Clinical competence: general ability or case-specific?

Diagnostic Activities and Diagnostic Practices in Medical Education and Teacher Education: An Interdisciplinary Comparison

In this article, we investigate diagnostic activities and diagnostic practices in medical education and teacher education. Previous studies have tended to focus on comparing knowledge between disciplines, but such an approach is complicated due to the content specificity of knowledge. We compared 142 learners from medical education and 122 learners from teacher education who were asked to (a) diagnose eight simulated cases from their respective discipline in a simulation-based learning environment and (b) write a justificatory report for each simulated case. We coded all justificatory reports regarding four diagnostic activities: generating hypotheses, generating evidence, evaluating evidence, and drawing conclusions. Moreover, using the method of Epistemic Network Analysis, we operationalized diagnostic practices as the relative frequencies of co-occurring diagnostic activities. We found significant differences between learners from medical education and teacher education with respect to both their diagnostic activities and diagnostic practices. Learners from medical education put relatively more emphasis on generating hypotheses and drawing conclusions, therefore applying a more hypothesis-driven approach. By contrast, learners in teacher education had a stronger focus on generating and evaluating evidence, indicating a more data-driven approach. The results may be explained by different epistemic ideals and standards taught in higher education. Further research on the issue of epistemic ideals and standards in diagnosing is needed. Moreover, we recommend that educators think beyond individuals' knowledge and implement measures to systematically teach and increase the awareness of disciplinary standards.

Clinical Case Discussions - a novel, supervised peer-teaching format to promote clinical reasoning in medical students

Background: Clinical reasoning (CR) is a clinical core competence for medical students to acquire. While the necessity for CR teaching has been recognized since the early 20^th century, to this day no consensus on how to best educate students in CR exists. Hence, few universities have incorporated dedicated CR teaching formats into their medical curriculum. We propose a novel case-based, peer-taught and physician-supervised collaborative learning format, dubbed "Clinical Case Discussions" (CCDs) to foster CR in medical students. Project description: We present the curricular concept of CCDs and its development according to a six-step approach (problem identification and general needs assessment; targeted needs assessment; goals and objectives; educational strategies; implementation; evaluation and feedback). Our goal is to strengthen the physician roles (CanMEDS/NKLM) and CR competence of medical students. CCDs are offered at our institution as an elective course and students work on real-life, complex medical cases through a structured approach. Over the course of five years we evaluated various aspects of the course and trained student teachers to optimize our course concept according to the feedback of our participants. We also obtained intro and exit self-assessments of CR competence using an established CR questionnaire. Results: We found an unmet need for CR teaching, as medical students in their clinical years view CR as highly important for later practice, but only 50% have ever heard of CR within the curriculum. Acceptance of CCDs was consistently high with over 85% of participants strongly agreeing that they would re-participate in the course and recommend it to a friend. Additionally, we observed significant improvements in CR self-assessments of participants. Conclusion: CCDs are a feasible teaching format to improve students' CR competence, have a high acceptance and involve students in medical education through peer-teaching.

Educational intervention to improve the competence of Mexican physicians to provide nutritional management for diabetes mellitus type 2

OBJECTIVE

To evaluate the effect of a participative educational intervention on the clinical competence of Mexican family physicians regarding the nutritional management of patients with diabetes mellitus Type 2.

MATERIALS AND METHODS

Quasi-experimental study with a before-and-after control group. Convenience sample included 60 family physicians distributed in two social security primary health care units, randomly selected: 30 in the "A" unit and 30 in the "B" unit. Unit "A" was assigned randomly as control group, and "B" unit as intervention group. The intervention consisted of a theoretical-practical course-workshop that lasted six months where real cases were discussed and solved. Clinical competence was evaluated by means of an instrument designed ex professo, with a maximum theoretical value of 100 and 94% reliability according to the Kuder-Richardson test. Medians of clinical competence were compared among groups, before and after intervention, using the Mann-Whitney U test, while frequencies distribution of clinical competence level were analyzed with the Kolmogorov-Smirnov test (p≤0.05).

RESULTS

Overall medians and intervals for unit "A" were 28 (9-45) pre-intervention and 34 (11-51) pos-intervention, with before-after difference p>0.05; for unit "B", values were 32 (12-50) pre-intervention, 61 (36-82) pos-intervention, and before-after difference p≤0.05. No significant differences were found among groups pre-intervention (p>0.05), although they were observed pos-intervention (p≤0.05).

CONCLUSIONS

The educational intervention evaluated proved to improve, in a statistically significant way, the overall and by dimensions clinical competence level of Mexican family physicians for nutritional management of patients with diabetes mellitus type 2.

Factors Important to Top Clinical Performance in Emergency Medicine Residency: Results of an Ideation Survey and Delphi Panel

OBJECTIVES

We explore attributes, traits, background, skills, and behavioral factors important to top clinical performance in emergency medicine (EM) residency.

METHODS

We used a two-step process-an ideation survey with the Council of Emergency Medicine Residency Directors and a modified Delphi technique-to identify: 1) factors important to top performance, 2) preresidency factors that predict it, and 3) the best ways to measure it. In the Delphi, six expert educators in emergency care assessed the presence of the factors from the ideation survey results in their top clinical performers. Consensus on important factors that were exemplified in >60% of top performers were retained in three Delphi rounds as well as predictors and measures of top performance.

RESULTS

The ideation survey generated 81 responses with ideas for each factor. These were combined into 89 separate factors in seven categories: attributes, personal traits, emergency department (ED)-specific skills and behaviors, general skill set, background, preresidency predictors, and ways to measure top performance. After three Delphi rounds, the panel achieved consensus on 20 factors important to top clinical performance. This included two attributes, seven traits, one general skill set, and 10 ED-specific skills and behaviors. Interview performance was considered the sole important preresidency predictor and clinical competency committee results the sole important measure of top performance.

CONCLUSION

Our expert panel identified 20 factors important to top clinical performance in EM residency. Future work is needed to further explore how individuals learn and develop these factors.

Why assessment in medical education needs a solid foundation in modern test theory

Despite the frequent use of state-of-the-art psychometric models in the field of medical education, there is a growing body of literature that questions their usefulness in the assessment of medical competence. Essentially, a number of authors raised doubt about the appropriateness of psychometric models as a guiding framework to secure and refine current approaches to the assessment of medical competence. In addition, an intriguing phenomenon known as case specificity is specific to the controversy on the use of psychometric models for the assessment of medical competence. Broadly speaking, case specificity is the finding of instability of performances across clinical cases, tasks, or problems. As stability of performances is, generally speaking, a central assumption in psychometric models, case specificity may limit their applicability. This has probably fueled critiques of the field of psychometrics with a substantial amount of potential empirical evidence. This article aimed to explain the fundamental ideas employed in psychometric theory, and how they might be problematic in the context of assessing medical competence. We further aimed to show why and how some critiques do not hold for the field of psychometrics as a whole, but rather only for specific psychometric approaches. Hence, we highlight approaches that, from our perspective, seem to offer promising possibilities when applied in the assessment of medical competence. In conclusion, we advocate for a more differentiated view on psychometric models and their usage.

Problematizing the concept of the "borderline" group in performance assessments

INTRODUCTION

Many standard setting procedures focus on the performance of the "borderline" group, defined through expert judgments by assessors. In performance assessments such as Objective Structured Clinical Examinations (OSCEs), these judgments usually apply at the station level.

METHODS AND RESULTS

Using largely descriptive approaches, we analyze the assessment profile of OSCE candidates at the end of a five year undergraduate medical degree program to investigate the consistency of the borderline group across stations. We look specifically at those candidates who are borderline in individual stations, and in the overall assessment. While the borderline group can be clearly defined at the individual station level, our key finding is that the membership of this group varies considerably across stations.

DISCUSSION AND CONCLUSIONS

These findings pose challenges for some standard setting methods, particularly the borderline group and objective borderline methods. They also suggest that institutions should ensure appropriate conjunctive rules to limit compensation in performance between stations to maximize "diagnostic accuracy". In addition, this work highlights a key benefit of sequential testing formats in OSCEs. In comparison with a traditional, single-test format, sequential models allow assessment of "borderline" candidates across a wider range of content areas with concomitant improvements in pass/fail decision-making.

Competencia clínica de médicos de seguridad social guatemaltecos para manejar hepatitis virales en atención primaria

Objetivo Medir la competencia clínica para el diagnóstico y manejo de hepatitis virales en médicos de primer nivel de atención a la salud.Metodología Se efectuó un estudio transversal en el que usando un instrumento previamente validado se midió la competencia y posteriormente se comparó entre médicos adscritos a diversas unidades médicas de atención primaria a la salud (UMAPS) del Instituto Guatemalteco de Seguridad Social (IGSS). La información fue analizada mediante estadística descriptiva e inferencial no paramétrica. Se evaluaron 104 médicos de 5 UMAPS del IGSS.Resultados Se encontró un nivel muy bajo de competencia clínica para el diagnóstico y tratamiento de las hepatitis virales, dentro de un intervalo de 9 a 62 puntos obtenidos en el instrumento que tiene un valor máximo teórico de 88, sin encontrar diferencias estadísticamente significativas entre UMAPS. Conclusiones Se requiere educación continua en los médicos de las UMAPS del IGSS para mejorar sus competencias en hepatitis virales.

Breadth versus volume: Neurology outpatient clinic cases in medical education

This study examined how volume in certain patient case types and breadth across patient case types in the outpatient clinic setting are related to Neurology Clerkship student performance. Case logs from the outpatient clinic experience of 486 students from The University of Chicago Pritzker School of Medicine, USA, participating in the 4week Neurology Clerkship from July 2008 to June 2013 were reviewed. A total of 12,381 patient encounters were logged and then classified into 13 diagnostic categories. How volume of cases within categories and the breadth of cases across categories relate to the National Board of Medical Examiners Clinical Subject Examination for Neurology and a Neurology Clerkship Objective Structured Clinical Examination was analyzed. Volume of cases was significantly correlated with the National Board of Medical Examiners Clinical Subject Examination for Neurology (r=.290, p<.001), the Objective Structured Clinical Examination physical examination (r=.236, p=.011), and the Objective Structured Clinical Examination patient note (r=.238, p=.010). Breadth of cases was significantly correlated with the National Board of Medical Examiners Clinical Subject Examination for Neurology (r=.231, p=.017), however was not significantly correlated with any component of the Objective Structured Clinical Examination. Volume of cases correlated with higher performance on measures of specialty knowledge and clinical skill. Fewer relationships emerged correlating breadth of cases and performance on the same measures. This study provides guidance to educators who must decide how much emphasis to place on volume versus breadth of cases in outpatient clinic learning experiences.

Assessing clinical reasoning (ASCLIRE): Instrument development and validation

Clinical reasoning is an essential competency in medical education. This study aimed at developing and validating a test to assess diagnostic accuracy, collected information, and diagnostic decision time in clinical reasoning. A norm-referenced computer-based test for the assessment of clinical reasoning (ASCLIRE) was developed, integrating the entire clinical decision process. In a cross-sectional study participants were asked to choose as many diagnostic measures as they deemed necessary to diagnose the underlying disease of six different cases with acute or sub-acute dyspnea and provide a diagnosis. 283 students and 20 content experts participated. In addition to diagnostic accuracy, respective decision time and number of used relevant diagnostic measures were documented as distinct performance indicators. The empirical structure of the test was investigated using a structural equation modeling approach. Experts showed higher accuracy rates and lower decision times than students. In a cross-sectional comparison, the diagnostic accuracy of students improved with the year of study. Wrong diagnoses provided by our sample were comparable to wrong diagnoses in practice. We found an excellent fit for a model with three latent factors-diagnostic accuracy, decision time, and choice of relevant diagnostic information-with diagnostic accuracy showing no significant correlation with decision time. ASCLIRE considers decision time as an important performance indicator beneath diagnostic accuracy and provides evidence that clinical reasoning is a complex ability comprising diagnostic accuracy, decision time, and choice of relevant diagnostic information as three partly correlated but still distinct aspects.

Impact of placement type on the development of clinical competency in speech-language pathology students

BACKGROUND

Speech-language pathology students gain experience and clinical competency through clinical education placements. However, currently little empirical information exists regarding how competency develops. Existing research about the effectiveness of placement types and models in developing competency is generally descriptive and based on opinions and perceptions. The changing nature of education of speech-language pathology students, diverse student cohorts, and the crisis in finding sufficient clinical education placements mean that establishing the most effective and efficient methods for developing clinical competency in students is needed.

AIMS

To gather empirical information regarding the development of competence in speech-language pathology students; and to determine if growth of competency differs in groups of students completing placements that differ in terms of caseload, intensity and setting.

METHODS & PROCEDURES

Participants were students in the third year of a four-year undergraduate speech-language pathology degree who completed three clinical placements across the year and were assessed with the COMPASS® competency assessment tool. Competency development for the whole group across the three placements is described. Growth of competency in groups of students completing different placement types is compared. Interval-level data generated from the students' COMPASS® results were subjected to parametric statistical analyses.

OUTCOMES & RESULTS

The whole group of students increased significantly in competency from placement to placement across different placement settings, intensities and client age groups. Groups completing child placements achieved significantly higher growth in competency when compared with the competency growth of students completing adult placements. Growth of competency was not significantly different for students experiencing different intensity of placements, or different placement settings.

CONCLUSIONS & IMPLICATIONS

These results confirm that the competency of speech-language pathology students develops across three clinical placements over a one-year period regardless of placement type or context, indicating that there may be a transfer of learning between placements types. Further research investigating patterns of competency development in speech-language pathology students is warranted to ensure that assumptions used to design clinical learning opportunities are based on valid evidence.

Cognitive problem solving patterns of medical students correlate with success in diagnostic case solutions

Context

Problem-solving in terms of clinical reasoning is regarded as a key competence of medical doctors. Little is known about the general cognitive actions underlying the strategies of problem-solving among medical students. In this study, a theory-based model was used and adapted in order to investigate the cognitive actions in which medical students are engaged when dealing with a case and how patterns of these actions are related to the correct solution.

Methods

Twenty-three medical students worked on three cases on clinical nephrology using the think-aloud method. The transcribed recordings were coded using a theory-based model consisting of eight different cognitive actions. The coded data was analysed using time sequences in a graphical representation software. Furthermore the relationship between the coded data and accuracy of diagnosis was investigated with inferential statistical methods.

Results

The observation of all main actions in a case elaboration, including evaluation, representation and integration, was considered a complete model and was found in the majority of cases (56%). This pattern significantly related to the accuracy of the case solution (φ = 0.55; p<.001). Extent of prior knowledge was neither related to the complete model nor to the correct solution.

Conclusions

The proposed model is suitable to empirically verify the cognitive actions of problem-solving of medical students. The cognitive actions evaluation, representation and integration are crucial for the complete model and therefore for the accuracy of the solution. The educational implication which may be drawn from this study is to foster students reasoning by focusing on higher level reasoning.

A systematic review of the relationship between patient mix and learning in work-based clinical settings. A BEME systematic review: BEME Guide No. 24

BACKGROUND

Clinical workplace-based learning has been the means to becoming a medical professional for many years. The importance of an adequate patient mix, as defined by the number of patients and the types of medical problems, for an optimal learning process is based on educational theory and recognised by national and international accreditation standards. The relationship between patient mix and learning in work-based curricula as yet remains unclear.

AIM

To review research addressing the relationship between patient mix and learning in work-based clinical settings.

METHOD

The search was conducted across Medline, Embase, Web of Science, ERIC and the Cochrane Library from the start date of the database to July 2011. Original quantitative studies on the relationship between patient mix and learning for learners at any level of the formal medical training/career were included. Methodological quality was assessed and two reviewers using pre-specified forms extracted results.

RESULTS

A total of 10,420 studies were screened on title and abstract. Of these, 298 articles were included for full-text analysis, which resulted in the inclusion of 22 papers. The quality of the included studies, scored with the Medical Education Research Study Quality Instrument (MERSQI), ranged from 8.0 to 14.5 (of 18 points). A positive relationship was found between patient mix and self-reported outcomes evaluating the progress in competence as experienced by the trainee, such as self-confidence and comfort level. Patient mix was also found to correlate positively with self-reported outcomes evaluating the quality of the learning period, such as self-reported learning benefit, experienced effectiveness of the rotation, or the instructional quality. Variables, such as supervision and learning style, might mediate this relationship. A relationship between patient mix and formal assessment has never been demonstrated.

CONCLUSION

Patient mix is positively related to self-reported learning outcome, most evidently the experienced quality of the learning programme.

Biomedical knowledge, clinical cognition and diagnostic justification: a structural equation model

CONTEXT

The process whereby medical students employ integrated analytic and non-analytic diagnostic strategies is not fully understood. Analysing academic performance data could provide a perspective complementary to that of laboratory experiments when investigating the nature of diagnostic strategy. This study examined the performance data of medical students in an integrated curriculum to determine the relative contributions of biomedical knowledge and clinical pattern recognition to diagnostic strategy.

METHODS

Structural equation modelling was used to examine the relationship between biomedical knowledge and clinical cognition (clinical information gathering and interpretation) assessed in Years 1 and 2 of medical school and their relative contributions to diagnostic justification assessed at the beginning of Year 4. Modelling was applied to the academic performance data of 133 medical students who received their md degrees in 2011 and 2012.

RESULTS

The model satisfactorily fit the data. The correlation between biomedical knowledge and clinical cognition was low-moderate (0.26). The paths between these two constructs and diagnostic justification were moderate and slightly favoured biomedical knowledge (0.47 and 0.40 for biomedical knowledge and clinical cognition, respectively).

CONCLUSIONS

The findings suggest that within the first 2 years of medical school, students possessed separate, but complementary, cognitive tools, comprising biomedical knowledge and clinical pattern recognition, which contributed to an integrated diagnostic strategy at the beginning of Year 4. Assessing diagnostic justification, which requires students to make their thinking explicit, may promote the integration of analytic and non-analytic processing into diagnostic strategy.

Learning the facts in medical school is not enough: which factors predict successful application of procedural knowledge in a laboratory setting?

BACKGROUND

Medical knowledge encompasses both conceptual (facts or "what" information) and procedural knowledge ("how" and "why" information). Conceptual knowledge is known to be an essential prerequisite for clinical problem solving. Primarily, medical students learn from textbooks and often struggle with the process of applying their conceptual knowledge to clinical problems. Recent studies address the question of how to foster the acquisition of procedural knowledge and its application in medical education. However, little is known about the factors which predict performance in procedural knowledge tasks. Which additional factors of the learner predict performance in procedural knowledge?

METHODS

Domain specific conceptual knowledge (facts) in clinical nephrology was provided to 80 medical students (3rd to 5th year) using electronic flashcards in a laboratory setting. Learner characteristics were obtained by questionnaires. Procedural knowledge in clinical nephrology was assessed by key feature problems (KFP) and problem solving tasks (PST) reflecting strategic and conditional knowledge, respectively.

RESULTS

Results in procedural knowledge tests (KFP and PST) correlated significantly with each other. In univariate analysis, performance in procedural knowledge (sum of KFP+PST) was significantly correlated with the results in (1) the conceptual knowledge test (CKT), (2) the intended future career as hospital based doctor, (3) the duration of clinical clerkships, and (4) the results in the written German National Medical Examination Part I on preclinical subjects (NME-I). After multiple regression analysis only clinical clerkship experience and NME-I performance remained independent influencing factors.

CONCLUSIONS

Performance in procedural knowledge tests seems independent from the degree of domain specific conceptual knowledge above a certain level. Procedural knowledge may be fostered by clinical experience. More attention should be paid to the interplay of individual clinical clerkship experiences and structured teaching of procedural knowledge and its assessment in medical education curricula.

Clinical reasoning and case-based decision making: the fundamental challenge to veterinary educators

Confusion about the nature of human reasoning and its appropriate application to patients has hampered veterinary students' development of these skills. Expertise is associated with greater ability to deploy pattern recognition (type 1 reasoning), which is aided by progressive development of data-driven, forward reasoning (in contrast to scientific, backward reasoning), analytical approaches that lead to schema acquisition. The associative nature of type 1 reasoning makes it prone to bias, particularly in the face of "cognitive miserliness," when clues that indicate the need for triangulation with an analytical approach are ignored. However, combined reasoning approaches, from the earliest stages, are more successful than one approach alone, so it is important that those involved in curricular design and delivery promote student understanding of reasoning generally, and the situations in which reasoning goes awry, and develop students' ability to reason safely and accurately whether presented with a familiar case or with a case that they have never seen before.

Factors confounding the assessment of reflection: a critical review

BACKGROUND

Reflection on experience is an increasingly critical part of professional development and lifelong learning. There is, however, continuing uncertainty about how best to put principle into practice, particularly as regards assessment. This article explores those uncertainties in order to find practical ways of assessing reflection.

DISCUSSION

We critically review four problems: 1. Inconsistent definitions of reflection; 2. Lack of standards to determine (in)adequate reflection; 3. Factors that complicate assessment; 4. Internal and external contextual factors affecting the assessment of reflection.

SUMMARY

To address the problem of inconsistency, we identified processes that were common to a number of widely quoted theories and synthesised a model, which yielded six indicators that could be used in assessment instruments. We arrived at the conclusion that, until further progress has been made in defining standards, assessment must depend on developing and communicating local consensus between stakeholders (students, practitioners, teachers, supervisors, curriculum developers) about what is expected in exercises and formal tests. Major factors that complicate assessment are the subjective nature of reflection's content and the dependency on descriptions by persons being assessed about their reflection process, without any objective means of verification. To counter these validity threats, we suggest that assessment should focus on generic process skills rather than the subjective content of reflection and where possible to consider objective information about the triggering situation to verify described reflections. Finally, internal and external contextual factors such as motivation, instruction, character of assessment (formative or summative) and the ability of individual learning environments to stimulate reflection should be considered.

Becoming familiar with competency-based student assessment: an evaluation of workshop outcomes

The identification and specification of competency-based standards in speech-language pathology has provided practitioners, educators, employers, and government regulators with information and guidance. This paper reports the outcomes of workshops that provided familiarization with the new competency-based assessment tool, COMPASS®, which was introduced for the assessment of speech-language pathology (SLP) students across all 13 SLP professional preparation programs in Australia during 2007. An anonymous evaluation was administered before and after the first eight familiarization workshops held nationally, involving 240 clinical educators. Quantitative data were analysed descriptively, and qualitative data were entered into NVivo qualitative analysis software for content analysis. Post-workshop, results indicated partial or full uptake of the main concepts involved in the new approach to assessment. Least uptake was observed for the need for direct observation of competence in workplace performance. Qualitatively, post-workshop, formative assessment was more apparent within student goals formulated in response to a hypothetical scenario. A possible contributor to this outcome is suggested to be the alignment between the tool and the professional community of practice, due to the collaborative process of its development. Research into the longer term impact of the new assessment in the context of everyday practice is suggested.

Relationship between case question prompt format and the quality of responses

OBJECTIVES

To compare the effectiveness of 2 case question formats (multiple choice and open ended) to prompt faculty members and students to explore multiple solutions and use factual evidence to defend their solutions.

METHODS

Doctor of pharmacy (PharmD) faculty members and students responded to 2 pharmacy law/ethics cases, one followed by a case question prompt in multiple-choice format and the other by a question in open-ended format. The number of conclusions and the quality of the arguments generated were assessed using general linear modeling.

RESULTS

PharmD faculty members outperformed students on every outcome variable measured, demonstrating expert problem-solving skills. All participants provided better quality arguments when the case prompt question was in multiple-choice format.

CONCLUSIONS

The better quality arguments prompted by multiple-choice case questions suggests this format should be used when constructing case question prompts.

Is case-specificity content-specificity? An analysis of data from extended-matching questions

Case-specificity, i.e., variability of a subject's performance across cases, has been a consistent finding in medical education. It has important implications for assessment validity and reliability. Its root causes remain a matter of discussion. One hypothesis, content-specificity, links variability of performance to variable levels of relevant knowledge. Extended-matching items (EMIs) are an ideal format to test this hypothesis as items are grouped by topic. If differences pertaining to content knowledge are the main cause of case-specificity, variability across topics should be high and variability across items within the same topic low. We used generalisability analysis on results of a written test composed of 159 EMIs sat by two cohorts of general practice trainees at one university. Two hundred and twenty-seven trainees took part. The variance component attributed to subjects was small. Variance attributed to topics was smaller than variance attributed to items. The main source of error was interaction between subjects and items, accounting for two-thirds of error. The generalisability D study revealed that for the same total number of items, increasing the number of topics results in a higher G coefficient than increasing the number of items per topic. Topical knowledge does not seem to explain case-specificity observed in our data. Structure of knowledge and reasoning strategy may be more important, in particular pattern-recognition which EMIs were designed to elicit. The causal explanations of case-specificity may be dependent on test format. Increasing the number of topics with fewer items each would increase reliability but also testing time.

Transition to clinical training: influence of pre-clinical knowledge and skills, and consequences for clinical performance

CONTEXT

Many students experience a tough transition from pre-clinical to clinical training and previous studies suggest that this may constrict students' progress. However, clear empirical evidence of this is lacking. The aim of this study was to determine: whether the perceived difficulty of transition influences student performance during the first 2 weeks of clerkships; whether it influences students' overall performance in their first clerkship, and the degree to which the difficulty of transition is influenced by students' pre-clinical knowledge and skills levels.

METHODS

Clerks (n = 83) from a university hospital and eight affiliated hospitals completed a questionnaire measuring the perceived difficulty of the transition period. Data collected included student scores on pre-clinical knowledge and skills, their performance during the second week of the first clerkship, and their overall performance in the first clerkship. Univariate and multivariate multiple regression analyses were used to analyse the data.

RESULTS

The perceived difficulty of transition was neither predictive of student performance during the transition period (adjusted R(2) = 11.8%, P = NS), nor of their overall clerkship performance (adjusted R(2) = 8.6%, P = NS). Students' pre-clinical knowledge and skills played a minor role in the perceived difficulty of the transition period.

CONCLUSIONS

The negative effect of the transition period on student progress suggested in the literature was not found in this study. A possible explanation for the limited influence of students' knowledge and skills on performance during the transition period is that the workload in this period causes a cognitive overload, interfering with students' abilities to apply their pre-clinical knowledge and skills.

The impact of case specificity and generalisable skills on clinical performance: a correlated traits-correlated methods approach

CONTEXT

The finding of case or content specificity in medical problem solving moved the focus of research away from generalisable skills towards the importance of content knowledge. However, controversy about the content dependency of clinical performance and the generalisability of skills remains.

OBJECTIVES

This study aimed to explore the relative impact of both perspectives (case specificity and generalisable skills) on different components (history taking, physical examination, communication) of clinical performance within and across cases.

METHODS

Data from a clinical performance examination (CPX) taken by 350 Year 3 students were used in a correlated traits-correlated methods (CTCM) approach using confirmatory factor analysis, whereby 'traits' refers to generalisable skills and 'methods' to individual cases. The baseline CTCM model was analysed and compared with four nested models using structural equation modelling techniques. The CPX consisted of three skills components and five cases.

RESULTS

Comparison of the four different models with the least-restricted baseline CTCM model revealed that a model with uncorrelated generalisable skills factors and correlated case-specific knowledge factors represented the data best. The generalisable processes found in history taking, physical examination and communication were responsible for half the explained variance, in comparison with the variance related to case specificity. Conclusions Pure knowledge-based and pure skill-based perspectives on clinical performance both seem too one-dimensional and new evidence supports the idea that a substantial amount of variance contributes to both aspects of performance. It could be concluded that generalisable skills and specialised knowledge go hand in hand: both are essential aspects of clinical performance.