Introduction
Pulse palpation is among the most fundamental physical examination skills in clinical and surgical practice. It enables the clinician to assess heart rate, rhythm, volume, and character at the bedside - features that automated monitoring does not reliably capture in all patient populations.
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is highly prevalent in surgical patients, contributing perioperatively to stroke, hemodynamic instability, intensive care admission, and prolonged hospital stay.1–4 Guideline bodies including the National Institute for Health and Care Excellence (NICE) and the European Society of Cardiology (ESC) recommend opportunistic pulse palpation as a first-line screening tool for AF, particularly in patients aged over 65 years.5,6 The reported sensitivity of manual palpation for detecting AF ranges from 87% to 97%, compared with 94% to 98% for electrocardiography (ECG).6
Despite its diagnostic importance, current undergraduate curricula typically describe the anatomical site for palpation without providing explicit instruction in how to optimize technique. As a result, learners may develop inconsistent habits that limit the diagnostic yield of this bedside assessment.7,8
We developed the ORB Technique - an acronym for Occlude, Release, Back-down - as a structured three-step approach to address this gap. The technique proceeds as follows: (1) occlude the radial artery completely using two or three fingertips; (2) fully release the occlusion; (3) reapply downward pressure incrementally until the point of maximum pulse amplitude is identified. This sequence is hypothesized to enhance the perceived pulse signal through mechanical optimization of finger placement and transient physiological changes, including proximal back-pressure during occlusion and localized reactive vasodilation following release, consistent with established models of arterial pulse wave mechanics.9
The objectives of this study were to: (1) evaluate medical students’ subjective perceptions of the ORB Technique relative to standard radial pulse palpation; and (2) assess their intention to incorporate the technique into future clinical practice, with a view to informing its integration into undergraduate surgical skills curricula.
Methods
A cross-sectional survey was conducted. Ethical approval was obtained from the relevant institutional research ethics committee prior to commencement. Participation was voluntary and all responses were anonymous. Informed consent was obtained from all participants prior to completing the survey.
The target population was medical students with prior clinical exposure, enrolled at University College Cork (UCC), eligible participants included Year 2 students from the five-year direct-entry undergraduate program (DEM2) and Year 1 students from the four-year graduate-entry program (GEM1). Final-year students were excluded owing to concurrent examination commitments.
A standardized two-minute instructional video was produced demonstrating the ORB Technique, including correct hand and finger positioning, the occlusion and release sequence, and identification of the point of maximum amplitude. All participants viewed the video immediately prior to completing the questionnaire, ensuring consistency of educational exposure across individuals.
A brief structured questionnaire assessed two primary outcomes: (1) participants’ subjective comparison of the ORB Technique with their habitual pulse palpation method, rated on a four-point scale (significantly better / better / no difference / worse); and (2) likelihood of future adoption, rated on a three-point scale (very likely / likely / unlikely). The survey was piloted with a small group prior to distribution and was estimated to take 2 to 3 minutes to complete.
At UCC, the survey was distributed in paper format during student lectures; researchers were present to explain the study and obtain written consent, and data were subsequently transcribed to a spreadsheet. An online version was later created using SurveyMonkey with the embedded instructional video and distributed via its e-learning platform. All responses were subsequently pooled for primary analysis.
A minimum of 110 respondents was required to achieve 95% confidence with a margin of error ≤9%, based on a combined eligible population of 1,460 students. Descriptive statistics were used to summarize demographic and survey response data; frequencies and proportions are reported for categorical variables. Spearman rank-order correlation (ρ) was used to assess the association between ordinal perception and intention scores. Statistical significance was set at p < 0.05. The overall margin of error for the study was 8.76% at a 95% confidence interval.
Results
Participant Demographics
A total of 115 medical students participated in the study. Participants were stratified by year group, comprising 29 students from the DEM2 cohort and 86 students from the GEM1 cohort. Demographic characteristics are presented in Table 1.
Perceptions of the ORB Technique
Participants’ perceptions of the ORB Technique compared with their standard pulse palpation method are summarized in Table 2. Overall, the majority of participants rated the ORB Technique favorably, with 73 (63.5%) rating it as “better” and 11 (9.6%) rating it as “significantly better”. Combined, 84 (73.1%) of participants responded positively to the technique.
A Mann-Whitney U test was conducted to compare perception scores between DEM2 and GEM1 year groups. There was no statistically significant difference between year groups in perception of the ORB Technique (U = 1078.50, p = 0.207) (Table 3).
Intention to Adopt
Participants’ stated intention to use the ORB Technique in future clinical practice is presented in Table 4. More than half (59, 51.3%) indicated they were “likely” to use the technique, while an additional 16 (13.9%) stated they were “very likely” to adopt it. Combined, 75 (65.2%) of participants expressed positive intention to adopt the technique.
A Mann-Whitney U test was conducted to compare intention scores between DEM2 and GEM1 year groups. Results indicated a statistically significant difference between year groups in intention to adopt (U = 797.00, p = 0.001) (Table 5) and indicated that DEM2 students were more likely to adopt the ORB Technique.
Association Between Perception and Intention
Spearman’s rank-order correlation was conducted to examine the relationship between participants’ perception of the ORB Technique and their intention to adopt it in future practice. A statistically significant positive correlation was found between perception and intention scores (p=0.503, p < 0.001), indicating that participants who rated the technique more favorably were moderately more likely to express intention to use it (Table 6).
Discussion
This study demonstrates that the ORB Technique is perceived favorably by medical students, with three quarters rating it superior to their standard approach and over 65% expressing intention to adopt it in future practice. To our knowledge, this is the first study to evaluate a structured technique enhancement for radial pulse palpation in an educational context, and the findings provide a foundation for its formal integration into surgical skills curricula.
Educational Rationale and Curriculum Integration
Although pulse palpation is taught universally in undergraduate medical training, the literature reveals a consistent absence of standardized instruction in technique optimisation.1,7,8 Existing curricula describe where to palpate and what features to assess, but do not address how to maximize the quality of the pulse signal perceived. The ORB Technique fills this gap by providing a reproducible three-step sequence that can be taught, practiced, and formally assessed.
The technique is simple enough to be introduced early in training and practiced on peers in skills laboratory settings. The two-minute video used in this study was sufficient to convey the method to participants with no prior exposure, suggesting that embedding the technique into existing curricula would require minimal additional teaching time. The structured three-step sequence is also well-suited to Objective Structured Clinical Examination (OSCE) assessment, where a reproducible procedure can be evaluated against a structured mark scheme.
The observation that GEM1 graduate-entry students were significantly less likely (U = 797.00, p = 0.001) to intend to adopt the technique than DEM2 undergraduates is of interest. Graduate-entry students may have established clinical habits - having had varied prior healthcare exposure - making them less receptive to adopting a new structured method. This finding suggests that early introduction of the ORB Technique, before clinical habits become entrenched, may yield higher adoption rates and is consistent with broader evidence that procedural skills training is most effective when initiated in the pre-clinical phase.
Clinical Relevance: Atrial Fibrillation Screening
The clinical imperative for improved palpation technique is substantial. AF affects approximately 1–2% of the general population and is markedly more prevalent in older surgical patients, where it contributes to stroke, hemodynamic compromise, and prolonged hospitalisation.2,4 Manual pulse palpation is recommended as the first-line screening step by NICE and ESC guidelines, yet its sensitivity (87–97%) falls short of ECG (94–98%), a gap that may partly reflect technique variation among examiners.5,6
Taggar et al, in a systematic review and meta-analysis, found that manual palpation had lower diagnostic specificity than electronic detection devices for AF, partly because examiners could not reliably distinguish transient from sustained irregularities.10 The authors noted that sensitivity was broadly maintained, suggesting that technique rather than the modality itself may be the limiting factor - a finding that directly supports the premise of the ORB Technique. Jaakkola et al assessed the reliability of self-palpation for AF detection among elderly individuals and found that patients could detect sinus rhythm with 97% accuracy and AF with 82–92% accuracy.11 These findings indicate that systematic technique improvements could yield clinically meaningful gains, particularly for inexperienced examiners and patient self-screening programs.
The ORB Technique may be of particular value in acutely unwell surgical patients. Rimbi et al reported poor correlation between pulse oximetry-derived and ECG-derived heart rates in acutely ill patients, reinforcing the continued importance of manual assessment where waveform quality is diminished.12 Hobbs et al demonstrated that systematic pulse palpation combined with 12-lead ECG was a cost-effective approach to AF screening in those aged over 65 years - a model in which any improvement in palpation technique would enhance the first-line screening step.13
Physiological Basis
The proposed mechanism of the ORB Technique is plausible on physiological grounds. Brief arterial occlusion followed by release produces transient reactive hyperemia and localized vasodilation, which may transiently augment the pulse pressure wave proximal to the release point. Furthermore, the incremental reapplication of pressure in step 3 allows the examiner to identify the point of maximum arterial wall displacement - a maneuver supported by models of arterial pulse wave mechanics, where the rate of change of wall displacement is greatest at a specific pressure threshold.9 Whether these mechanisms translate into objectively improved arrhythmia detection rates requires prospective clinical evaluation, but the consistent subjective benefit reported across two cohorts justifies that next investigational step.
A further mechanistic rationale for the ORB Technique’s effectiveness may lie in its ability to enable the performer to more accurately identify the point of maximum pulse perception. From a biomechanical standpoint, this point corresponds to the instant at which the rate of change of arterial diameter is greatest - that is, the inflection point on the rising portion of the arterial pressure waveform at which radial wall velocity peaks.14,15 When external digital pressure is applied suboptimally - whether too light or too heavy - the arterial wall is either unloaded or over-compressed, and in either case the palpable displacement signal is attenuated. By incrementally reapplying pressure following full release, as prescribed in step 3 of the ORB sequence, the examiner converges on the threshold at which the transmitted pulse amplitude is maximal, corresponding to the point of peak circumferential wall velocity. At this optimal loading point, even subtle beat-to-beat variations in waveform morphology - such as those characteristic of atrial fibrillation - are rendered more perceptible to the examining finger.14,15 This conceptual framework is consistent with established models of arterial pulse wave mechanics16 and suggests that the clinical benefit of the technique may be attributable not merely to a reduction in examiner variability, but to a systematic optimization of the biomechanical interface between the arterial wall and the palpating digit.
Limitations
Several limitations should be acknowledged. The primary outcome was subjective self-reported perception, which is susceptible to novelty bias and social desirability effects. No objective measurement of pulse amplitude or arrhythmia detection accuracy was performed, and the study did not include a comparator group learning standard palpation without the ORB sequence.
The study population comprised medical students rather than qualified clinicians or the patient populations in whom the technique would ultimately be applied; student perceptions may not generalize to more experienced examiners.
Finally, the instructional video, while standardized, did not permit hands-on practice with feedback prior to survey completion. It is plausible that the perceived and objective benefit of the technique would be greater following guided practical training - a hypothesis that future studies should explore.
Conclusions
The ORB Technique is a simple, structured, three-step enhancement to radial pulse palpation that was viewed favorably by clinically exposed medical students. Three quarters of participants rated it superior to their standard approach, and over 65% expressed willingness to adopt it in future clinical practice. Positive perception was associated with intent to adopt the technique. These findings support the formal integration of the ORB Technique into undergraduate surgical and clinical skills curricula, where it offers both a practical teaching tool and a readily assessable procedural skill.
Prospective clinical studies should now evaluate the technique’s diagnostic accuracy for AF detection relative to ECG in clinical populations, assess its effect when taught with structured hands-on practice, and examine its utility as a patient self-screening tool for community-based arrhythmia detection programs.
Acknowledgements
The authors thank the class representatives and faculty staff at UCC for facilitating survey distribution. No external funding was received for this study.