Group exercises, patient simulations, standardized patients, and virtual patients); however, additional assessments may need to be developed to measure EPAs and competencies. 
To assess preclinical students’ preresidency EPA behaviors, the A.T. Still University Kirksville College of Ostoepathic Medicine (ATSU-KCOM) is currently using large-group physician-mentored patient rounds (PMPRs). This program provides a clinical context that requires a real patient and a physician mentor. The purpose of this study was to determine whether PMPRs could be used to assess the expected behaviors of EPA 1 (gather a history and perform a physical examination) and EPA 2 (prioritize a differential diagnosis). We believe that PMPRs are a novel means to prepare preclinical students to perform preresidency EPAs 1 and 2 with greater confidence as they enter clerkships. 
Methods
We used a nonexperimental design with a convenience sample of second-year medical students across 3 class cohorts in a single osteopathic medical school. The PMPRs were implemented during a 5-week respiratory section in the fall semester of the second preclinical year in 2014, 2015, and 2016 (classes of 2017-2019). The classes of 2017, 2018, and 2019 participated in 2, 1, and 0 PMPRs, respectively, at the time of the current study. The protocol for this study was reviewed by the institutional review board and was exempted from further review. The patients gave oral and written informed consent to participate in PMPRs and to have their medical information used during the PMPR sessions to enable the students to complete assignments. 
Physician-Mentored Patient Rounds
The PMPR program at ATSU-KCOM takes place over several weeks (30-minute sessions per week), during which students gather a patient's history (sessions 1 and 2), observe a physical examination by the physician mentor (session 2), analyze diagnostic test results (session 3), and formulate a treatment plan (session 4). The current study did not include the session-4 treatment plan. The class of 2017 had a 5-session PMPR program as previously described.6 A 4-session PMPR program was given to the classes of 2018 and 2019. The fifth session for the class of 2017 was a wrap-up session. It did not add to the students’ experience and was eliminated in PMPR experiences with the classes of 2018 and 2019. 
Experiences were physician-mentored and student-driven. The PMPRs for all 3 classes used a real patient with chronic obstructive pulmonary disease (COPD; chief complaint: shortness of breath [class of 2017] or chronic cough [classes of 2018 and 2019]). The teaching model used the patient for sessions 1 and 2 to obtain the patient's history (session 1) and to observe a physician-modeled physical examination (session 2). One patient was available for the classes of 2017 and 2018, and a different patient was available for the class of 2019. During session 1, students were encouraged by the physician (M.R.H.) to ask the patient questions. Students were not required to use any format for obtaining patient history (eg, OPQRST [onset, provocation, quality, region, severity, time]). They were required to take notes during the PMPR sessions. Three investigators (N.R.C., P.S.S., R.W.B.) attended the sessions to observe the student-patient and student-physician encounters. 
Students were required to sign in to the PMPRs by printing and signing their name on a form available at the entrance of the classroom. Faculty were present to observe students while signing in to ensure that they did not sign in for those who did not attend. 
PMPR Assignments
To obtain credit for each PMPR session, students were required to submit a PMPR assignment. Assignment items were sent to students using Google Forms by email within 2 hours after each PMPR session (Table 1). They had to submit their completed assignments within 79 hours after each PMPR session using their university email account. Students submitted their estimated time spent on each assignment using the same Google Forms. Up to 14 other items, not discussed in this study, were included in each assignment. Student responses were aggregated into a database and analyzed and summarized for physician feedback in the subsequent PMPR session. Summarized feedback was converted into histogram graphs that the physician could use to guide the student sessions (eg, top 20 diagnoses overall, top 10 first diagnoses, top 10 second diagnoses). Figure construction and conversion to PowerPoint (Microsoft) was performed using R software. This study only included the analysis of assignments from PMPR sessions 1 through 3. A previous study described the analysis of students’ treatment plans obtained during PMPR session 4.6 
Table 1.
Overview of Physician-Mentored Patient Rounds With Second-Year Osteopathic Medical Students
Session Activity Discussion Assignment
1 Students obtained a patient history Students asked questions; physician guided group in how to phrase questions and noted the need for students to ask questions to get a more complete history List 5 (class of 2017) or 6 (classes of 2018 and 2019) diagnoses. What will you do next and why (class of 2017)? What regions of the patient would you like to focus on during your physical examination (classes of 2018 and 2019)?
2 Students finished patient history; physician modeled physical examination Students’ differential diagnosis; breadth of the students’ differential diagnosis; appropriate and unlikely diagnoses List 3 (classes of 2017 and 2018) or 6 (class of 2019) diagnoses. Select diagnostic tests.
3 Discussion of diagnostic testing Students’ differential diagnosis and their diagnostic test choices; ordering appropriate diagnostic tests to narrow the differential diagnosis list List 1 (class of 2019) or 2 (classes of 2017 and 2018) diagnoses. Explain how you narrowed your differential diagnosis list.
Table 1.
Overview of Physician-Mentored Patient Rounds With Second-Year Osteopathic Medical Students
Session Activity Discussion Assignment
1 Students obtained a patient history Students asked questions; physician guided group in how to phrase questions and noted the need for students to ask questions to get a more complete history List 5 (class of 2017) or 6 (classes of 2018 and 2019) diagnoses. What will you do next and why (class of 2017)? What regions of the patient would you like to focus on during your physical examination (classes of 2018 and 2019)?
2 Students finished patient history; physician modeled physical examination Students’ differential diagnosis; breadth of the students’ differential diagnosis; appropriate and unlikely diagnoses List 3 (classes of 2017 and 2018) or 6 (class of 2019) diagnoses. Select diagnostic tests.
3 Discussion of diagnostic testing Students’ differential diagnosis and their diagnostic test choices; ordering appropriate diagnostic tests to narrow the differential diagnosis list List 1 (class of 2019) or 2 (classes of 2017 and 2018) diagnoses. Explain how you narrowed your differential diagnosis list.
×
Statistical Analysis
All student data were deidentified before analysis, and a unique identifier was given to each student to match student responses across PMPR sessions. Descriptive statistics (mean [SD]) were used to identify each class's attendance by session. Differences in total group inclusion of patient diagnosis before and after the physical examination were compared using McNemar χ2 analysis for paired data (2×2 contingency table; rows included COPD in the differential diagnosis before physical examination, yes [row 1] and no [row 2]; columns included COPD in the differential diagnosis after physical examination, yes [column 1] and no [column 2]). Differences in total student group identification of their most likely diagnosis before and after the physical examination were compared with a 2×2 contingency table using McNemar χ2 analysis for paired data (rows included patient diagnosis as most likely diagnosis before physical examination, yes [row 1] and no [row 2]; columns included patient diagnosis as most likely diagnosis after physical examination, yes [column 1] and no [column 2]). Group means with McNemar χ2 statistic values greater than 3.8 and P<.05 were considered significant. Statistical analysis was performed using the R statistical package. Qualitative inquiry and coding was used to observe student verbal and nonverbal behaviors and to identify themes during students’ patient history taking. 
Results
All 3 sessions took place in a lecture hall. A total of 516 students were included in the study, with 172 each in the classes of 2017, 2018, and 2019. Attendance and assignment completion were not mandatory but did give students an opportunity to obtain points in their internal medicine course (1.8% of total points in course).6 The mean (SD) percentages of students in attendance were high: session 1, 92.1% (158 [1.15]); session 2, 87.8% (151 [7.94]); session 3, 91% (157 [5.13]); and session 4, 91% (157 [4.04]). 
The mean (SD) assignment completion time was 31.3 (18.3) minutes. No statistically significant differences were found in average completion times between assignments or between student classes. The maximum time recorded was 180 minutes, and the minimum time was 1 minute. 
EPA 1: Gather a Patient History
The physician mentor (M.R.H.) greeted the students, introduced the patient, gave the patient's chief complaint, and asked the students, “What do you want to know about our patient's history?” To observe student history-taking skills, we did not tell students to follow a specific history-taking routine. 
The first thing observed in all classes was that patient history taking was disorderly. For example, one student would ask what made the patient's chief complaint better, and the next student would ask if the patient had any surgeries in the past. In some instances, students’ questions affected subsequent students’ questioning. We also observed that the way a question was phrased had an effect on patient answers. Several times per session, the physician would ask a student to rephrase the question because the patient did not understand what he or she was asking. The question may have been too vague or used medical terminology the patient did not know. The students complied with the physician requests as appropriate. 
The problems observed during history taking—namely, disorderly procedure and inexperience in framing questions—could have had at least 2 adverse effects on differential diagnosis development. Students’ differential diagnosis might not have included COPD, or the differential diagnosis might have been too narrow, potentially missing life-threatening conditions. After session 1, we asked students to submit a differential diagnosis with 5 different diagnoses differential diagnosis in order from most likely to least likely. 
Both patients had a confirmed diagnosis of COPD. If students included COPD, chronic bronchitis, or emphysema in their differential diagnosis, we counted them as including COPD. Most students included COPD after session 1 (class 2017, 94.4%; class 2018, 81.5%; class 2019, 83.6%; mean [SD] percentage for all classes, 86.5% [6.92%]; Table 2). Fewer students listed COPD as the most likely diagnosis (class 2017, 60.4%; class 2018, 36.3%; class 2019, 51.6%; mean [SD] percentage for all classes was 49.5% [12.2%]; Table 3). 
Table 2.
Physician-Mentored Patient Rounds (PMPR): Percentage of Students Who Included COPD in Their Differential Diagnosis (N=516)a
Class After History (PMPR Session 1) After Physical Examination (PMPR Session 2) After Diagnostic Tests (PMPR Session 3)
2017c 94.4 (150/159) 98.7 (152/154) 100 (158/158)
2018c 81.5 (128/157) 98.6 (140/142) 100 (161/161)
2019b,c 83.6 (133/159) 93.6 (147/157) 98.7 (149/151)
All classesc 86.5 (SD, 6.92) (411/475) 96.9 (SD, 2.91) (439/453) 99.6 (SD, 0.75) (468/470)

a Chronic obstructive pulmonary disease (COPD), chronic bronchitis, or emphysema diagnosis was considered to be a diagnosis of COPD.

b A different patient with COPD was used in 2019.

c Significant difference was found between “after history” and “after physical examination” (P<.05).

Table 2.
Physician-Mentored Patient Rounds (PMPR): Percentage of Students Who Included COPD in Their Differential Diagnosis (N=516)a
Class After History (PMPR Session 1) After Physical Examination (PMPR Session 2) After Diagnostic Tests (PMPR Session 3)
2017c 94.4 (150/159) 98.7 (152/154) 100 (158/158)
2018c 81.5 (128/157) 98.6 (140/142) 100 (161/161)
2019b,c 83.6 (133/159) 93.6 (147/157) 98.7 (149/151)
All classesc 86.5 (SD, 6.92) (411/475) 96.9 (SD, 2.91) (439/453) 99.6 (SD, 0.75) (468/470)

a Chronic obstructive pulmonary disease (COPD), chronic bronchitis, or emphysema diagnosis was considered to be a diagnosis of COPD.

b A different patient with COPD was used in 2019.

c Significant difference was found between “after history” and “after physical examination” (P<.05).

×
Table 3.
Physician-Mentored Patient Rounds (PMPR): Percentage of Students Who Listed COPD as the Most Likely Diagnosis (N=516)a
Class After History (PMPR session 1) After Physical Examination (PMPR session 2) After Diagnostic Tests (PMPR session 3)
2017c 60.4 (96/159) 93.5 (144/154) 100 (158/158)
2018c 36.3 (57/157) 90.8 (129/142) 100 (161/161)
2019b,c 51.6 (82/159) 71.3 (112/157) 98.7 (149/151)
All classesc 49.5 (SD, 12.2) (235/475) 85.2 (SD, 12.1) (385/453) 99.6 (SD, 0.75) (468/470)

a Chronic obstructive pulmonary disease (COPD), chronic bronchitis, or emphysema diagnosis was considered to be a diagnosis of COPD.

b A different patient with COPD was used in 2019.

c Significant difference was found between “after history” and “after physical examination” (P<.05).

Table 3.
Physician-Mentored Patient Rounds (PMPR): Percentage of Students Who Listed COPD as the Most Likely Diagnosis (N=516)a
Class After History (PMPR session 1) After Physical Examination (PMPR session 2) After Diagnostic Tests (PMPR session 3)
2017c 60.4 (96/159) 93.5 (144/154) 100 (158/158)
2018c 36.3 (57/157) 90.8 (129/142) 100 (161/161)
2019b,c 51.6 (82/159) 71.3 (112/157) 98.7 (149/151)
All classesc 49.5 (SD, 12.2) (235/475) 85.2 (SD, 12.1) (385/453) 99.6 (SD, 0.75) (468/470)

a Chronic obstructive pulmonary disease (COPD), chronic bronchitis, or emphysema diagnosis was considered to be a diagnosis of COPD.

b A different patient with COPD was used in 2019.

c Significant difference was found between “after history” and “after physical examination” (P<.05).

×
EPA 2: Prioritize a Differential Diagnosis After a Clinical Encounter
Students completed their patient history and then observed while the physician mentor performed a physical examination, which was based on the students’ responses from assignment 1: provide 5 diagnoses. The physician then shared his findings with the students. 
Students were given assignment 2: narrow the differential diagnosis from 5 to 3 diagnoses based on the history and physical examination findings. The differential diagnosis lists were analyzed from assignment 2, and the percentage of students who included COPD in the differential diagnosis increased significantly compared with assignment 1, from 86.5% to 96.9% (χ2=29.8; P<.001) (Table 2). The inclusion of COPD in the differential diagnosis by class increased from 94.4% to 98.7% (class 2017, χ2=5.82; P<.016); 81.5% to 98.6% (class 2018, χ2=19.53; P<.001); and 83.6% to 93.6% (class 2019, χ2=4.32; P<.038). The common diagnoses listed in assignment 2 were fewer compared with assignment 1 (assignment 1: COPD [53.3%], asthma [53.7%], lung cancer [49.0%], emphysema [40.4%], congestive heart failure [40.2%], and chronic bronchitis [30.9%]; assignment 2: COPD [66.4%], asthma [48.6%], emphysema [41.7%], congestive heart failure [31.6%], and chronic bronchitis [24.5%]). 
Compared with assignment 1, significantly more students listed COPD as their most likely diagnosis in assignment 2 (49.4% vs 85.2%, respectively; χ2=52.48; P<.001) (Table 3). The most likely diagnosis included by class increased from 60.4% to 93.5% (class 2017, χ2=39.51; P<.001); 36.3% to 90.8% (class 2018, χ2=70.58; P<.001); and 51.6% to 71.3% (class 2019, χ2=10.58; P<.001). 
During PMPR session 3, the physician showed the students what diagnostic tests the entire class ordered. He then gave the students the results of the diagnostic tests and gave them assignment 3: narrow the differential diagnosis to the most likely diagnosis. Four hundred sixty-eight students of 470 (99.6%) chose COPD (Table 3). Increases in the percentage of students listing COPD as the most likely diagnosis were not significantly higher than in session 2. Two students did not list COPD as the most likely diagnosis, instead ranking pulmonary hypertension or sarcoidosis as the most likely diagnosis. 
Nearly all students (439 [96.9%]) included COPD in their differential diagnosis after histories and physical examinations were complete. Many students (385 [85.2%]) listed COPD as the most likely diagnosis after the history and physical examination. After receiving the diagnostic test results, the number of students who included COPD in the differential diagnosis increased by a small percentage (439 [96.9%] to 468 [99.6%]). 
Discussion
During their training, medical students acquire an enormous amount of knowledge, develop numerous skills, and enhance their values and attitudes, which are all used to provide quality patient care. Competencies are used to measure their progress. However, the large number of competencies and their instruction and assessments may be overwhelming to both students and educators. The AAMC and AACOM EPAs provide a clearer focus on where these competencies should lead.4,5 
Combining the competencies into preresidency EPAs provides a path for educators to teach and assess medical students. Because many pre-EPA assessments measure a few competencies at a time, current assessments should be modified and novel assessments should be developed to assess students’ abilities to perform preresidency EPAs. 
We developed a novel PMPR assessment to measure the expected behaviors of preclinical students’ with regard to EPA 1 and 2. The assignments that followed each PMPR session allowed us to assess students’ thought processes. Analysis of the assignments and graphical presentation of their responses allowed students to see their aggregate thinking and how their peers responded. During sessions 2 and 3, the physician discussed the performance expectations students might encounter during clerkships. 
This study determined whether the PMPR program could assess preclinical students’ ability to obtain a patient history; to make an accurate diagnosis after a history, after a physical examination, and after analysis of diagnostic test results; and to prioritize a differential diagnosis. 
The current study did not conduct an in-depth analysis of the history-taking sessions, though they were observed. Our observations revealed that preclinical students, when compared with practicing physicians, need more deliberate practice when taking a history. Student responses to assignment 1 indicate that they also need more practice developing a differential diagnosis from their patient's history.7 Our students’ disorderly history taking could have been a function of the large-group dynamic but could also have been due to inexperience. The history-taking routine will likely further develop during clerkships. 
Data gathered during a patient's history is essential to develop a differential diagnosis.7-9 Others8 have shown that nearly 80% of third-year medical students correctly diagnosed rheumatoid arthritis after taking a patient history. It has also been shown that physical and diagnostic test results are used to confirm the most likely diagnosis.9 Our students beginning their second year of medical school were less experienced in developing a differential diagnosis. However, despite their inexperience with history taking, the majority of these students included the correct diagnosis in their differential diagnosis. Their preclinical diagnostic accuracy was similar to what others have observed with third-year medical students and physicians.8,9 
The differential diagnosis identified in the literature in a patient with chronic cough and shortness of breath were broader in scope than those of the students in the current study.10-12 However, many of our students included appropriate life-threatening diagnoses in their differential diagnosis. We also observed that students were imprecise when assigning diagnoses to a patient. Many students listed COPD and emphysema or chronic bronchitis in their differential diagnosis, not realizing that emphysema and chronic bronchitis are forms of COPD and would not be considered 2 different diagnoses. With this knowledge, we hope to help our students create history-taking routines and to increase their precision in assigning patient diagnoses. 
Analysis of student responses from PMPR sessions 2 and 3 allowed us to see how students prioritize their differential diagnosis after physical examination and again after diagnostic testing. Approximately 14% of students did not include the correct diagnosis in their differential diagnosis after taking the patient's history. That number decreased to 3.1% after the physical examination and to 0.5% after diagnostic test result analysis. With more data came an increase in assigning a correct diagnosis. About half of students listed the patients’ diagnosis as the most likely diagnosis after session 1, and that number increased to 85.2% and 99.6% after session 2 and 3, respectively. Participants in previous studies8,9 did not show improvement in diagnostic accuracy after the physical examination and diagnostic testing, and the percent changes in diagnostic accuracy were lower. However, these studies were performed in a shorter amount of time using written cases as opposed to in person with real patients. The study participants could not obtain peer consultations, and there was no physician mentor present. Factors that could account for the larger increases seen in the current study may have been the large amount of time students had to work on these assignments, to consult with peers, and to work with the physician mentor. The diagnostic accuracy of our students was a little lower than what has been reported with residents and physicians.7 
We believe that other EPAs can be assessed with PMPRs. In a previous study, we demonstrated that students order too many diagnostic tests and that physician mentoring can reduce the number and cost of testing (EPA 3).6 Physician-mentored patient rounds have also been used to determine what resources students access to find information to complete assignments (EPA 7).13 We have used PMPRs to observe how students develop treatment plans, and we discovered that some confused the terms antagonist and agonist when prescribing medications for patients with COPD (EPA 4).6 
Limitations of the current study include the fact that the study was conducted at 1 medical school, only 1 physician mentor was used during all PMPR sessions, and only 1 patient diagnosis was studied. Different physicians would likely mentor students using different approaches that could limit or enhance student participation in the PMPR sessions. Students at other medical schools with different curricula might also respond in different ways to PMPR assignments. Diagnostic accuracy can also be affected by a patient's diagnosis and the level of difficulty in forming a differential diagnosis.14 
In the future, we plan on doing a more thorough analysis of PMPR history-taking sessions using transcripts to determine whether large student groups use common means to gather a patient's history. Are there things they routinely miss? What order, if any, do they follow? What means, if any, can be used to decrease disorderly history taking by large groups of preclinical students? Is history taking dependent on the patient, the patient's diagnosis, the physician mentor, group size, prior training in history taking, or the length of time to complete PMPR assignments? We would also like to determine whether students’ diagnostic accuracy is dependent on student class rank, the patient present, the patient's diagnosis, the physician-mentor, and time to submit assignments. Will PMPR exercises aid physicians in entrusting students to perform EPA 1 and EPA 2 during clerkships? Can PMPRs improve clerkship EPA 1 and EPA 2 entrustment in medical students at other medical schools? 
Conclusion
In the present study, we used a novel PMPR program to assess preclinical students’ ability to obtain a patient history; to make an accurate diagnosis after a history, after a physical examination, and after analysis of diagnostic test results; and to prioritize a differential diagnosis (EPAs 1 and 2). Future studies should investigate the use of such a program at other medical schools and for additional EPAs. 
Acknowledgment
We thank the patients who generously agreed to come before our medical students and share their medical stories with the hope of contributing to the next generation of high-quality osteopathic physicians. We also acknowledge the efforts of our students as they work toward becoming those osteopathic physicians. 
References
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Table 1.
Overview of Physician-Mentored Patient Rounds With Second-Year Osteopathic Medical Students
Session Activity Discussion Assignment
1 Students obtained a patient history Students asked questions; physician guided group in how to phrase questions and noted the need for students to ask questions to get a more complete history List 5 (class of 2017) or 6 (classes of 2018 and 2019) diagnoses. What will you do next and why (class of 2017)? What regions of the patient would you like to focus on during your physical examination (classes of 2018 and 2019)?
2 Students finished patient history; physician modeled physical examination Students’ differential diagnosis; breadth of the students’ differential diagnosis; appropriate and unlikely diagnoses List 3 (classes of 2017 and 2018) or 6 (class of 2019) diagnoses. Select diagnostic tests.
3 Discussion of diagnostic testing Students’ differential diagnosis and their diagnostic test choices; ordering appropriate diagnostic tests to narrow the differential diagnosis list List 1 (class of 2019) or 2 (classes of 2017 and 2018) diagnoses. Explain how you narrowed your differential diagnosis list.
Table 1.
Overview of Physician-Mentored Patient Rounds With Second-Year Osteopathic Medical Students
Session Activity Discussion Assignment
1 Students obtained a patient history Students asked questions; physician guided group in how to phrase questions and noted the need for students to ask questions to get a more complete history List 5 (class of 2017) or 6 (classes of 2018 and 2019) diagnoses. What will you do next and why (class of 2017)? What regions of the patient would you like to focus on during your physical examination (classes of 2018 and 2019)?
2 Students finished patient history; physician modeled physical examination Students’ differential diagnosis; breadth of the students’ differential diagnosis; appropriate and unlikely diagnoses List 3 (classes of 2017 and 2018) or 6 (class of 2019) diagnoses. Select diagnostic tests.
3 Discussion of diagnostic testing Students’ differential diagnosis and their diagnostic test choices; ordering appropriate diagnostic tests to narrow the differential diagnosis list List 1 (class of 2019) or 2 (classes of 2017 and 2018) diagnoses. Explain how you narrowed your differential diagnosis list.
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Table 2.
Physician-Mentored Patient Rounds (PMPR): Percentage of Students Who Included COPD in Their Differential Diagnosis (N=516)a
Class After History (PMPR Session 1) After Physical Examination (PMPR Session 2) After Diagnostic Tests (PMPR Session 3)
2017c 94.4 (150/159) 98.7 (152/154) 100 (158/158)
2018c 81.5 (128/157) 98.6 (140/142) 100 (161/161)
2019b,c 83.6 (133/159) 93.6 (147/157) 98.7 (149/151)
All classesc 86.5 (SD, 6.92) (411/475) 96.9 (SD, 2.91) (439/453) 99.6 (SD, 0.75) (468/470)

a Chronic obstructive pulmonary disease (COPD), chronic bronchitis, or emphysema diagnosis was considered to be a diagnosis of COPD.

b A different patient with COPD was used in 2019.

c Significant difference was found between “after history” and “after physical examination” (P<.05).

Table 2.
Physician-Mentored Patient Rounds (PMPR): Percentage of Students Who Included COPD in Their Differential Diagnosis (N=516)a
Class After History (PMPR Session 1) After Physical Examination (PMPR Session 2) After Diagnostic Tests (PMPR Session 3)
2017c 94.4 (150/159) 98.7 (152/154) 100 (158/158)
2018c 81.5 (128/157) 98.6 (140/142) 100 (161/161)
2019b,c 83.6 (133/159) 93.6 (147/157) 98.7 (149/151)
All classesc 86.5 (SD, 6.92) (411/475) 96.9 (SD, 2.91) (439/453) 99.6 (SD, 0.75) (468/470)

a Chronic obstructive pulmonary disease (COPD), chronic bronchitis, or emphysema diagnosis was considered to be a diagnosis of COPD.

b A different patient with COPD was used in 2019.

c Significant difference was found between “after history” and “after physical examination” (P<.05).

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Table 3.
Physician-Mentored Patient Rounds (PMPR): Percentage of Students Who Listed COPD as the Most Likely Diagnosis (N=516)a
Class After History (PMPR session 1) After Physical Examination (PMPR session 2) After Diagnostic Tests (PMPR session 3)
2017c 60.4 (96/159) 93.5 (144/154) 100 (158/158)
2018c 36.3 (57/157) 90.8 (129/142) 100 (161/161)
2019b,c 51.6 (82/159) 71.3 (112/157) 98.7 (149/151)
All classesc 49.5 (SD, 12.2) (235/475) 85.2 (SD, 12.1) (385/453) 99.6 (SD, 0.75) (468/470)

a Chronic obstructive pulmonary disease (COPD), chronic bronchitis, or emphysema diagnosis was considered to be a diagnosis of COPD.

b A different patient with COPD was used in 2019.

c Significant difference was found between “after history” and “after physical examination” (P<.05).

Table 3.
Physician-Mentored Patient Rounds (PMPR): Percentage of Students Who Listed COPD as the Most Likely Diagnosis (N=516)a
Class After History (PMPR session 1) After Physical Examination (PMPR session 2) After Diagnostic Tests (PMPR session 3)
2017c 60.4 (96/159) 93.5 (144/154) 100 (158/158)
2018c 36.3 (57/157) 90.8 (129/142) 100 (161/161)
2019b,c 51.6 (82/159) 71.3 (112/157) 98.7 (149/151)
All classesc 49.5 (SD, 12.2) (235/475) 85.2 (SD, 12.1) (385/453) 99.6 (SD, 0.75) (468/470)

a Chronic obstructive pulmonary disease (COPD), chronic bronchitis, or emphysema diagnosis was considered to be a diagnosis of COPD.

b A different patient with COPD was used in 2019.

c Significant difference was found between “after history” and “after physical examination” (P<.05).

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